Restorative Care Unit

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1 INFORMATION BOOKLET Restorative Care Unit Digby General Hospital 75 Warwick Street Digby, Nova Scotia B0V 1A0 Phone: Ext Fax:

2 Mandate & Philosophy The Restorative Care Program at Digby General Hospital, serving South West Health and the Annapolis Valley Health, is a comprehensive, holistic, patientfocused program which focuses on maximizing an optimal level of functioning enabling patients to regain/retain their independence following the debilitating effects of illness or injury such as stroke, major joint surgery, musculoskeletal disorders, traumatic or pathological fractures, and amputation. Restorative Care: Focuses on health, not illness Foster motivation in patients Promotes individual independence Works with families/caregivers of patient for transition to home Restorative care is an interdisciplinary team effort. The team works together with the patient/caregiver/family to establish realistic functional goals, develop and follow an individualized rehabilitative treatment program to improve functional abilities and allow the patient to return home after illness, injury or deconditioning. 2

3 Restorative Care Is An Interdisciplinary Team Effort The Restorative Care Team will: assess patient s physical, psychological, emotional and social health status upon referral through a well-defined interdisciplinary assessment process. attempt to set up a support service network as necessary to facilitate independent living as identified by patient/caregiver in conjunction with the Interdisciplinary Team. A home visit may be considered by the team. provide individual/group treatment and therapy programs that will address specific general goals as identified through the assessment process in conjunction with goals of patient and caregiver. provide supportive services to caregivers and encourage participation in patient treatment plan. provide follow-up evaluation to determine effectiveness of treatment plan within 6-8 weeks after discharge, if appropriate. review patient progress to assess effectiveness of treatment and therapy programs as determined by patient/caregiver and the Interdisciplinary Team which may include a family/patient meeting prior to discharge or midway through rehabilitation program to determine if it is appropriate to continue. identify and track performance indicators to monitor, evaluate and improve the quality of patient care. promote the Restorative Care Program to increase awareness and visibility within South West and Annapolis Valley Health. 3

4 Introduction The Restorative Care Unit located in Digby General Hospital is a 13 bed unit for patients who require rehabilitation. Admissions come either from home or other health care facilities. We believe that with teaching, encouragement and cooperation, acting involvement, patients can achieve their optimum level of independence. Accommodations and Environment: Accommodations include two private, four semi-privates and one ward with three beds. Each room has closet space, beds, night tables, over bed tables and bathroom; call bells are located beside each bed and in the bathroom. Assignment of rooms is by availability and need. Requests for specific accommodations are taken into consideration and provided if possible. The unit has a combination lounge/dining room, access to a kitchenette for patient needs. There are two gyms on the unit for physio/o.t. training. There is an ADL (Activities of Daily Living) suite off the unit. This is used for some patients when they are preparing to return home, making the transition easier. A color TV is available in the lounge area. This facility promotes a scent-free and smoke-free environment. 4

5 Selection/Referral Process Selection Process: Candidates for selection may come from anywhere that DHA 2 & 3 patients are located. These candidates include, but are not limited to, inpatient and ambulatory areas, community, the Nova Scotia Rehab Centre, and the QEII. Steps: 1. Screening Form completed by a member of the health care team from the sending facility. 2. Phone the Restorative Care Unit Coordinator, Maria Amero, extension 3246, to discuss. Referral Process: Referrals can be generated by any health care professional, but require the support of the patient s attending physician. Steps: 1. After discussion with the Restorative Care Unit Coordinator, if deemed an appropriate candidate, then the Restorative Care Unit Referral Form must be completed by a member of the health care team who can fill it out in its entirety, and signed by the physician from the sending facility. 2. The Coordinator visits the patient, when possible, and determines eligibility by completing the assessment. 3. If appropriate, then the Coordinator notifies the Restorative Care Unit physician or designate to discuss. The Coordinator then notifies the referring physician and the availability of bed and possible date of transfer is discussed. 4. If not appropriate, then decision is written in the interdisciplinary notes and the referring physician is informed. 5

6 Services Continuing Care: The Continuing Care Coordinators are available to assist with discharge planning to home or alternative community setting. If necessary, appointments with continuing care agencies can be facilitated prior to discharge. Continuing Care Coordinators will be part of the weekly interdisciplinary team for evaluation/support for discharge home. Dietary: The dietician and dietary staff work with other members of the health care team to ensure meals are provided to meet the individual s needs. The dietician will visit with patients who have been identified to have special needs such as swallowing or chewing problems, or who have nutritional problems or concerns. Nursing: The nursing staff considers each patient as an individual. Patients and their families are encouraged to participate in activities, on going care and goal planning to facilitate the optimum health of the patient. The goal of the nursing staff is to assist patients to achieve their maximum level of self-care and to promote their independence. The staff is always pleased to answer any questions or concerns. The phone number is extension Pharmacy: All resident s medications and treatments are reviewed at the time of order and monthly by a physician. Those still required are recorded and those no longer needed are discontinued. All medication, ordered by the physician, are obtained and issued on an individual basis by the pharmacy at Digby General Hospital, which operates Monday to Friday. All medications will be blister packed. Physician: While patients are in this hospital, a physician will be assigned to direct their care. Doctors usually visit twice weekly or as required. 6

7 Rehab Team: All patients on the unit will be assessed by the Occupational Therapist, Physiotherapist, and the Recreation Therapist. The goal of the rehabilitation services is to regain and/or maintain a patient s optimal level of independence through physical, social, emotional, and cognitive functioning. The Occupational Therapist will address issues such as: seating, positioning, cognition, perception, hand therapy, and promoting independence in self care and household activities. The Physiotherapist will address issues such as: balance, strength, range of motion and mobility. The Recreation Therapist will address issues such as: leisure awareness, leisure education, leisure resources, and promoting healthy (previous or new) leisure activities. Social Worker: A medical social worker is available to patients and to their families to provide support around the emotional and social factors related to hospitalization, including role changes and increased stress. The medical social worker assists in locating and referring to resources in the community to help restore optimal functioning. Speech Language Pathology: For patients with speech and language difficulties, the services of a Speech Language Pathologist will be available on a limited basis. Telehealth Network: Nova Scotia Telehealth Network uses computer video-conferencing technology with the use of secure lines to connect patients and health care providers for consultations and assessment if requested. 7

8 Rights: Patients Rights and Responsibilities The right to be protected in a safe environment. The right to receive respectful care in recognition of personal dignity. The right to privacy and confidentiality. The right to be involved in decisions involving your health care. The right to accept or refuse medical care after having been provided with the medical consequences of your decision. The right to be kept informed by your physician of your diagnosis and prognosis in terms that you can understand. The right to work together with staff to solve any grievances you may have. The right to expect and receive assistance during time of emergency or illness. The right to expect that the health care you receive is kept current through education. Responsibilities: Respecting hospital property and the property of other residences. Providing your physician and caregivers with a complete and up to date health record. Making health care workers aware of any changes in your condition. Cooperating with your physician and other staff members involved with your treatment. Participating in your rehabilitation care plan. Being considerate of the rights of the other patients and staff. 8

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