Week 5 Discussion: Interprofessional Collaboration (graded

Planning for our patients during times of transitions (for example: hospital to home, home to rehabilitation facility) involves collaboration with a number of healthcare professionals. Please address the following questions:

How does your facility promote interprofessional collaboration during times of patient transitions?

What is the role of the nurse in patient transitions?

  • What gaps can you identify in this process related to quality of care? (If you are not currently in practice, please use a previous role or clinical experience in your answers.)
  • I will also need one reply to two classmates, I am attaching their responses, thank you 
  • Tacara:

How does your facility promote interprofessional collaboration during times of patient transitions?

With so many transitioning patients in various stages of recovery, it is challenging to provide seamless care for all. Many changes happen during treatment and after release from the hospital or rehabilitation facility. Nursing homes and hospitals must establish collaborations and shared business practices supporting effective patient care management. When patients are discharged from a hospital or rehab center, a team of healthcare providers will be involved in the discharge process (Eika & Hvalvik, 2022). These providers might include primary care physicians, therapists, and case managers. There must also be an effective communication network in place so that everyone is appropriately informed throughout the transition process. The communication plan should be initiated at least one week before discharge. This gives all parties ample time to understand the patient’s needs and ensure everything is ready for their return home or transfer to another facility. One way to initiate this process is with a meeting attended by all parties, including the therapist and case manager.

What is the role of the nurse in patient transitions?

Once a patient is discharged from the hospital or rehab center, their care is transferred to the nursing home. The nurse plays a significant role in planning for the transition process. They must review the charts of all patients scheduled for discharge so that an assessment can be conducted before release (Malley et al., 2015). The evaluation includes a plan of care, goals, and implementation of these plans with any collaborated services necessary, such as occupational therapy, physical therapy, speech-language pathology, and case management.

What gaps can you identify in this process related to the quality of care?

We have many transitioning patients, and it is our job to ensure their care is seamless. However, I see quality gaps in this area. It can be challenging to balance multiple transitions co-occurring in a nursing home with limited staffing. We do not always have enough nursing staff to provide complete and thorough assessments on these special discharge days. In these situations, it would be helpful if all the team members could come together before the transitions and conduct a comprehensive assessment including a discharge summary that covers everything discussed during the meeting and planned by each healthcare provider involved in the patient’s care. This will allow everyone involved to feel confident when transitioning a patient in poor health who may no longer require medical assistance on site.


Eika, M., & Hvalvik, S. (2022). Municipal healthcare professionals’ interprofessional collaboration during older patients’ transitions in the municipal health and care services: a qualitative study. BMC health services research, 22(1), 1-15. https://bmchealthservres.biomedcentral.com/article… (Links to an external site.)

Malley, A., Kenner, C., Kim, T., & Blakeney, B. (2015). The role of the nurse and the preoperative assessment in patient transitions. AORN Journal, 102(2), 181-e1. https://www.sciencedirect.com/science/article/pii/…

kaitilin: Professor and Class,

Interprofessional collaboration is very important in times of transitioning. “Clinical health outcomes and health disparities can be improved through interprofessional collaborations among multidisciplinary clinicians, health care services researchers, and patients” (Ferguson LA;Arnold C;Morris J;Rademaker A;Davis T;). Patients go through a lot of change and transitions throughout their stay as well as after their stay at a facility. One way my facility promotes interprofessional collaboration is by communication. Communication is important with transitions to coordinate care and keep the patient involved with a plan. Communication will get each team member on the same page. The nurse is often viewed as the communicator and coordinator. The role is the patient advocate and voice for the patient. The nurse’s job is to incorporate the appropriate team members in coordination to create a quality plan and outcome for the patient. As an ER nurse it is our duty to communicate with a lot of different teams depending on the patient’s needs. We collaborate with OR, the floors, respiratory, psych, other facilities for transfer, other facilities for discharges, along with all of the specialties such as ortho, cardiology etc. There is a lot of collaboration in the ER, so assuring that there is a clear, smooth plan for these patients is important. The gap that I can identify in this process would be bridging gaps. Where I work the interprofessional collaboration that I would say these bridging gaps occur are the psychiatric facilities being transferred to psychiatric facilities. Although going to these facilities improves the quality of care most times it is difficult to get these patients accepted and admitted in a timely manner. This gap can cause a delay of care for these patients. Another gap would be knowledge gaps. The knowledge gaps are lack of communication or documentation within the interprofessional teams.


Ferguson LA;Arnold C;Morris J;Rademaker A;Davis T; (n.d.). The nurse practitioner as a bridge to Interprofessional Research Team Collaboration in rural community clinics. Journal of the American Association of Nurse Practitioners. Retrieved September 25, 2022, from https://pubmed.ncbi.nlm.nih.gov/32251036/ 

American Nurses Association (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association (ANA).