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 asks questions to make sure you receive the unique services your individual situation requires.  When a patient isn’t able to effectively communicate, family members are heavily relied upon for key information needed to help the patient feel comfortable and get as well as possible.  A broad spectrum of information about the patient is taken into consideration, from medical data such as diagnosis and prior level of function, to personal information such as likes and dislikes, religious preference, social and family support and personal history and interests.

Getting Started: The Care Plan Meeting

Every effort is made to schedule the Care Plan Meeting to accommodate the availability of the patient and family, to ensure that the patient and family participate in the development of the Care Plan to the fullest extent possible. Family members and/or the responsible party are encouraged to attend the meeting. The Care Plan Meeting is typically conducted within the 1 ^st or 2 ^nd week after admission.

The Care Plan Meeting involves the Interdisciplinary Care Team (IDCT) which includes, but is not limited to, the following professionals:

• 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 resident
• Director of Rehabilitation/ Rehabilitation Specialist/ Physical Therapist/ Occupational Therapist/ Speech Language Pathologist, as indicated
• Nursing Assistant responsible for resident

As an interested family member, this is your opportunity to get your questions and concerns answered, and we’re here to help. We understand what an anxious process this can be, so we take our time explaining the details of what your loved one’s care and stay with us will involve, how you can assist in their recovery, and what to expect along the way.

Once a plan is in place, frequent updates are given to involved parties to improve the plan of care and ease any concerns.

Get Well and Go Home:  The Discharge Plan

Discharge planning is initiated upon admission as the Care Plan is developed by the IDCT. Included in the discharge planning is the resident’s discharge outcome goal. The Discharge Plan provides a “road map” for returning the patient to their home and prior level of function, or to the highest level of function possible.

The discharge outcome goalis a reflection of the professional opinion of the team based on the initial evaluation, and is open for change based on the patient’s progress. The discharge outcome goal includes the following components:

• It will be developed with the resident and/or family goals in mind.
• It will include destination of the resident, sources of assistance available to the resident, level of assistance needed by the resident, adaptive equipment needed, and appropriate referral required.

Home Or Away, We’re Still Here to Help:  The Outpatient Care Plan

Our outpatient programs are designed so that our patients can return to our therapy clinic for continued therapy if needed. The same therapists they got to know during their stay with us can continue to follow up with the patient through outpatient therapy. Our therapy programs are also often involved in local Assisted Living Centers and Senior Centers to provide wellness classes, ongoing training and education, and health screenings.