It’s time for you to get the care you need, and when you’re in our hands, you can rest assured that you’re getting the best there is. We strive every day to be the skilled nursing facility of choice in our community, so we make sure that each day you spend with us is filled with the caliber of service that will make your stay comfortable, safe and therapeutic. The entire staff will know you by name, and each day when we greet you, we’ll ask you how you are, and whether there is anything we can do for you. We never forget that you’re our valued guest, and the reason we’re here! And remember, if you have a special request, please don’t hesitate to ask. That’s why we’re here – for you!
Upland Rehabilitation & Care Center
The Care Plan
For the Family: Tailored So YOU Can Make a Difference!
Shortly after admission to our facility, the Interdisciplinary Care Team (IDCT) will meet with each patient and their family members to develop a Care Plan. Each discipline (Nursing, Therapy, Nutrition, Activities, Social Service) of the IDCT asks questions to make sure the patient receives the unique services each 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, get well, and gain self-sufficiency. 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, personal history, and interests.
Getting Started: The Care Plan Meeting
Every effort is made to accommodate the availability of the patient and family in the scheduling of the Care Plan Meeting and 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 1st or 2nd week after admission by a member of our social services team.
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 a great opportunity to get questions and concerns answered and we’re always here to help. We understand what an anxious process this can be so we take our time explaining the details of what a loved one’s care and stay with us will involve, how family can assist in the recovery process, 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 patient’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 goal is 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 patient and/or family goals in mind.
- It will include destination of the patient, sources of assistance available, level of assistance needed, adaptive equipment needed, and appropriate referral required.
- It will include a copy of the discharge care plan.