Wow Jaime~ What a great topic (and one that is near and dear to my heart LOL) The issue I am running into with increasing frequency is that staff/floor nurses are not involved in the process at all. This is evidenced by both lack of self involvement (ie not my job, call the case manager) and by lack of being invited- by said case manager- into the process. It is a common occurence in my area for the discharge to be a surprise to both the pt and his/her nurse that day. I represent an business not connected to the hospital where I am primarily based that provides/coordinates discharge to SNFs for rehab etc and often times I am the one that informs the pt they are leaving that day! And these are generally not short LOS I might add!

Didn't mean to highjack your thread and get off topic, so I will conclude with the thought that much more teamwork and interdisciplinariness (is that a word I just made up??) needs to occur. I have observed both a disconnect and a lack of communication that prevents positive outcomes.

DivaRN