1. Lucas, Michelle A. BSN, RN-BC

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One of the many items that the Outcome and Assessment Information Set (OASIS) has us ask patients at the start of care is, "What are your goals during this time of home care?" Most patients want to be independent again, be able to walk without a walker, or be able to drive themselves to their appointments. With these goals in mind, the home healthcare team jumps into action. Patient success is a team effort. But how does the home healthcare team work together when we often don't see each other? As a home healthcare nurse, I know my efforts to stabilize patients medically are only one piece of the puzzle. Although I am working to stabilize a patient's heart failure symptoms of dyspnea and lower extremity edema, physical therapy is working to increase their muscle strength, range of motion, and endurance. At the same time, occupational therapy is working to help the patient complete activities of daily living efficiently and safely. The social worker has set up Meals on Wheels along with transportation to medical appointments. As we each play our role, communication through the electronic medical record, emails, and phone calls is extremely important. We each must communicate the patient's progress, any concerns we have, and any other important updates about our patients to be successful. Without realizing it, we are practicing the multidisciplinary approach.


After decades of healthcare disciplines operating in silos, the multidisciplinary approach has encouraged health disciplines to work together harmoniously. According to VanderVeen (2020), the multidisciplinary approach in healthcare increases the success of long-term care and decreases the chances of rehospitalization. Like a team sport, when all components of the multidisciplinary team are working together toward a successful patient outcome, the effect is a "well-oiled machine" (Barkway & O'Kane, 2019).


As a registered nurse, I am usually the first point of contact with a new patient when they are discharged from the hospital or rehabilitation facility. They are often tired and overwhelmed during this first visit. Many times, they will be resistant to having so many people come to see them during the week. The thought of nurses, aides, therapists, and social workers visiting several times a day/week sounds exhausting to them after their in-patient stay. This is my opportunity to sing the praises of our team and why each discipline is important! Many patients do not realize how home healthcare specialties can be tailored to each patient's unique needs. It is important to explain how each discipline brings important and unique knowledge and skills to help patients reach their goals quickly. After the first visit of each discipline, their fears are calmed, and they are on board with the plan of care.


The end "product" is a patient who feels stronger, healthier, and more confident in their ability to be independent. I often feel as proud as a parent at their child's graduation while watching my homebound patient take those "steps" toward discharge and independence. And I know that it truly was a team effort from all of us. As the saying goes-"it takes a village." I am privileged to work with such a talented and committed "village" whose collective goals are quality patient outcomes. The multidisciplinary approach to home care allows all of us to be successful.




Barkway P., O'Kane D. (2019). Communication in healthcare practice. In Psychology: An Introduction for Health Professionals. Elsevier Health Sciences. [Context Link]


VanderVeen S. K. (2020). The transition from hospital to home for a patient with bronchopulmonary dysplasia: A multidisciplinary approach. Pediatric Nursing, 46(4), 184-188. [Context Link]