Overlapping Roles

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

1. 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.
2. 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.
3. Explain how the interprofessional team might best decide whose role and responsibility it is to evaluate Mrs. Hansen’s home environment.
4. 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?

1. Understanding of Roles and Responsibilities:
   • The physician specializing in physical medicine and rehabilitation can help by providing medical insights into Mrs. Hansen’s condition and prognosis, ensuring that the team considers her physical limitations and needs.
   • The physical therapist can help by explaining the specific rehabilitation goals, such as improving mobility and ensuring that Mrs. Hansen can safely use her walker at home.
   • The occupational therapist can clarify her role in assessing Mrs. Hansen’s ability to perform activities of daily living (ADLs) at home, which is essential for her overall independence.
   • The registered nurse can contribute by discussing Mrs. Hansen’s medical needs, including medication management and wound care, and helping to coordinate any necessary home healthcare services.
   • The social worker can provide insights into the patient’s psychosocial needs, including evaluating her living situation, assessing her support system, and addressing the family’s concerns.
2. Interdependent Team Relationships:
   • The physician and physical therapist can collaborate closely to set rehabilitation goals that align with Mrs. Hansen’s desire to go home. The PT can provide feedback on Mrs. Hansen’s progress during rehabilitation sessions.
   • The occupational therapist and physical therapist can work together to ensure that Mrs. Hansen can safely use her walker at home and perform ADLs independently.
   • The registered nurse and social worker can coordinate to assess the patient’s overall needs and the safety of her home environment. The nurse can provide medical insights, while the social worker can evaluate psychosocial factors.
   • The patient, Mrs. Hansen, should actively participate in decision-making, with support from the team. The team should engage in shared decision-making to respect her autonomy.
3. Deciding Whose Role and Responsibility to Evaluate the Home Environment: To determine who should evaluate Mrs. Hansen’s home environment, the team should engage in a collaborative discussion. Here’s a suggested approach:
   • The social worker can take the lead in coordinating the home evaluation since it falls within their scope of practice and involves assessing psychosocial aspects.
   • The physical therapist can accompany the social worker to assess whether the home is suitable for using a walker safely.
   • The nurse can also participate, focusing on identifying any environmental hazards that may affect Mrs. Hansen’s safety and health.
   • The occupational therapist can provide input on the kitchen setup and other aspects of the home environment that relate to ADLs.
   • The team should ensure that Mrs. Hansen’s preferences and concerns are taken into account during the evaluation.
4. Role and Responsibilities of the Social Worker: As the social worker for Mrs. Hansen, I would describe my role and responsibilities as follows:
   • To assess and address the psychosocial aspects of Mrs. Hansen’s care, including her emotional well-being, support system, and concerns of both the patient and family.
   • To coordinate with other team members to ensure a comprehensive approach to her care, including collaborating with the physical therapist, occupational therapist, nurse, and physician.
   • To conduct a home visit, in conjunction with the physical therapist and nurse, to evaluate the home environment for safety and suitability.
   • To facilitate communication between Mrs. Hansen, her family, and the healthcare team, ensuring that everyone’s concerns and preferences are heard.
   • To provide resources and referrals for any social or community services that may be needed to support Mrs. Hansen’s transition back home.

   To assess the understanding of my role by the patient, family, and professionals, I would engage in open and transparent communication. I would encourage questions and feedback, ensuring that they are informed about the scope of my practice and how my contributions will benefit Mrs. Hansen’s well-being and discharge plan. Additionally, I would seek feedback from the team and inquire if they have any concerns or questions about my role and responsibilities throughout the care planning process. This ongoing communication would help ensure that everyone is on the same page and that the patient’s best interests are prioritized.