What to Expect during your Post Acute Residential Rehabilitation stay

The Initial Evaluation & Assessment Phase: The first 7- 10 days will focus on getting to know each other, assessing the strengths and needs of the client, and crafting the singular plan that guides therapeutic efforts to help achieve your goals. Each client undergoes thorough evaluation:

• Medical Director completes a comprehensive history & physical.
• Nursing completes assessment and develops care plan.
• Physical Therapy (PT), Occupational Therapy (OT), and Speech Pathology (SLP) completes functional assessments.
• A behavioral baseline is developed based on behaviors recorded in ½ hour increments, 16 hours/day, capturing both desirable/functional behaviors and behaviors that put the client at risk or risk to others.
• The individual client Master Treatment Plan (MTP) is completed by Day 10. Incorporating the goals of the client, family, and payer source, the MTP becomes our working document that guides the team efforts and estimates a project length of stay.

The Structured Rehabilitation Phase: This phase, defined by highly structured and coordinated therapeutic activities, is the core of the rehabilitation process.

• Daily therapy schedule of 3-5 hours, a combination of skilled therapies, therapeutic activities, and volunteer work activities.
• Therapeutic schedule is 7 days a week.
• Therapeutic day is structured from awakening to bedtime, incorporating individual and group sessions, rest periods and recreational activities.
• Medication trials are closely monitored by the physician/pharmacology team in weekly Team Meetings to review progress including comparison to behavioral data to assess real time effectiveness of the overall treatment plan. Changes in medication and/or treatment program occurs based on success in achieving the desired changes in cognition, function, and behavior.
• Neuropsychological Screen and/or Comprehensive Evaluations are completed as appropriate
• Family Education is emphasized including Team Conferences with stakeholders.

Transition & Discharge Planning: As the Structured Rehabilitation phase progresses and desired improvements emerge and stabilize, the discharge plan becomes more defined: where, how much supervision will be needed, who will provide the support and structure needed following discharge, and what community resources and productive activities will be available to sustain functional gains and promote optimum community integration. The last few weeks you can expect:

• Increased frequency of family education and counseling
• Implementation of progressive therapeutic trial home visits, supervised and unsupervised
• Home and community assessments
• Referrals to essential support services and community resources including volunteer/work in the community of your choice, critical to a sustainable, successful discharge.