Team conference and discharge planning

Part of your rehabilitation program involves a weekly conference in which your doctor, therapists, psychologist, social worker, nurse case manager, and nurse representative get together to discuss goals and the progress necessary for you to return home. Your physician will communicate your progress and the social worker or case manager will keep you informed of your discharge date and anticipated services you will need at home. If at any time you have questions or concerns, please do not hesitate to speak with members of your team.

Physiatry follow up

In addition to following up with your primary care provider, your physiatrist (doctor in the rehabilitation unit) may want to follow up with your care after your discharge. The physiatrist will determine what is needed for your condition and will make the appropriate recommendations. You will be informed of your follow-up care appointments at the time of discharge.

Medical equipment and discharge follow up care

As part of your discharge plan, the social worker and/or RN case manager will order any medical equipment that is recommended by your physician and rehabilitation team. The social worker or case manager will arrange for the equipment and services by contacting the appropriate providers and will work with vendors to provide the right equipment and follow-up care based on your insurance coverage. The RN case manager will schedule follow-up appointments. If you or your family have any questions or preferences about the equipment or followup care, please discuss them with the social worker and case manager.