PREPARING FOR YOUR STAY
What to Expect
Entering a nursing and rehabilitation center or placing a loved one in a center can be a difficult decision. There are many things to consider. Our goal is to help you understand our admissions process and assist you in setting expectations for the stay.
During the Stay
Our Executive Director is the leader of the nursing and rehabilitation center and is responsible for all oversight. He or she will meet with you during the initial admissions time frame and periodically thereafter. We encourage you to share your comments with our Executive Director or any other staff member.
Our Director of Nursing Services is the leader of our clinical team. Please share any concerns you have about your clinical needs. Thank you for the confidence you have placed in Concordia Care to manage your medical care. Each member of our team is available to answer your questions and hear your comments.
The Admissions Process
Our Admissions Team will meet with you or your caregiver prior to or during the admissions process to gather important information. It is imperative that we obtain several important documents from you to help us develop your clinical plan and to ensure proper billing.
Please provide the following prior to or during the admissions process:
- Medicare card
- Medicaid card
- Managed care or insurance card
- Social Security card
- Medicare Part D (drug benefit) card
- Advance directives, living will, etc. (if applicable)
- Clinical and/or financial Power of Attorney documents
- Long-term care/supplemental insurance policies
- Name of person to be contacted with change in condition/financial status
Our admissions personnel will review all state and federally required documents and provide you with a copy. They will also explain programs and services provided in our nursing and rehabilitation center and answer any questions.
You may also meet with a member of our business office to review any financial matters and ask questions. We will need to know where you have resided for the calendar year.
We will work with you to get to the highest level of functioning possible.
The Clinical Admissions Process
A member of our Clinical Nursing Team will meet with you or your caregiver soon after you are settled to gather clinical information, perform a clinical evaluation and orient you to our nursing and rehabilitation center.
The Admitting Nurse will ask you a number of clinical questions about your diagnoses, medications, hospital stay, activity level, etc. You will also be assessed from head to toe to note any conditions that may need to be addressed during the stay. This may occur regularly depending on the condition. You or your loved one will be asked about bathing preferences and a convenient schedule will be arranged for you. Also, you will be weighed periodically to maintain your weight record.
Clinical interventions are focused on the special needs of our patients and are designed to promote a safe and timely discharge. Members of the interdisciplinary team will meet with you or your loved one within the first week of your stay. The team includes the Case Management Coordinator, Activities Director, Rehabilitation Coordinator, Registered Dietitian and Social Services Director. They will collect important information about your diagnoses, clinical and psycho-social needs, lifestyle and discharge plans.
The Case Management Coordinator will review your current clinical status, explain aspects of the medical recovery process, develop timelines for recovery and serve as your Medicare/insurance expert. Communication guidelines will be outlined to update the progress made toward goals as well as any effect this may have in discharge plans. Particular attention will be given to explaining acuity associated with your medical condition. The Case Management Coordinator will meet with you in the first few days of your stay, in which we will review your clinical and psycho-social needs and determine a plan of care. We will also schedule a care planning meeting approximately 14 days after admission to update your progress and discuss goals.
During the initial days of your stay the Case Management Coordinator and members of the Interdisciplinary Team will ask you or your caregiver to think of things that need to be accomplished during the stay to achieve discharge goals. For example, you may have to walk up steps or be able to independently transfer from a wheelchair to a chair. You will be provided with a guide to help you make these decisions, and your treatment plan will address these goals.
The Rehabilitation Coordinator is a therapist or therapy assistant (physical therapist, occupational therapist or speech-language therapist). The Coordinator will review the rehab interventions that apply to the medical condition and recovery timelines. Particular attention will include a focus on the functional recovery process as it relates to the medical diagnosis.
The Social Services Director will gather lifestyle information and develop a plan of care to address any psycho-social issues that may affect a safe discharge. They will also determine and help arrange any services that may be needed upon discharge.
The Activities Director will review any preferences to incorporate leisure activities into the medical recovery plan.
A Registered Dietitian will compile medical information related to the admitting diagnoses and develop a plan of care to address the impact your nutritional needs may have on the recovery process.
Choice of Provider of Professional Services
For your convenience, the center may arrange providers of professional services, or you may wish to select your own providers. If you do so, please remember to bring their names, addresses and telephone numbers with you on the day of admission, if you haven’t already provided this information. We request that these providers of professional services comply with all applicable rules and regulations.
- Physician – one who is available to visit you at the center as required by licensure/certification
- Alternate physician
- Funeral home
- County caseworker
- Church/clergy name
We encourage you to bring personal items from home as space allows. As with all personal belongings, these items should be labeled with your name. Any electrical product – such as lights, TVs, and radios – must be checked and approved for use by our Maintenance Department.
Planning for the Stay
Since most of our patients participate in rehabilitation activities, we recommend that you bring about a week’s worth of comfortable clothing and shoes that are suitable for rehabilitation activities. Some people change clothing throughout the day, so you should plan for this as well. All clothing should be marked with labels written or printed in indelible ink and sewn to the garment.
The following is a suggested list of clothing to bring:
- dresses, slacks, shirts or blouses
- undergarments, undershirts and shorts
- comfortable shoes
- socks or hose
- pajamas and robe
- coat, hat and scarf (seasonal)