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A model for interdisciplinary discharge planning in a university hospital.

This paper presents a model for an interdisciplinary discharge planning team, with emphasis on functional status and improved coordination and continuity among providers, along with a description of the design and implementation of such a program in a university hospital. Results show that more patients are discussed and served, with more emphasis on the functional ability of patients, in an interdisciplinary versus traditional setting. Communication and education between house staff and team members increased substantially with this approach.