There are several pathways in which a patient may experience rehabilitation in a skilled nursing facility (SNF). In my experience, I have found that the most advantageous procedure that not only benefits the patient and caregivers, but also provides an easier working relationship among service providers, is when there is a consistent and well-directed interdisciplinary team (IDT) meeting on a regular schedule.
An IDT meeting most often consists of the Director of Rehab, primary therapists (physical, occupational, and speech), primary social workers, rehab unit charge nurse, Director of Nursing, Director of Restorative (Maintenance Therapy), Minimum Data Set (MDS) Coordinator, and an attending physician, where possible.
Each participant in the IDT meeting has a critical role in the “big picture” of the patient’s SNF experience and transition to home or an alternative setting. Their roles are described below.
The best IDT is one that meets at minimum on a weekly basis and discusses the entire rehab caseload, regardless of payer source. Delegation of follow-up procedures for any critical aspects of care is essential to provide the best experience for the patient, family, and caregivers.