Subacute Care

Summary

Marianne Ruff, a discharge coordinator at Sister's Hospital, discusses Mrs. Vaughn's treatment for congestive heart failure (CHF) and subsequent stabilization. Emphasizing the Catholic Health System's special care paths, she outlines the benefits of their subacute services, including six-day-a-week therapy, interdisciplinary care teams, and a focus on patient outcomes and satisfaction. The summary highlights the comprehensive approach to rehabilitation, from medical treatment to recreational activities, ensuring a swift and safe recovery.

Takeaways

• 🏥 Mrs. Vaughn was admitted to Sister's Hospital with congestive heart failure (CHF) and has been stabilized after treatment.
• 📈 She no longer requires intensive hospital care but needs nursing care and rehabilitation to regain independence.
• 🛑 The Catholic Health System offers a special care path for CHF that continues from inpatient stay through various levels of care.
• 👩‍⚕️ Subacute services are recommended for adults managing chronic conditions or recovering from injuries or surgeries.
• 🏢 Choosing the Catholic Health System provides access to a range of care settings and a simple transition process.
• 🏅 Partners in Rehab, a part of the Catholic Health System, offers comprehensive rehabilitation with high standards and national recognition.
• 📈 The outcomes of the rehab program are consistently at or above national standards, with awards for quality and patient satisfaction.
• 👩‍⚕️ The rehab team includes a physician, registered nurses, certified nursing assistants, occupational therapists, physical therapists, and speech-language pathologists.
• 💊 The physician evaluates and prescribes medical treatments, including possible dietary needs, and is available 24/7 for emergencies.
• 👨‍⚕️ The interdisciplinary team works together to develop a personalized care plan for each patient, focusing on quick and safe recovery.
• 🌟 Patients at Partners in Rehab experience a caring and compassionate environment with staff dedicated to their well-being.

Q & A

What was Mrs. Vaughn diagnosed with during her hospital stay?

Mrs. Vaughn was diagnosed with congestive heart failure, sometimes referred to as CHF.

What is the role of a discharge coordinator in a hospital?

A discharge coordinator, like Marianne Ruff, is responsible for planning and coordinating the transition of patients from the hospital to other levels of care, ensuring they receive appropriate nursing and rehabilitation services.

Why is Mrs. Vaughn no longer in need of comprehensive medical care?

Mrs. Vaughn's condition has stabilized after successful treatment for congestive heart failure, so she no longer requires the full medical care provided by a hospital.

What is the Catholic Health System's approach to patient care for conditions like CHF?

The Catholic Health System offers special care paths developed for diagnoses such as CHF, which continue from the inpatient stay through all levels of care within the system.

What is the purpose of subacute services in the Catholic Health System?

Subacute services are designed for transitional care between a hospital stay and returning home, catering to adults managing chronic conditions or recovering from injuries or surgeries.

How often do patients receive therapy at the Catholic Health System's rehabilitation facilities?

Patients receive therapy six days per week at the Catholic Health System's facilities with dedicated subacute units.

What awards has the Catholic Health System won for its quality initiatives?

The Catholic Health System has won national, state, and local awards for its quality initiatives, reflecting its commitment to maintaining high standards of patient care.

What is the role of a physician in the rehabilitation team?

The physician evaluates the patient's medical condition and rehabilitation needs, prescribes medications and treatments, and develops a rehabilitation therapy plan to restore the patient's health, strength, and function.

What support do certified nursing assistants (CNAs) provide to patients?

CNAs assist patients with activities of daily living such as bathing, grooming, or getting dressed, and provide support and companionship as patients regain strength.

How does an occupational therapist contribute to a patient's recovery?

Occupational therapists help patients learn to perform activities of daily living that are difficult due to their condition, teach the use of assistive devices, and work on improving strength, mobility, and control.

What additional services does the Catholic Health System offer to support a patient's holistic recovery?

