Over time, the IPCCs developed a key role in decision-making about patients, including using information gathered to make independent decisions. This role was not reflected in the original job description.
For instance, the observation data demonstrate that IPCCs identified patients in accident and emergency or on the ward early in admission who were perceived likely to benefit from their input. They selected patients using a combination of pre-determined criteria (for example, patient has had a stroke, patient is over 65) and/or following a request from interprofessional team colleagues. The IPCC would then usually consult the patient’s nursing and/or medical documentation, and
may supplement this by questioning the patient and/or their family. These sources were used by the IPCC to gather information on the patient’s living situation, clinical problems, investigation needs and any likely discharge delays. These practices, commonly reflected in the observation data, illustrate how IPCCs often selected patients for their input independently from referrals from interprofessional colleagues and decided on the depth and scope of initial assessment they
performed.
The observation data reflect that the IPCC would then decide, often independently (but at other times, in consultation with an interprofessional colleague), what (if any) input the patient needed that related to the patient’s discharge from the
service. If such input was required, the IPCC immediately tried to enable this input at an early stage. This frequent interpretation of the information gathered and independent decision-making are not reflected in the IPCC job description. The following field note extracts give a flavour of the type of information that the IPCCs gathered and how it was then deployed:
IPCC2 told social worker patient was very short of breath, sisters think he’s not coping, lives alone, by the sound of the sisters doesn’t do a lot. Patient agreed he may need help with cleaning and that. ‘Speak to him and see how you feel’. (Field note extract, 13089:85-94)
IPCC3 to physiotherapist: He tells me he’s coping okay but I’m worried about his falls. Could you have a look at him, see what you think and I’ll do an [occupational therapy] referral as well (Field note extract, 19089: 120-129)
IPCC2 to social worker: She’s very sweet. She’s all there. She’s worried about managing on her own at home with the falls she’s been having and the thought of maybe going into a home has been in her mind. She hasn’t been eating for a month and maybe, once she’s eaten something to get her strength up and maybe she gets better, she could go home with support. But perhaps you could go and have a chat with her (Field note extract, 13089: 3-10)
Study observations also reflect that, once patients have been selected, the IPCC then retained a central role in discharge co-ordination by regularly visiting the wards to liaise with the interprofessional team members involved in that patient’s care. Liaison included gathering information, sharing information, discussion and joint decision making. It is clear from interviews and focus groups with the IPCCs’ interprofessional colleagues that they viewed the IPCCs as central in knowing and
co-ordinating what was going on for individual patients. This was viewed as a change in practice from using nurses as the source for this sort of information.
If a social worker is asking what’s happening, I can phone [the IPCC] and ask and she can tell me because she knows what’s happening to each individual (Doctor, 15020F, FG)
Although [the IPCCs] have a big caseload, they used to amaze me if I’d ask that someone who’d been in like 6 years ago, they’d know all the out- patients appointment and all this sort of family history and brothers and all the rest of it. And, importantly, very sort of aware of the individual. (Social worker, 15049, Int)
I have to say that if I wanted to know if someone had been referred to OT, I don’t go to the nurse anymore because the nurse often says ‘I don’t know’ or ‘I’ll go and check in the Kardex24’ in which case [the IPCC] has probably written in the Kardex anyway’. (Physiotherapist, 15020F, FG) For the co-ordination role, the link with the ward, [the IPCC] has her finger on the pulse with regard to the detail of what’s going on regarding the patient’s treatment, etc. (Social worker, 13128, Int)
Observation data and participant accounts also reflect other aspects of practice and decision-making that were independent of other team members. For example, ward visits by IPCCs were used to check the medical and/or nursing documentation for accounts of patient progress and to talk to patients and/or their family to gather more information or provide information on plans made.
Wednesday afternoon: Onto admissions ward for IPCC to go through Kardex of all patients to see if any input required. A name came up which IPCC recognised – has had previous involvement but can’t recall exactly what. She will check on another new patient who is 75 with unstable angina, lives with her husband, not sure if she has social services or not. Asked ward manager about this patient who said ‘she’s fine’. IPCC: ‘does she need anything? No OT or anything?’. Ward manager: ‘no’. Checking ward’s book against own patient list to see where patients who were on admissions ward have moved to. Asked ward clerk about a patient and what input he had last time. Ward manager checked that another patient had been referred to IPCCs. IPCC went to see patient but she was asleep so IPCC told staff nurse she wanted to see patient later. (Field note extract, 18089: 270-96)
If I go to speak to a patient I’ll try to tell them exactly what I do, I’m not a social worker but I can help to refer you to one. Little things like often patients come in and they’ve not collected their benefit or they’ve not paid their rent and they are really worried that they haven’t paid their rent. So rather than get a social worker involved to do anything, we will phone up
the housing people to tell them that this patient is in and can you make a note of the reason that he hasn’t been down to pay his rent, he is really worried about it. (IPCC, 08128, Int)
These findings provide more detail of the IPCC role in actual practice, and illustrate the central role that IPCCs now played in decision-making in the team, and the extent to which they operated and made decisions independently of other team members. This independent level of functioning was not reflected in the original job description.