Case Study: Overlapping Roles
The interprofessional team is meeting to determine the best plan for the after-discharge care of Judith Hansen, a 75-year-old patient in a rehabilitation facility who fractured her left hip after a fall at home, where she lives alone. She wants to go home, but her family is not comfortable with her being alone, fearing for her safety and ability to care for herself. The family prefers that she is transferred to a nursing home after discharge. The family requests that the interprofessional team evaluate the situation and offer their recommendations. The team consists of a physician specializing in physical medicine and rehabilitation, a physical therapist, an occupational therapist, a registered nurse, a social worker, the patient, Mrs. Hansen, and her family.
When the team meets, the patient and family are not present. The professionals begin by discussing aspects of Mrs. Hansen’s care. The occupational therapist (OT) states that Mrs. Hansen is able to dress herself and prepare simple meals and therefore should be able to go home. The physical therapist (PT) states that the patient is able to ambulate independently using a walker. The nurse has concerns about the patient’s transportation needs, but the physician says the social worker should deal with that. Several team members think that a home visit will help in determining whether discharge to home is safe. This leads to discussion and uncertainty about who will to do the home visit. The PT planned to go to see whether the home is safe for using a walker, the nurse intended to have a member of the nursing staff go to determine environmental hazards, the OT expected to observe whether the kitchen is set up so that the patient can prepare meals, and the social worker says it is his job to make home visits. The team must determine who will do the home visit because the roles of several team members seem to overlap; making a home visit for the purpose each described is within each professional’s legal scope of practice. The physician points out that the patient should be the one to decide where she wants to live, provided she is competent to do so, and suggests a psychiatric consult to evaluate the patient’s competency to decide where she will go after discharge before proceeding further.
Discussion Questions
- Explain how each team member’s understanding of the roles and responsibilities of the other team members could help the team to work together effectively in providing comprehensive care to Mrs. Hansen.
- For each team member mentioned in this case study, describe an interdependent team relationship that could improve Mrs. Hansen’s discharge plan and health outcomes.
- Explain how the interprofessional team might best decide whose role and responsibility it is to evaluate Mrs. Hansen’s home environment.
- Imagine you are the social worker for Mrs. Hansen. How would you describe your role and responsibilities to the patient, family, and professionals on the team? How would you be able to assess their understanding of your explanation?
