Your interdisciplinary team will be determined through the assessment and individual planning process. The team should be viewed as a dynamic group of individuals that may change as you and, with your permission, family or a family member, progress through the program. They will assist, encourage, and support you and your family while helping plan any care you may need after discharge. The individuals who are always on your team are you, a rehabilitation physician, and registered nurses with rehabilitation experience.
Rehabilitation physician: Your physician works as a team member to prescribe your plan of care and offer medical direction. He or she will meet with you several times each week to determine how you are progressing, and will help make decisions about your care and eventual discharge.
Rehabilitation nurse: Your rehabilitation nurse is an important part of the team and is available 24 hours a day. In addition to working with you on therapy goals established by the team, your rehabilitation nurse focuses on bowel and bladder independence, self care (including medication administration), health management and prevention, nutrition, skin care, and other goals.
Physical therapist: Your physical therapist (PT) will work with you to develop the strength and mobility you need to return home. This might include:
- Ambulation training and equipment needs
- Mobility (bed and wheelchair)
- Modalities including heat, cold, water, and electrical stimulation
- Therapeutic exercises such as endurance and strength
- Balance skills
Occupational therapist: Your occupational therapist (OT) will work with you to develop independence in activities of daily living and personal care such as grooming, dressing, cooking, and other activities. Your OT will also work on activities involving fine motor coordination, energy conservation, cognition, and other areas geared to enhance your functioning.
Speech/language pathologist: Your speech/language pathologist will work on key areas of communication (both expression and comprehension), swallowing, cognition, improved voice, speech, language, thinking skills, conversational skills, memory, orientation, problem solving, attention, and other functional activities.
Social worker/Case manager: Your social worker/case manager helps coordinate activities with you and your family. He or she will help with orientation to the program, coordinate educational needs, provide supportive counseling, and assist with discharge planning and follow-up services.
Psychologist: The psychologist is available to assist you and/or your family in coping with the various psychological and emotional challenges associated with illness or injury.
Personal physician: Your personal physician may still follow your progress to help with your medical care and treatment.
