Interdisciplinary Team Assessment
Once you are accepted into the Rehabilitation Center, an Interdisciplinary Team Assessment (ITA) takes place within the first 48 hours of your arrival. During the ITA, you and your family are asked to identify goals for your individualized rehabilitation program. Following the ITA, the team meets about your patient focused plan of care and to determine an estimated length of stay. The plan of care will be reviewed and updated regularly, as part of the staff inpatient team conferences.
Therapy days are designed to closely follow what you can expect once you return home. For some, the morning routine will be similar to life at home, and for others it will be very different. Therapy may occur in your room, in one of our many gyms, or out in the community. Your family is expected to participate in your therapy and learn how to assist you as needed. You will learn how to train your family and caregivers in various aspects of your care.
Our staff will help you organize how you will care for yourself, including activities like showering, grooming, dressing, eating, and going to the toilet. Staff will make sure you understand your medications and dosages. You will also be assigned a primary nurse for the day, in addition to the nurse who oversees your entire stay.
You will also have a primary Occupational and Physical Therapists, and in some cases a Speech Pathologist, who will design a program just for you. You will also be seen by therapy assistants and other therapists who will know your specific goals.
You will be expected to attend the educational classes that apply to your individual situation. Towards the end of your stay you may be involved in the Transition to Home Program (TTH) which allows you and your family to practice all the skills that are required to make a safe transition to home.
Our entire team is available to answer any questions as they come up. Your full participation in your rehabilitation program will help you reach your goals and develop the skill you will need to live as independently as possible.
REHABILITATION TEAM ROLES
You - The Patient
- The most important member of the team
- Participates in treatment activities
- Communicates goals to the team
Family and Friends
- Participate in education process
- Provide emotional support
- Learn caregiver role Physician
- A physiatrist is a doctor who specializes in Physical Medicine and Rehabilitation.
- The physiatrist directs and coordinates your overall rehabilitation program and medical care.
- Two physicians may be part of the team. There will be an attending physician (board certified physiatrist) and usually a resident (MD training to be specialized in Physical Medicine and Rehabilitation).
Registered Nurse (RN)
- Monitors your care and condition 24 hours a day
- Helps you practice what you have learned
- Provides educational opportunities for you and your family on a continual basis
- Monitors and administers medications
- Provides medical treatment as ordered by your physician
Physical Therapist (PT)
- Helps you strengthen your muscles and use them for daily activities
- Helps you with problems such as stiff muscles and joints
- Teaches you breathing exercises
- Helps you build stamina and strength
Occupational Therapist (OT)
- Teaches you how to use your body to perform activities of daily living such as dressing, eating, showering and going to the toilet
- Assists with ordering equipment such as a wheelchair, bath equipment and other adaptive devices
- Assesses your home, work and school situations and suggests modifications that will make living and working easier Recreational Therapist
- Plans activities and outings that help build up stamina and strength
- Provides you with the opportunity to re-learn swimming skills
- Gives you information on adaptive sports and leisure activities
- Provides opportunities for outings into the community
Respiratory Care Practitioner ( RCP)
- Assesses respiratory problems
- Provides treatments to keep your lungs clear
- Assesses the need for respiratory equipment
- Provides assistance in gaining independence from the ventilator
Speech and Language Pathologist
- Helps you learn how to swallow safely and perform exercises that strengthen the muscles involved in eating
- Develops your individualized program to help with memory, speech, reading, writing, listening, thinking and eating
- Helps you and your family learn ways to live with your condition
- Gives you and your family members emotional support
- Facilitates peer support group with peer counselors
- Facilitates adjustment to behavioral changes with specific plans
- Assesses your nutrition needs
- Gives you and your family members emotional support
- If necessary, will help you with specific dietary needs
Case Manager/Patient Out come Coordinators
- Acts as a link between the team and insurance company
- Assists you with discharge planning
- Assist with orientation to Rehab stay and provides ongoing emotional support to you and your family.
- Assist with barriers to your discharge home.
- Provide resources for applying for financial assistance.
- Provides resource information to access transportation and other community resource in your home County.
Interdisciplinary Team Assessment
A Case Manager will oversee your stay and work one-on-one with you to help you transition from the hospital to the next setting. Your Case Manager gathers essential information from your interdisciplinary team and presents this to insurance companies. This information may include things like the patient status and level of performance.
