Because each patient progresses at a different rate, we use an interdisciplinary approach to provide greater continuity and communication about your care and treatment. Yourself, your family, your primary physician and/or the inpatient hospitalists and staff from all disciplines (nursing, rehabilitative therapies, etc.) make up the team. The team meets weekly to discuss expected discharge goals specific to your needs and the progress with current treatment for each patient.
The care manager discusses with you and your family (as appropriate) your needs and concerns before the meetings, represents you at the meetings and reviews the outcome of the meetings within 24 to 48 hours after.
The team or the patient/family may request a meeting specific to their care with appropriate team members to discuss the discharge plan in more details as needed.
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