The Catholic Health System provides chaplains for spiritual care, care managers to assist with discharge planning, and speech-language pathologists to help with communication and swallowing difficulties.

Outlines

00:00

🏥 Marianne Ruff Introduces Catholic Health System's Subacute Services

Marianne Ruff, a discharge coordinator at Sister's Hospital, introduces Mrs. Vaughn, who was admitted four days prior for congestive heart failure (CHF). Mrs. Vaughn has been stabilized post-treatment and now requires nursing care and rehabilitation to regain independence. Marianne highlights the Catholic Health System's special care paths for conditions like CHF, which provide continuity of care across different levels of the healthcare system. Subacute services are recommended for patients needing transitional care, and the Catholic Health System offers various settings to facilitate a smooth transition. The system's Partners in Rehab provides therapy six days a week with dedicated subacute units, maintaining high standards and achieving outcomes that meet or exceed national standards. The facility has won awards for quality and patient satisfaction. The rehab process involves an interdisciplinary team, including physicians, nurses, certified nursing assistants, occupational therapists, and physical therapists, all focused on the patient's comprehensive recovery.

05:00

👩‍⚕️ Comprehensive Rehabilitation Team at Partners in Rehab

The script continues to detail the roles of various team members at Partners in Rehab within the Catholic Health System. A physician evaluates and prescribes treatments and rehabilitation plans, while registered nurses coordinate overall care, administer medications, and provide wound care. Certified nursing assistants assist with daily living activities. Occupational therapists help patients with activities of daily living and use of assistive devices. Physical therapists guide patients through exercises to regain strength and mobility. Speech-language pathologists aid patients who have lost speech or comprehension abilities and assist with safe swallowing. Chaplains provide spiritual care, and care managers help with discharge planning, including equipment needs and arranging for further therapy. The team works together to ensure optimal patient outcomes, as evidenced by positive patient testimonials highlighting the focus on well-being, encouragement, and the comprehensive nature of the care provided.

Keywords

💡Congestive Heart Failure (CHF)

Congestive Heart Failure, often abbreviated as CHF, is a chronic condition where the heart fails to pump blood effectively. In the script, Mrs. Vaughn is diagnosed with CHF, which necessitates her hospitalization and subsequent rehabilitation. The term is central to understanding the medical context of the video and the services provided by the Catholic Health System to manage this condition.

💡Discharge Coordinator

A Discharge Coordinator, like Marianne Ruff mentioned in the script, is a healthcare professional responsible for planning and coordinating the transition of patients from one level of care to another. They ensure a smooth and appropriate transfer, which is crucial for patient recovery and continuity of care, as illustrated by the discussion about Mrs. Vaughn's transition to rehabilitation.

💡Rehabilitation

Rehabilitation refers to the process of helping individuals recover and regain skills, strength, and abilities after an illness, injury, or surgery. In the context of the video, Mrs. Vaughn requires rehabilitation to function independently and return to her normal activities, highlighting the importance of this service in the patient's journey to recovery.

💡Subacute Services

Subacute Services are a level of healthcare that provides a transitional care setting between a hospital stay and returning home. They are designed for patients who need more intensive care than what can be provided at home but are not sick enough to require hospitalization. The script mentions that subacute services are often recommended for patients like Mrs. Vaughn, managing chronic conditions or recovering from injuries.

💡Care Path

A Care Path in healthcare is a predefined plan of treatment and care that follows a patient from admission through discharge and beyond. The script emphasizes the Catholic Health System's special care paths for diagnoses like CHF, which guide Mrs. Vaughn's treatment and rehabilitation, ensuring a structured and coordinated approach to her care.

💡Interdisciplinary Team

An Interdisciplinary Team consists of professionals from various disciplines working together to provide comprehensive care to patients. The script describes how the team at Partners in Rehab, including physicians, nurses, therapists, and others, collaborate to develop and implement a care plan tailored to Mrs. Vaughn's needs, demonstrating the collaborative nature of modern healthcare.

