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.
- Director of Rehab (DOR) – Synthesizes all information provided by the IDT, to determine the best course of action for continuing or discharging from skilled therapy services. This includes all payer sources, such as Medicare, Medicaid, and private insurance policies.
- Physical, Occupational, and Speech Therapists – Share relevant aspects of each patient’s care and any barriers preventing a patient’s progress, such as difficulties with pain or cognitive deficits. Many IDT meetings do not include therapists, with the expectation that the DOR will speak on behalf of the clinicians.
- Social Workers – Provide pertinent information related to a patient’s psychosocial circumstances, such as informing the team that the patient expects to return home sooner than planned or the patient’s wife is seeking a divorce.
- Director of Nursing (DON) – Synthesizes all nursing information reported from supervisors that may impact or improve the patient’s rehab experience and potential to discharge from services.
- Director of Restorative – Compiles information regarding patients who may be discharged from skilled therapeutic services, but will continue to stay in the SNF and require continued maintenance therapies to prevent decline. He or she may also alert the IDT about any current residents on caseload who require a screen or re-evaluation by therapy.
- MDS Coordinator – Collects all indicated skilled therapy, nursing, restorative, and social work data to be submitted to the Center for Medical Services (CMS) for Medicare beneficiaries. Ensures that communication is clear for Medicare beneficiaries, in order to prevent default from skilled rehab services.
- Attending Physician – Integrates all shared information from the IDT and provides updates about the patient’s medical situation. Contributes to IDT by recommending further and necessary medical interventions or communicating to primary physicians the IDT concerns.
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.