Patient Education Resource Center: Journey Home

Welcome to our care center. Your goal is to return to the most optimal condition that you are capable of achieving. We can help you on your “Journey Home”, wherever this journey may be for you, independent living, assisted living, or a skilled-nursing center. Our objective is to help you obtain your own personal goals with the guidance of your physician’s care plan for you.

(From Interact III© program, 2011, Florida Atlantic University)

Nursing home residents are prone to many complications of care in a hospital. These complications may occur even in the best hospitals, because older age, chronic medical problems and the condition that caused the transfer all combine with the hospital environment to put nursing home residents at high risk for complications. These complications include:

• New or worsening condition
• More time spent in bed, which can increase the risk of:
• blood clots
• pressure ulcers
• muscle weakness
• loss of function and other complications
• Less sleep and rest due to tests, monitoring and noise increased risk for:
• Falls with injuries, such as cuts, bruises and broken bones
• New infections
• Depression due to limited opportunities to socialize with friends and family as well as being in an unfamiliar environment

There are many symptoms and conditions that usually require treatment in the hospital. For example, if vital signs are very abnormal (temperature, heart rate or breathing rate), or if symptoms are severe and can’t be controlled (such as pain or vomiting). Hospital care offers benefit in these situations, including:

• Ready availability of sophisticated lab tests, X-rays, and scans
• Access to doctors and specialists who are in the hospital every day
• Availability of surgery and other procedures if needed
• Intensive care units for people who are critically ill

There are benefits of staying in the nursing home when a new symptom or condition occurs assuming it is safe to treat the condition in the nursing home and staying in the nursing home is consistent with the preferences of the resident and his or her family. Treatment in the nursing home allows the resident to:

• Receive lab tests, x-rays and other tests that your physician orders
• On-call physicians available 24 hours a day, availability of visiting physicians and specialists
• Have continuity of care – This means that residents continue to receive care from staff members who know them, and who are able to respond to their individual preferences and needs
• Remain in a familiar environment with their personal possessions, and keep their individual routines as much as possible
• Avoid what is often an uncomfortable trip to the hospital with long delays waiting in the emergency room
• Avoid potential problems due to miscommunication between the hospital and nursing home
• Avoid other hospital related complications

Medical Oversight

There is a physician that is assigned to you who will be visiting, as well as remotely following your progress and changing your medication and treatment orders based on your needs. Nurses are available 24 hours a day/7 days a week to monitor for a change in your condition. Should you experience a condition change they will assess what is going on. They will communicate their findings to the Primary Care Provider, to ascertain what change is occurring and to receive new orders for care.

Stop And Watch Program

Our staff has been taught to “STOP & WATCH©”. This is a tool designed to help those caring for residents to report a change in condition. A staff member would circle the differences observed and give the tool to a nurse. Each letter in this tool stands for a condition change. For example “S” signifies “Seems different than usual”, “T” denotes “Talks or Communicates less than usual” and so on, all the way through the “H” at the end of Watch” which represents “Help with walking, transferring, toileting more than usual.” Please ask how you and your loved ones can participate in this program.

Management Team

Our managers are each assigned an area to do daily rounds and report any issues or concerns with the residents in their area as well as the environment. They are also instructed on the “STOP & WATCH©” tool.

You and/or Your Loved Ones

If able, let a staff member know when you feel bad before it gets worse. Many people are reluctant to bother staff, embarrassed or stoic in nature. NOBODY knows you better than you or your loved ones! Encourage your friends and family to report any changes they see even if they are “minor”. If you are a loved one and “something doesn’t seem right” please alert a nurse as well. It may be nothing, or it may be the beginning of a change of condition. Our clinical staff cannot address situations that we are unaware of. YOU are an invaluable part of our team. Permit our center the opportunity to care for your needs by following your Primary Care Provider’s prescription and the Healthcare Team’s recommendations. Please ask about our INTERACT program and how you and your loved ones can benefit and be involved in your care.

Professional Clinical Staff

Nurses strive to carry out all the orders from your Primary Care Provider competently, efficiently and effectively. The nurses may monitor your vital signs, lab reports, x-ray reports, evaluate your condition, provide medications that may be administered orally, injection or IV, and watch for side effects of any drug prescribed. Our nurses stay in contact with your healthcare provider to update them of your condition as required. They strive to be helpful, and to render care using their heart and hands.

State Certified Nursing Assistants (CNAs)

We consider the CNA’s at our care centers, our Ambassadors of Care. With pride, our care centers hire and sustain the employment of Certified Nursing Aides to provide assistance with your activities of daily living and comfort for you and your loved ones. Each nursing assistant works to assist the residents at our center with compassion, honesty, respect, integrity and passion.

Other

We have a Registered Dietician on staff to assist with any nutritional needs, a consultant pharmacist to review medications for safety and appropriateness, physical, occupational and speech therapists to provide rehabilitative services, as well as consulting physicians, nurse practitioners, specialists and psychological services where available. We also have 24 hour outside lab and pharmacy, as well as daily x-ray, ultrasound, EKG and admission.