💡Physical Therapist (PT)

A Physical Therapist is a healthcare professional who helps patients restore strength, mobility, and function through physical therapy and exercises. In the script, the PT plays a crucial role in guiding Mrs. Vaughn through her subacute stay, aiming to improve her physical coordination and endurance, which is a key component of her recovery process.

💡Occupational Therapist (OT)

An Occupational Therapist assists patients in regaining the ability to perform daily activities that have become difficult due to illness or injury. The script mentions that OTs help CHF patients with tasks like dressing and using assistive devices, which is vital for Mrs. Vaughn's recovery and independence.

💡Speech-Language Pathologist

A Speech-Language Pathologist specializes in helping patients who have lost the ability to speak or comprehend language due to illness or injury. While not directly applicable to Mrs. Vaughn's case as described in the script, the mention of this role underscores the comprehensive nature of the rehab team, ready to address a wide range of patient needs.

💡Patient Satisfaction

Patient Satisfaction refers to a patient's contentment with the healthcare services they receive. The script highlights the Catholic Health System's commitment to high patient satisfaction, as evidenced by awards and positive feedback. This concept is central to the video's message about the quality of care and the patient-centered approach of the health system.

💡Quality Initiatives

Quality Initiatives are programs or measures taken by healthcare organizations to improve the standard of care. The script discusses how the Catholic Health System has won awards for its quality initiatives, indicating a focus on excellence and continuous improvement, which is a key aspect of the system's identity and service delivery.

Highlights

Mrs. Vaughn was admitted to the hospital with congestive heart failure (CHF) and has been stabilized after treatment.

CHF patients like Mrs. Vaughn benefit from the Catholic Health System's special care paths for continuous care.

Subacute services are recommended for adults managing chronic conditions or recovering from injuries.

Transitioning within the Catholic Health System is made simple for patients.

Partners in Rehab offers therapy six days per week with dedicated subacute units.

The Catholic Health System's outcomes are consistently at or above national standards.

Partners in Rehab has won awards for quality initiatives and high patient satisfaction.

The rehab facility provides a welcoming environment with friendly staff.

An interdisciplinary team focuses on the unique needs of each patient for a quick and safe recovery.

The physician leads the team, evaluating medical conditions and prescribing treatments.

Registered nurses coordinate overall care and are available 24/7.

Certified nursing assistants help with activities of daily living as patients regain strength.

Occupational therapists assist patients in performing daily activities despite their condition.

Physical therapists guide patients through exercises to regain strength and mobility.

Speech-language pathologists help patients regain language and swallowing skills if needed.

Chaplains provide spiritual care, and care managers assist with discharge planning.

The team at Partners in Rehab works together to ensure optimal patient outcomes.

Patients at Partners in Rehab experience a holistic approach to healing with compassion.

