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Our services include post-hospital transitional and rehabilitation care, sub-acute
ventilator care, and long-term residential/custodial care. Patients receive coordinated
care from a interdisciplinary team of healthcare professionals, including physicians,
nurses with advanced clinical skills, physical, speech, respiratory and occupational
therapists, case managers and other support staff. Together, they provide the expert
care necessary to meet complex medical, emotional and psychosocial needs of
the patient.
The therapists who make up our Transitional Care Rehabilitation Team are a caring
group of professionals from many different health disciplines. Care is coordinated
by a case manager, under the direction of a physician. The therapeutic team develops
a personalized treatment plan for each patient, based on individual needs and conditions.
Patients are periodically evaluated against established goals to assess progress.
Family involvement is encouraged.
Rehabilitation team members include:
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Rehabilitation Physician – Leads the interdisciplinary team. The rehabilitation
physician sees patients several times a week and coordinates weekly team and family
conferences.
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Nurse Practitioner – Assists patients in achieving their individual maximum result.
The nurse practitioner is present during the day and serves as an extension of the
physician in meeting the patient’s medical needs and assisting the therapeutic
staff.
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Case Manager/Discharge Planner – Coordinates admission and discharge planning, and
serves as the liaison between the patient, therapeutic team and family. The case manager
is also available to assist in addressing health insurance-related issues. The discharge
planner helps the family with the transition of the patient to home and arranges for home
health services when needed.
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Rehabilitation Therapy Team – Includes physical therapists, occupational therapists,
and speech and language therapists, as well as other professionals skilled in neurological
and orthopedic rehabilitation.
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Rehabilitation Nursing Staff – An integral part of the team. Their skills include
expertise in skin care, bowel and bladder programs and the prevention and treatment of
disability-related complications, in addition to a comprehensive range of general
medical/surgical skills.
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Rehabilitation Professionals – Includes program directors, pharmacists, dietitians,
social workers, psychologists and other support staff.
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