For the Family: The Initial Care Plan is Family-Tailored So YOU Can Make a Difference
Shortly after admission to our facility, the Interdisciplinary Care Team (IDCT) will meet with you and your family members to develop a Care Plan. Each discipline (Nursing, Therapy, Nutrition, Activities, Social Service) of the IDCT will be present at this meeting to make sure you receive the unique services your individual situation requires. A broad spectrum of information is taken into consideration: medical data (diagnosis and prior level of function); personal information (likes and dislikes, religious preferences, social and family support); personal history and interests. In instances when a patient isn’t able to communicate effectively, family members are relied-upon for key information.
Getting Started: The Care Plan Meeting
Our objective is to have the patient and family participate in the development of the Care Plan to the fullest extent.
The Care Plan meeting is typically conducted within the first or second week after admission, and involves:
- The Attending Physician
- Registered Nurse/Nurse Representative/Director of Nursing
- Dietary Services Supervisor/Registered Dietician
- Director of Social Services/Social Worker/Social Services staff responsible for the resident
- Activity Director/Activity staff responsible for the resident
- Director of Rehabilitation/Rehabilitation Specialist/Physical Therapist/Occupational Therapist/Speech Language Pathologist, as needed
- Nursing Assistant responsible for the resident
As a concerned family member, this meeting is an opportunity to get your questions answered. We understand what a worrisome process this can be, so we carefully explain the details of what to expect during your loved one’s stay with us, and how you can assist in their recovery.
Frequent updates on progress, improvements or adjustments in the Plan of Care are always given, to keep families well-informed and free from concern.
Get Well and Go Home: The Discharge Plan
Discharge planning is initiated once the Care Plan is developed by the IDCT.
The Discharge Plan provides a “road map” for bringing a resident home, functioning at the highest level possible. Included in the discharge planning is the resident’s Discharge Outcome Goal.
The Discharge Outcome Goal is based upon the professional opinions of the IDCT during their initial evaluation, and is always open for necessary changes indicated by a patient’s progress. It will be developed with resident and/or family objectives in mind: destination of the resident, sources of assistance available, level of needed assistance, any adaptive equipment necessary, and appropriate required referrals.
Home or Away, We’re Still Here to Help: The Outpatient Care Plan
Outpatient programs are designed for patients who can return to our clinic for continued therapy. Our Outpatient Therapists are usually the same therapists the patient became familiar with during their stay with us, so follow-up is most-effective.
Additionally, our Therapy programs often involve local Assisted Living Centers and Senior Centers, providing wellness classes, ongoing training and education, and health screenings.