Collecting this information is primarily done by the case manager and used to help justify your length of stay. The main goal of the Case Manager is to look into and arrange for follow up services, and to help you identify available community resources. Follow up services include making a referral to an outside medical provider, sending the provider the information needed to assist in your care, and helping you make a follow-up appointment. If you need supplies or equipment when you leave the hospital, we will work with a vendor who can then contact your insurance company and make arrangements based on our recommendations.
Before you leave the hospital, your and your family will have a conference with your rehabilitation team to address concerns, issues, and formulate a home treatment plan. Social Services will provide information if you qualify for:
- Social Security
- In-home care
- Medical coverage
- Benefits and services
Medical Social Workers in the Rehabilitation Center will have information about a variety of community resources that may be available to you. The Medical Social Worker on your unit will meet with your family to provide information and assistance. Through these meetings, you and your family can get help in completing applications for benefits and community resources.
Some of those resources include:
- DMV placard
- Outreach transportation services
- Social Security Disability and SSI information
- State Disability application
- Family Leave application
- PG&E Medical Baseline Discount
- California Telephone Access Program
- Lifeline Program
- Department of Rehabilitation
INFORMATION FOR PATIENTS & FAMILIES
*Visiting hours subject to change, please confirm current
visitor hour policy with the Rehab unit.
Visiting hours are 12:00 p.m. to 8:00 p.m. Monday through Friday, and all day Sunday. An adult must supervise children at all times. There is a limit of two visitors in the room at a time. The day room, patio and the cafeteria are available for larger groups. Visiting during therapy sessions is limited to family members and caregivers only
One family member (18 or older) may spend the night to practice and provide hands-on care. The patient or family member needs to notify the charge nurse well in advance so arrangements can be made.
All patients must remain on campus throughout their stay. Patients may leave only when accompanied by staff or with a written pass by your physician and authorized by your insurance company.
Clothing and Personal Items
Limited closet space is made available to store clothing, shoes, and patient belongings. Here are a few things to remember:
All clothing should be labeled with the patient's name using a permanent marker.
Casual street clothing should be worn during daily activities and therapies. Cotton sweats and comfortable, loose-fitting clothing works best. Jeans and khakis are discouraged.
Shoes should be one to two sizes bigger than your regular shoe size and should be comfortable and provide support.
A washer and dryer may be available for use. You and your family are responsible for doing your own laundry.
Although the hospital provides shampoo and lotion, you may want to bring your own toiletry items to make you feel more comfortable during your stay.
Cash and Valuables
Santa Clara Valley Medical Center is not responsible or li able for money, jewelry, clothing, cell phones, or other articles of value left at the bedside. Money and valuables should be deposited at the Protective Services Office for safekeeping. At the time of discharge, call the Protective Services Office at (408) 885-5567 to arrange for picking up these items.
For lost articles, contact the Customer Services Department at (408) 885-4826
Personally owned appliances - including personal refrigerators, hot plates and microwaves - are not allowed. You may use a battery-operated electric razor.
A personal computer is allowed and in some areas wireless Internet is accessible.
TVs, VCRs and DVD players are available to patients free of charge. To avoid disturbing other patients, the volume should be kept low on all TVs, DVD players, cell phones and radios. Headphones are encouraged between the hours of 11:00 p.m. and 6:00 a.m.
Phones and Cell Phones
You will have a phone in your room for your private use. You will be assigned a phone number when you are admitted, and that number will be the same throughout your hospital stay. You will not be charged for calls made in the local 408 area code. You need to dial a "9" before entering the number you are going to call.
If you need to call an area code outside of the 408 area, a calling card is recommended. Long-distance calls may also be billed to a home phone or can be billed collect.
Non-emergency calls are not allowed between 10:00 p.m. and 8:00 a.m.
Cell phones are allowed on 1Rehab and 2Rehab only. Cell phones are not permitted in the Rehab Trauma Center.
- Santa Clara Valley Medical Center is a smoke-free facility and smoking is not permitted anywhere on hospital grounds.
Alcohol and Drugs
- The use of drugs (except as ordered by the doctor) or alcoholic beverages is not allowed in the hospital or on the hospital grounds. Possession of alcohol on hospital property is a criminal offense and reportable to law enforcement.
- Drugs and alcohol are also not allowed when on outings or when using CRL passes.
- If alcohol or drug use is suspected, patients will be asked to take a screening test. If tested positive for drugs or alcohol, the patient may be discharged from rehabilitation and/or the hospital.