It’s time for you to get the care you need, and when you’re in our hands, you can rest assured that you’re getting the best there is. We strive every day to be the skilled nursing facility of choice in our community, so we make sure that each day you spend with us is filled with the caliber of service that will make your stay comfortable, safe and therapeutic. The entire staff will know you by name, and each day when we greet you, we’ll ask you how you are, and whether there is anything we can do for you. We never forget that you’re our valued guest, and the reason we’re here! And remember, if you have a special request, please don’t hesitate to ask. That’s why we’re here – for you!
Montecito Post Acute Care & Rehabilitation
My Care Plans
For the Family: Tailored So YOU Can Make a Difference!
Shortly after admission to our facility, the Interdisciplinary Care Team (IDCT) will meet with you and your family members to develop a Care Plan. Each discipline (Nursing, Therapy, Nutrition, Activities, Social Service) of the IDCT asks questions to make sure you receive the unique services your individual situation requires. When a patient isn’t able to effectively communicate, family members are heavily relied upon for key information needed to help the patient feel comfortable and get as well as possible. A broad spectrum of information about the patient is taken into consideration, from medical data such as diagnosis and prior level of function, to personal information such as likes and dislikes, religious preference, social and family support and personal history and interests.
Getting Started: The Care Plan Meeting
Every effort is made to schedule the Care Plan Meeting to accommodate the availability of the patient and family, to ensure that the patient and family participate in the development of the Care Plan to the fullest extent possible. Family members and/or the responsible party are encouraged to attend the meeting. The Care Plan Meeting is typically conducted within the 1st or 2nd week after admission.
The Care Plan Meeting involves the Interdisciplinary Care Team (IDCT) which includes, but is not limited to, the following professionals:
• Nursing Representative
• Dietary Services Supervisor/ Registered Dietician
• Social Services Representative
• Activity Director
• Treating Therapist or Representative
• The Administrator, Director of Nursing, Attending Physician, Nursing Assistant responsible for resident, and others may attend as needed
As an interested family member, this is your opportunity to get your questions and concerns answered, and we’re here to help. We understand what an anxious process this can be, so we take our time explaining the details of what your loved one’s care and stay with us will involve, how you can assist in their recovery, and what to expect along the way.
Once a plan is in place, frequent updates are given to involved parties to improve the plan of care and ease any concerns.
The Discharge Plan: Get Well and Go Home
Discharge planning is initiated upon admission as the Care Plan is developed by the IDCT. Included in the discharge planning is the resident’s discharge outcome goal. The Discharge Plan provides a “road map” for returning the patient to their home and prior level of function, or to the highest level of function possible.
The discharge outcome goal is a reflection of the professional opinion of the team based on the initial evaluation, and is open for change based on the patient’s progress. The discharge outcome goal includes the following components:
• It will be developed with the resident and/or family goals in mind.
• It will include destination of the resident, sources of assistance available to the resident, level of assistance needed by the resident, adaptive equipment needed, and appropriate referral required.
The Outpatient Care Plan: Home Or Away, We’re Still Here to Help
Our outpatient programs are designed so that our patients can return to our therapy clinic for continued therapy if needed. The same therapists they got to know during their stay with us can continue to follow up with the patient through outpatient therapy. Our therapy programs are also often involved in local Assisted Living Centers and Senior Centers to provide wellness classes, ongoing training and education, and health screenings.
On-Site Decision Makers
We Don’t Wait To Make Important Decisions
In order to provide the best care possible, our caregivers must be empowered to make decisions, because in many cases, every second counts. So rather than waiting for a decision from higher-ups who might not understand the crucial details of any given situation, we leave the decisions to those who are closest and know best: the caregivers, doctors, and nurses who work with our patients 24 hours a day, seven days a week.
It’s important to us that our patients, as well as their family members, feel loved, informed and comfortable during their stay at our facility. Quality of life is just as important as quality of care in a skilled nursing facility – and we work hard to make sure that every patient is as happy and comfortable as possible. Every staff member on the floor and in the office knows each patient by name. They make eye contact as they greet them, and once a request is met, they ask if there is anything else they may need. If there is a request, the team member is then empowered to carry it through. We’ve found that with this kind of team member empowerment, patients have consistently shown greater motivation to reach their goals.
My Rehab Team
Many Disciplines — One Goal
Once the patient is on the road to recovery, the rehab therapy team rolls into action. The team consists of physical therapists (PT), physical therapy assistants (PTA), occupational therapists (OT), certified occupational therapy assistants (COTA), a speech and language pathologist (SLP), and a rehab aide/technician, who work together based on the individual needs of each patient.
The Physical Therapist assesses and treats impairments in strength and function that occur as a result of injury, disease, age-related degeneration, or environmental factors. Physical therapy treatments are performed by the physical therapist, or a physical therapy assistant who treats under the direction of the supervising physical therapist.
The Occupational Therapist assesses the impact that a decline in function has in the patients’ ability to participate in their life by performing everyday tasks such as dressing and bathing, or being able to return to work or engage in previous hobbies. Occupational therapy treatments are performed by the OT (or a COTA working under the direction of the supervising OT).
The Speech Therapist and/or Language Pathologist assesses language, cognition, and swallowing dysfunction. A Speech Therapist’s main goal is helping resident with swallowing difficulties. They will work with residents that may have modified diets to help them get back to eating the types of foods they love.
These three disciplines work together along with nursing, social services, activities, the business office, families, caregivers, and local communities to assess functional potential, and collaborate on the unique goals for every patient. Family members are essential contributors to this interdisciplinary rehab team, as they provide the background and detail of their loved one’s life to incorporate into our plan of care.
While in our care, please know that your loved one will be well taken care of. Because all of our rehab therapists are in-house (rather than outside contractors), our relationships with our residents are superior. Our therapists and nurses work together as a team, and due to the continuity of their care, a strong trust is built with our residents. There is comfort in knowing that the same smiling face will be there to help them through their rehab each day.