skilled nurse talking to patient about care plan

Gateway Post Acute Guide: How We Create Rehabilitation Plans for Each Resident

No two people are the same. That means that no two rehabilitation plans are the same. Every patient leaving the hospital has different goals and requirements for rehabilitation. So, each resident will require individualized care plans to ensure that they are reaching their recovery goals.  

At Gateway Post Acute, our staff will work closely with all our residents to create a recovery game plan for rehabilitation, treatment, and needed support. Whether the resident is transitioning from the hospital or dealing with a chronic condition, our personal rehabilitation care plans are designed to ensure patient recovery success.   

What Are Rehabilitation Plans? 

Rehabilitation care plans are personalized roadmaps for patients. These can vary depending on the person’s specific physical or rehabilitation requirements.  

Rehabilitation plans will lay out both the needed rehabilitation (physical, speed, occupational, etc.) and the timeline for these steps. It will also include expected outcomes, designed to help the patient gain independence and confidence. 

Why Personal Rehabilitation Plans Are Necessary 

A one-size-fits-all rehabilitation plan won’t address everyone’s needs. No two surgery or hospitalization rehab journeys are the same. Healthcare providers focus on treatments, exercises, and recovery goals that best fit each patient.  

Creating an individualized rehabilitation care plan can: 

  • Increase a patient’s mobility and strength 
  • Help a resident get back to daily activities 
  • Decrease pain and discomfort 
  • Lower chances of being readmitted to the hospital 
  • Prevent complications 
  • Support throughout the rehabilitation process 

How We Create Comprehensive Rehabilitation Plans 

At Gateway Post Acute, we take the rehabilitation process very seriously. To ensure that the patients get the care that they need, we follow this process. 

Initial Evaluation 

Before beginning therapy, Gateway Post Acute staff will do a comprehensive evaluation: 

  • Reviewing medical history and current medications 
  • Physical exam 
  • Physical, occupational, and speech evaluation 
  • Pain and fall risk evaluation 
  • Cognitive and communication screening 

Selecting Your Team 

The success of rehabilitation depends on the assigned team. Depending on the patient, the people on their team may differ. But typically teams are made up of: 

  • Physicians 
  • Nurses 
  • Physical, occupational, and speech therapists 
  • Social workers 
  • Dietitians 

Establishing Therapy Goals 

The goal of rehabilitation is to improve the patients’ conditions and meet desired outcomes. Measurable goals may include: 

  • Increasing strength and endurance 
  • Improving balance and walking 
  • Regaining independence 
  • Effectively managing pain 
  • Improving cognitive, speech, and swallowing functions 
  • Preparing to return home 

Goals may be adjusted as the patient improves. Rehabilitation doesn’t remain static over time. Your health team will regularly evaluate your progress and change the rehabilitation plan if needed. 

Deciding on Rehabilitation Services 

Depending on the patient’s requirements, these may include: 

  • Physical therapy  
  • Occupational therapy  
  • Speech therapy  
  • Skilled nursing care  
  • Medication management  
  • Wound care  
  • Respiratory therapy  
  • Nutritional counseling 
  • Planning for return to home 
  • Family participation 

Preparing for Discharge 

As the patient improves, the rehabilitation team will lay out what is required outside of the facility to maintain recovery momentum. This may include: 

  • Home exercises 
  • Home health services 
  • Medical equipment 
  • Medication instructions 
  • Follow-up appointments 
  • Caregiver or family training 

The goal is to restore the patient back to their normal routines and state of independence.  

Trust the Team at Gateway Post Acute 

As the trusted short-term rehabilitation and skilled nursing facility in Porterville, CA, our team believes in patient-centered rehabilitation. When you walk through our doors, you will be treated like family from day one.  

Schedule a facility visit today. We look forward to getting you or your loved one back on track.