Transcripts

good morning miss Vaughn yes my name is

Marianne ruff I'm a discharge

coordinator here at sister's hospital

four days ago

mrs. Vaughn was admitted to the hospital

and was diagnosed with congestive heart

failure sometimes referred to as CHF she

had successful treatment and her

condition is now stable although she no

longer requires the comprehensive

medical care of a hospital she does

require nursing care along with

rehabilitation to help her function

independently and to get back to doing

the things she's always enjoyed one of

the benefits of choosing the Catholic

health system is access to special care

paths that have been developed for

diagnosis such as CHF the care path

continues from your inpatient stay

through all levels of care in the system

we have many settings within our

Catholic health system and you'll find

that the transition can be quite simple

subacute services are often recommended

for adults of all ages patients may be

managing chronic pain or a chronic

illness like congestive heart failure or

they may be recovering from an injury or

orthopedic condition like a bone

fracture or joint replacement this level

of care is designed for people who need

a transitional care setting between

their hospital stay and their return to

home while you may search extensively

for the best physician to help you the

same effort should be given in finding

the right rehabilitation facility for

you when you choose partners in rehab

you benefit from the tremendous number

of resources supported by the Catholic

health system you will receive therapy

six days per week at facilities with

dedicated subacute units we're committed

to maintaining the highest of standards

and therefore continuously measure our

patients outcomes the results are very

reassuring our outcomes are consistently

at or above the national standard we've

won national state and local awards for

our quality initiatives and our patient

satisfaction is evident with positive

results in overall satisfaction and

recommendations to our facilities at our

partners in rehab facilities you'll be

greeted by friendly staff and feel right

at home the patient becomes the focus of

a caring and compassionate

interdisciplinary team who evaluates

your unique needs and develops a care

plan that's specifically designed for a

quick and safe recovery recreational

activities are available for both

patients and their families to enjoy

when not in therapy let's meet the

members of this team heading the team is

a physician who will evaluate the

patient's medical condition and

rehabilitation needs the physician will

prescribe any appropriate medications or

medical treatments along with a

rehabilitation therapy plan that will

restore the patient's health strength

and function the physician may also

prescribe a special diet for the patient

if necessary throughout the patient's

stay the physician will confer with

other members of the team to evaluate

progress and modify the treatment and

therapy plan as needed a physician is

also available 24 hours a day to respond

to any medical emergencies that might

arise

another member of the team is a

registered nurse who was responsible for

coordinating the overall care of the

patient the patient's care plan has been

developed with input from the entire

team of caregivers they are available

around the clock seven days per week the

nursing staff gives medications which

may include running an IV or monitoring

the patient's insulin if they're

diabetic time is spent with the patient

to make sure that everything about

medications is understood what they're

for how often they should be taken and

any possible side effects you may

encounter if the patient has a wound

possibly from surgery the registered

nurse will also provide wound care the

team includes certified nursing

assistants for CNAs who help patients

when they need assistance with

activities of daily living like bathing

grooming or getting dressed as patients

get stronger the CNAs won't need to help

as much although they are always nearby

if the patient needs help

or someone to make them smile another

important team member is the

occupational therapist or OT who helps

patients learn to do certain activities

of daily living that are difficult to

perform because of their condition

frequently CHF patients develop swelling

in their legs and the physician may

prescribe special hosiery to help

control the swelling oaties also teach

patients how to use assistive devices

like this sock aid which will make it

easier to dress until they have regained

enough strength mobility and control to

do this without the device the partners

in rehab team also includes the physical

therapist for PT who works closely with

patients throughout their subacute stay

as the PT guides them through physical

therapy and exercises the goal is to

regain strength endurance range of

motion and physical coordination

sometimes it's difficult work for

patients but our pts are there to give

encouragement and support although this

didn't happen to mrs. Vaughan if a

patient has lost the ability to speak or

comprehend language due to their illness

or injury the team includes

speech-language pathologists who help

patients regain those skills

these therapists also help patients with

their ability to swallow foods and

liquids safely they assist the dietitian

in developing meal plans that will

provide proper consistency and

nourishment other members of the

partners and rehab team include

chaplains who are available for

Spiritual Care and care managers who

work with our patients and their

families to help them make appropriate

arrangements for the patient's

discharged to home or another setting if

necessary this might include special

equipment needs in-home nursing or rehab

services or arranging appointments for

outpatient therapy most importantly all

of these individuals we've met work

together as an interdisciplinary team to

ensure that patients like mrs. Vaughan

achieve their optimal outcome as quickly

and safely as possible we see evidence

every day that our partners in rehab

subacute team is fulfilling the mission

of the Catholic Health System and its

long tradition of healing with

compassion and respect for the unique

needs of each person we serve well many

people feel that they should rely on

friends and family they really do need

to consider something like partner than

rehab there are people here who are

completely and solely focused only on my

well-being from the emotional to the

physical to the occupational even

dietary needs everyone was very focused

and very encouraging about wanting to

make sure that the patient's needs were

met that I was happy and comfortable and

encouraged me to get better and I cannot

say enough positive things about the

entire process of having been here