Team Approach to Care

Our Strong Health Team of Healthcare Professionals…

including nurses, a nursing care coordinator, a social worker, a community health nurse, physical therapists, an occupational therapist, lab technicians and board-certified physicians ensures a coordinated and seamless approach to care.

Pre-Admission Continuity of Care Team

Our Pre-Admission Continuity of Care Team is made up of pre-screening nurses, community health nurses and social workers and our goal is to make sure your discharge plan is one that will be safe and meet your health care needs. A member of our team may contact you before admission to:

  • Obtain and provide information that will help you prepare for admission and discharge
  • Speak with you about home health care agencies and rehabilitation facilities
  • Have you select which agency/facilities you would like to use
  • Offer a in-home visit by a community health agency physical therapist

Our team of community health nurses and social workers are available to you and your family for emotional support, counseling, resource assistance and advocacy, and discharge planning.

Nursing Care Coordinator

The nursing care coordinator will work with your orthopaedic physician, residents, nurse practitioners, and nurses to provide you with high quality care and teaching. They begin coordinating your discharge as soon as you are admitted and include you and your family in this planning. The Care Coordinator will work with the health care team to help you identify and anticipate your medical, nursing and specialized needs.

Social Worker

Social workers are available to you and your family before, during and after your admission. They provide emotional support and counseling, resource assistance and advocacy, and discharge planning. As a member of the health care team, the social worker:

  • Receives referrals from hospital staff
  • Responds to patient’s and families’ requests for services
  • Routinely screens and evaluates patients
  • Evaluates the support provided by family, friends or neighbors
  • Refers to community resources such as sliding fee-scale aides, family service agencies, geriatric services or a community health nurse for home health services
  • Evaluates options and refers to an inpatient rehabilitation program, as necessary

Physical Therapist

A physical therapist will teach you exercises that will aid in rehabilatation and will help you learn how to get out of bed on your own. Your therapist will instruct you how to use a walker or crutches as well as instruct you in exercises to help strengthen the muscles around your knee.

Occupational Therapist

The occupational therapist will instruct you in how to best manage your daily activities such as getting your shoes and socks on, getting dressed and generally on how to make yourself independent. If special adaptive devices are required, the occupational therapist will assist in choosing those items and the community health nurse can assist with obtaining and purchasing those items.

What About Rehabilitation

Support and rehabilitation continues after discharge. Rehabilitation is necessary to become stronger, restore and improve lost function following your total joint surgery.

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