Role of the Team in Discharge Planning: An Interprofessional Interview Project

TTUHSC Interprofessional Practice and Education (IPE) Experience

Title of the Interprofessional Practice and Education Experience

Role of the Team in Discharge Planning: An Interprofessional Interview Project

Experience Status


Approval Date Range

2/15/2024 - 2/15/2025

Criteria for Registering the IPE Experience

  • Involvement of two or more professions.
  • Opportunities to learn about, from, and with one another.
  • Significant interactivity between participants.
  • Teaching and/or learning about interprofessional practice and education is intentionally integrated into the activity. Interprofessional practice and education constructs are targeted with IPE learning objectives are also discussed, trained, reviewed, and/or assessed as part of the learning activity.

Type of IPE Experience

  • Didactic learning
  • Experiential and/or clinical learning
  • Clinical observation and/or professional interview
  • Interviews

IPEC Core Competencies Targeted by this IPE Experience

  • Communication: Communicate in a responsive, responsible, respectful, and compassionate manner with team members.
  • Roles and Responsibilities: Use the knowledge of one’s own role and team members’ expertise to address individual and population health outcomes.
  • Values and Ethics: Work with team members to maintain a climate of shared values, ethical conduct, and mutual respect.
  • Teams and Teamwork: Apply values and principles of the science of teamwork to adapt one's own role in a variety of team settings.

Quintuple Aim Strategic Goals Discussed in this IPE Experience

  • Enhancing the experience of care
  • Improving patient and/or population health outcomes
  • Reducing the cost of care

Detailed Description and Purpose of the IPE Experience

The transition from hospital to post-hospital care for those with a chronic health condition represents a time of increased vulnerability for the patient and the caregiver. It has been reported that 14% percent of individuals discharged from hospitals in 2018 were readmitted within 30 days following discharge (Weiss & Jiang, 2021). When seeking to optimize a patient's ability to self-manage their chronic health condition planning for discharge is a key component in treatment. The involvement of the caregiver and the interprofessional healthcare team is fundamental to achieving a successful discharge and diminishing the risk of readmission.

In this interprofessional interview project, students have didactic immersion into CMS and Joint Commission standards on managing transitions of care and a multidisciplinary approach to discharge planning. A major learning objective for this module states the student will: “Utilize an appropriate discharge planning strategy in developing an intervention based on patient and caregiver concerns and needs.” The assignment toward addressing this objective requires each student to interview a clinical social worker and a nurse practicing in the home care arena to determine the interviewees' observations of patient & caregiver knowledge regarding self-management of chronic health conditions, learning deficits, and recommendations on how to improve discharge teaching. The student also will reflect on the value of interprofessional collaboration during transitions in care.

To complete the learning activities, the student composes questions drawn from material covered in the CMS Joint Commission Standards module that they want to ask the interviewees. The purpose of the interviews is to determine how best to prepare a patient for transition from acute care to home or rehabilitation facility and identify 3 interprofessional or collaborative care strategies to reduce hospital readmissions. Students then summarize the findings of the interviews in a recorded audio presentation which is then uploaded to the Discussion forum embedded in the course.

Students then are expected to listen to at least one, preferably two other posted presentations and provide feedback to those students via the discussion board, with an emphasis on teamwork and collaboration to improve patient outcomes
Some suggested questions are offered below.
1. Name of each interviewee and credentials.
2. The types of organizations the interviewees are affiliated with for their practice, i.e. hospital, clinic, clinic pharmacy, retail pharmacy, long-term care facility, etc.
3. The types of patients they care for and the assistance that is provided.
4. The level of engagement with caregivers and family members.
5. What has been their professional observation about the knowledge patients have regarding disease, medication needs, post-hospital rehabilitation plans?
6. What are educational deficits regarding healthcare of the clients they see?
7. Ideas on how to improve discharge teaching for the patient and caregivers.
8. Other questions or avenues of thought you wish to explore as the interviews progress.

Evaluation of the assignment uses a rubric that evaluates the content of the students’ presentations and responses looking for integration of module content and use of outside research in their analysis of the interviews and the developed interprofessional recommendations. The ability to connect concepts and ideas from the students’ learning and research with material drawn from the interviews is a key aspect of determining the successful outcome of the oral presentation.

Level of IPE Integration

  • 1. Foundations Level: Consists of introductory learning activities that provide learners with the opportunity to interact and learn from professionals and peers from disciplines beyond their own. The desired outcome for activities offered at this level is that learners will gain a deeper understanding of their profession while gaining an appreciation for the perspective and roles of other professions.

Attendance or Participation in the IPE Experience

  • Course requirement - NURS 4332

Frequency of the IPE Experience

  • 02. Semesterly
  • RN to BSN Program length is 2 semesters; admitting 3X/year. Students complete this assignment in the second semester in NURS 4332 Chronic Health Conditions: Optimizing Wellness.

Duration and/or Timeline of the IPE Experience

  • 03. 4 to 5 hours

Campus and/or Location of the IPE Experience

  • Distance Education

Average Number of Learners Participating in the IPE Experience

  • 03. 101 to 150
  • Depending on enrollment the number participating will vary each semester.

Target Audiences

Graduate School of Biomedical Sciences Audiences

School of Health Professions Audiences

School of Medicine Audiences

School of Nursing Audiences

  • RN to BSN

School of Pharmacy Audiences

School of Population and Public Health Audiences


Post-licensure registered nurses and social workers

IPE Learning Objectives for the Experience

Values and Ethics

  • VE05. Value the expertise of health professionals and its impacts on team functions and health outcomes.

Roles and Responsibilities

  • RR02. Collaborate with others within and outside of the health system to improve health outcomes.


  • C02. Use communication tools, techniques, and technologies to enhance team function, well-being, and health outcomes.
  • C04. Promote common understanding of shared goals.

Teams and Teamwork

  • TT02. Appreciate team members’ diverse experiences, expertise, cultures, positions, power, and roles towards improving team function.
  • TT06. Reflect on self and team performance to inform and improve team effectiveness.
  • TT08. Facilitate team coordination to achieve safe, effective care and health outcomes.

Type of Learner Assessment Administered

  • Knowledge assessment
  • Peer feedback
  • Oral Presentation with feedback from instructor and peers.

Formal Assessment Protocol used, if Applicable

Type of Program Evaluation Administered

  • Satisfaction survey results

Provide Details on the Potential Sustainability of the IPE Experience

  • Integrated into a course and/or experiential rotation requirements

Provide Dedicated Funding Sources:

  • No dedicated funding

Roles of Faculty/Staff in the IPE Experience:

  • Assessors of student learning
  • Instructors and/or preceptors

Additional Information About the IPE Experience, if Necessary

IPE Experience Organizer

  • School of Nursing

Contact Person(s) and Contact Information for the IPE Experience

Melinda Mitchell Jones, RN, MSN, JD