Editing Management of Care (section)

== Interdisciplinary Collaboration ==

Effective teams share a mental model of the plan, communicate in a structured way, and have an explicit mechanism for any team member to stop the line when something is unsafe. The RN is most often the coordinator, because the RN is present continuously and holds the whole picture.

Common team members and what they contribute include the provider (diagnosis and orders), the pharmacist (drug interactions, dosing, reconciliation), the registered dietitian (nutrition and diet texture), physical therapy (mobility, strength, gait, and assistive devices), occupational therapy (activities of daily living and adaptive equipment), speech-language pathology (swallowing and communication), respiratory therapy (airway and ventilation), the social worker (psychosocial, financial, and placement resources), the case manager (coordination and utilization), the chaplain (spiritual care), and the wound, ostomy, and continence nurse.

'''Application note.''' A large family of examination items is answered simply by matching a patient need to the correct discipline. A patient who coughs while drinking thin liquids needs speech-language pathology, not a thickened-liquid order the nurse writes independently. A patient who cannot afford medications needs the social worker or case manager, not a lecture on adherence.