Team conference and discharge planning
Part of your rehabilitation program involves a weekly conference in which your doctor, therapists, psychologist, discharge planner, nurse case manager and nurse representative get together to discuss goals and the progress necessary for you to return home. Your rehabilitation team and physician will communicate your progress and the discharge planner 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.
Medical equipment and discharge follow up care
As part of your discharge plan, the social services specialist and/or RN case manager will order any medical equipment that is recommended by your physician and rehabilitation team. The social services specialist 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 attempt to schedule follow-up appointments. If you or your family have any questions or preferences about the equipment or follow-up care, please discuss them with the social services specialist and case manager.
Home evaluations
We offer in home evaluations on a case by case basis for local patients. We are unable to offer transportation, so your family, friend, or caregiver will need to provide transportation to and from the hospital. If required, you will receive assistance to get in and out of the vehicle. During the home evaluation we will see how you will be able to function in your home at discharge. It also helps us to make appropriate equipment and home modification recommendations.