I would suggest weekly plan of care meetings and it’s best to involve the patient or family. We call it interdisciplinary plan of care. I hope this helps.
We huddled twice a day with therapy, nursing, doctor and a few other disciplines. We made sure we kept it short and sweet but it definitely improved communication with everyone involved in patient care and coordination of discharge.
We did utilize a white board in the room and also had communication options (Skype or teams) to communicate in real time with those assigned to the patient.
Something different with inpatient rehab is the meetings at least 3 or 4 days a week with nursing, provider, therapy and case management. This is done with frontline staff to talk about medical issues, meeting goals for discharge and any barriers to discharge. This can be done through walking rounds with the team or a conference room. It does keep everyone up to speed on patient status and progress.
A couple of ways we made certain communication was consistent. We had a communication form for therapy specifically. You would write any requests, new orders or change of condition on the form and put it in their mailbox. You would keep a copy until you received their response whether it was picking them up for therapy, recommendation for a new cushion etc.
We also had pressure ulcer prevention (PUP)rounds. On a unit of 40 residents you would take 10 residents a week and round on those residents with dietician,someone from therapy, the nurse and aide. It took maybe 15 minutes total for all 10. You talk about the resident ie weight loss, change in transfers, skin issues and look at all equipment to be sure everything was in good repair. If there were suggestions you would put that on the PUP sheet and make those changes on the care plan after rounding. Every month each resident is rounded on at least once.
I worked on an end stage dementia unit with all 2 assists and after PUP rounds were implemented we had zero pressure ulcers two months later and remained at zero for facility acquired for 11 months.
Hope that helps!
In a rehab program, the health team consist of the Patients (and families), the Rehab Physicians, the nurses, the PT/OT/ST. Once the care plan is put is in place by the team, the team members must communicate with each other to ensure that the care plan is being followed, if not, how the care plan can be modified. Then, evaluate during care team rounds to help the patients meet their discharge goals in a timely manner.
Don’t be afraid to speak up and seek them out. Usually once they know you are invested and involved they will start coming to you, letting you know how the patient is doing.
make sure you have an office phone ready to go and for nursing be on top of your chart information your qualified for when its not bedside physical teamwork of caregiving skills qualifications.
Having worked for Moss Rehab for 10 years, I can say open communication between all the care givers is top. Beside care conference, you may need to email therapy about something going on with your patient especially if you work a off shift. If you see a need they are not aware of pass it on in shift report and email therapy. Shift report took me longer than any other job I had because acute care rehab usually has patients with a long medical history in the hospital and anyone new needs to know where they are coming from and if they have a supportive family.
Every Tuesday were Medical team rounds with the Attending Doctor, and one or two residents, which we got 2 new ones every July, Nursing, PT, OT, Speech,Psychology, Case management, Social worker, and a rep from Brain and Spine of Florida. We the team one by one discussed each patient case of their progress, their families progress with teaching and participation, their strengths and weaknesses and how the team might better respond or collectively focus on what would help the patient or family. This made us better as we listened and spoke to each specialty identifying with each case, learning not only about the patient and family member but each other. We grew closer and over the years developed into a world class rehabilitation facility. We made special rooms for family members to come and stay to learn the care, we sent the patients out on day pass to go and be integrated back into their homes and society. We sent them with therapists and other volunteers to swim with dolphins, and go sailing. We taught and carefully shared with family and even friends how to transfer, do cathing, trach care, suctioning and bagging. How to position and carefully feed, dress, explained the purpose of the Ted hose and the abdominal binders. We printed medication teaching, and demonstrated the showering and bowel programs. We gave the weekend meds and encouraged documentation of urine etc. We allowed the family to come to class to intermingle with the other patients and made parties all year round, at Christmas, Thanksgiving, Halloween, The 4th of July. We the team picked names and exchanged gifts, as patients fro years before were contacted and invited to come back to the party for a gift. I said all that to say how we listened to the patients and each other on the team to make it a special place, a place that restored the patients sense of having a future and to be able to respond to them as one man, all for one and one for all. We found a job that made us fall in love with coming to work and even to the inclusion of their families where they were inspired to care for their injured back home the way we were doing it here. I loved discharging them to their family with all their belongings their discharge instructions knowing we did our best and that they would be back hopefully for the next party!
If you work night shift, it is difficult to find out how a patient is doing in the therapies. I must make additional time to read their notes ( if possible at your hospital).