Our Care Team
The Care Manager coordinates patient health care services through a collaborative multi-disciplinary team approach. Care Managers ensure that the brain injury survivor’s plan of care promotes a safe and timely discharge, and they provide education and support for patients and families as well as hospital staff regarding community resources, managed care issues, or payment/payer issues. The Care Manager is the link between our patients and provider and payer organizations, physicians and the community in the transition of care throughout the healthcare continuum.
Discharge planning begins early during a patient’s inpatient stay. The Care Manager develops each patient’s discharge plan, including psychosocial, physical, educational and cultural considerations, and the plan is continually revised based on the patient’s response to treatment and their care team’s assessment.
At Gaylord, a physician leads the care team, and may be a specialist in Physical Medicine and Rehabilitation (Physiatry) or Internal Medicine. Since our patients with brain injuries have survived a very severe and, in many cases, life- threatening injury, continued management of any medical complications is essential and allows our patients to fully participate in a tailored rehabilitation program. The physician will assess and manage the ongoing health care needs of the brain injury survivor, including any pre-existing issues as well as new medical problems. The medical team may also include a physician’s assistant (PA) or a nurse practitioner (APRN), both of whom play key roles in managing the brain injury survivor’s ongoing health care needs.
A registered nurse ensures that each patient receives the optimal amount of nutrition and rest, administers medications and performs treatments that have been ordered by the physician. Our nurses also monitor patients to prevent or correct any physical problems that might occur, such as skin pressure areas, infection, deformities, bowel or bladder issues and excess weight, and physical, cognitive, social and emotional reactions are also observed and recorded.
Working with other members of the care team, rehabilitation nurses help our patients regain control of their lives and focus on assisting patients to build strength and skills so they gain more independence as discharge approaches.
Family involvement is an essential part of the patient’s recovery, and family members are encouraged to participate in learning how to help care for their loved one. Patient care techniques are taught in the therapy departments and on the nursing unit, and once learned, the family will be encouraged to help whenever they are present. Proper family training not only makes the transition from hospital to home easier but often can mean the difference between the patient being able to go home upon discharge or to another facility.
The role of the physical therapist (PT) is to assist brain injury survivors in attaining the highest level of mobility possible. The physical therapist will conduct an evaluation of movement comparing strength, sensation, tone and coordination, which often may be impacted following a brain injury. The therapist will also evaluate endurance, balance, and important mobility skills necessary for getting out of bed to walk, move from/to a bed or wheelchair (“transfer”), or use stairs. After a thorough evaluation, an individualized treatment program is developed.
Family education and training is an essential component to a brain injury survivor’s recovery, and family members may attend physical therapy sessions. If appropriate and the patient or family has set a goal for a discharge to home, family members will be trained to assist the patient with safe mobility in the home environment. Recommendations for necessary assistive equipment and continued therapy services will be made by the physical therapist prior to discharge. Wearing loose and comfortable clothing, including sneakers and pants (no skirts) is recommended for physical therapy.
The role of psychology for brain injury patients is to provide an evaluation of the patient’s emotional, personality, cognitive and behavioral functioning. In addition, a psychologist or neuropsychologist will assess the patient’s and family’s adjustment to the injury. Psychological treatment may include individual, family and/or group therapies to aid in adjustment issues and coping skills for the brain injury survivor and family members.
After discharge from the hospital, many brain injury survivors transition to our outpatient rehabilitation program. An assessment by a neuropsychologist or other clinician will be conducted to help guide coordinated treatment especially as brain injury survivors begin to resume their lives or seek additional services in their homes. Resource information is also provided to help the brain injury survivor reconnect with his/her community and bolster his/her support network.
The respiratory therapist (RT) plays a key role in the management of the brain injury patient. The RT will initially assess the patient’s respiratory needs, including oxygen, medication therapies, airway clearance modalities and airway interventions. The Respiratory Therapist works with members of the interdisciplinary team to ensure the patient begins walking as soon as appropriate because this activity aids in a quicker recovery and return to everyday activities. The RT staff will also provide education on breathing interventions to maintain optimal respiratory function.
If appropriate, brain injury survivors in the inpatient program are evaluated by a speech-language pathologist (SLP). As part of the patient’s care, an evaluation of swallowing, communication and/or cognition is conducted and an individualized treatment plan is developed. Goals are set by the patient, family members and therapist, and the care team assists each patient return to the highest level of function. Examples of speech therapy goals include: returning a patient to eating the least restrictive diet, using a speaking valve if a tracheostomy is in place, or remembering newly learned information. Treatment is provided in individual speech therapy sessions and group therapy if appropriate. Families are encouraged to participate in treatment sessions.
The role of the occupational therapist (OT) is to assist the patient in achieving the highest level of independence possible in activities of daily living (ADLs). This may include activities such as feeding, grooming, dressing, bathing, ability to get to and from the bathroom, and preparing meals. A brain injury may cause temporary or permanent weakness or paralysis on one side of the body, and patients may need to re-learn how to perform these activities with the use of one arm or leg, and to compensate for visual, perceptual, and cognitive or thinking deficits. The occupational therapist may recommend adaptive equipment or modify the environment to assist the brain injury survivor with their ability to perform these tasks more independently.
The occupational therapist also provides demonstrations and training to family members in the areas of self-care and mobility in preparation for a safe discharge home.
Food and Nutrition
As part of the care team, a registered dietitian (RD) may work closely with the speech-language pathologist (SLP) when a modified consistency diet is needed due to swallowing problems. A representative from the Food & Nutrition department meets with patients daily for individual menu selections.
The chaplain is a person with specialized training who has been authorized by a formal religious body to minister to brain injury survivors, families and staff in a healthcare setting. The goal of the chaplain is to help facilitate a person’s use of his/her own faith, belief system, religious experience, or heritage during a crisis. The chaplain can help provide religious resources, act as a helpful liaison with various religious bodies or communities, or assist the brain injury survivor and family to use faith and spiritual values to gain emotional support or spiritual strength.
Therapeutic recreation (TR), also called recreational therapy, uses leisure and recreation programs to improve a patient’s quality of life and to enhance independence. Therapeutic recreation helps to strengthen a patient’s abilities and physical, cognitive, social and emotional function. through participation in activities of interest to each patient, including board games, cards, Wii, video games, arts and crafts, iPad use, sports and community re-integration. Leisure education teaches or enhances recreation skills and attitudes that will be used throughout life. It can help patients discover new and exciting activities through interest exploration, and helps patients continue to participate in activities through the use of adaptive equipment.