Theme lead
Sabina Mette Staal
Clinical Development Occupational Therapist, Amager and Hvidovre Hospital.
Kira Marie Milandt Skibdal
Clinical Development Physiotherapist, Amager and Hvidovre Hospital
Focus
As a part of the Danish national leadership program the therapist-completed Plan for Discharge and Transitional Community Care (PDTCC, in Danish “Plejeforløbsplan") was selected as a focus area to enhance the transition between sectors. The aim of this improvement project was to determine whether therapist-completed care pathway plans support smooth transitions and limit the need for additional communication between municipalities and hospitals regarding further clarification of the PDTCC.
The project was conducted in the orthopedic surgery department 210 at Hospital of Hvidovre. It involved five physiotherapists, three occupational therapists, and discharge-responsible nursing staff. The project included patients with hip fractures and amputations from Copenhagen Municipality. The improvement model was used as well as interviews, small-scale testing, audits, and training.
During the trial period, 29 PDTCCs were completed, of which 63% were partially or completely rewritten due to the complex interdisciplinary workflow. Nineteen out of twenty-four PDTCC were from Copenhagen Municipality. Only four PDTCC were evaluated using a checklist in Copenhagen Municipality. The time spent completing the PDTCC was five minutes for physiotherapists and ten minutes for occupational therapists. The quality of therapist-completed PDTCC's was assessed as higher by the recipients, and therapists found the task meaningful.
In conclusion, completing PDTCC by therapists is complex and requires increased interdisciplinary coordination. The task is perceived as meaningful, and the referral process reports improved quality in therapist-completed sections. However, therapist-completed PDTCC do not reduce the need for telephone contact between municipalities and hospitals. Further investigation is needed to equalize workflows to reduce the number of rewrites and to stratify the target group for the therapist-completed PDTCC.
Selected outputs:
The good transition - Therapist-completed plan for discharge and transitional community care (Project posterProjectposterposter)