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Shortly after admission, the interdisciplinary care team (ICT) will meet with participants and develop a plan of care. Each Discipline (Nursing, Physical, Speech & Occupational Therapy, Activities Coordinator, Program Director and Social Services) of the ICT reviews the participant’s history and asks questions to make sure we develop a plan of care that meets individual needs.
When a participant is not able to effectively communicate, family members or circles of support are heavily relied upon for key information needed to help develop an individualized care plan. A broad spectrum of information about the participant is taken into consideration, from medical history, prior level of functioning, to personal information such as likes and dislikes, social and family support and personal history and interest.
Once all critical information is reviewed our care team develops a plan of care that will include monitoring of participant’s health such as checking blood sugar for diabetic participants (ex. Blood pressure, weight monitoring, seizure monitoring). Plan of care can include physical, occupational or speech therapy for those who may benefit such as post stroke victims. All care plans will also include planned activities which will encourage socialization and provide for meaningful interactions with peers. Social workers will develop individual goals for each participant and monitor outcomes. Our nutritionist will also assess each participant’s diet and will recommend dietary changes if needed.
Participant’s progress or changes in health are constantly monitored and communicated with participant’s physician. Care plans are updated every 6 months, which include a review of goals and recommendation by all disciplines.