Our Interdisciplinary Team (IDT) consists of personnel that represent all facets of care at our facility. This team approach to the management of complex diseases and rehabilitation provides our residents with the comprehensive, efficient care.
The Team can include: (but is not limited to)
Resident and attending physicians
Primary licensed nurse working with the resident
Primary certified nursing assistant assigned to the resident
Director of Nursing
Resident Assessment Director
Therapists (occupational, physical, and speech)
Director of Staff Development
Personnel from Social Services, Activities and Dietary
Patients are evaluated by our Interdisciplinary Team (IDT) within 72 hours of their arrival to assess clinical status, establish discharge goals, and develop an individualized care plan to meet specific needs.
This approach improves satisfaction and communication for our patients, their loved ones, and for our staff.
At the core of Covenant Care’s Onsite Point-of-Care Diagnostics is the INTERACT (Interventions to Reduce Acute Care Transfers) program.
Integrated into the very culture of our facilities in 2011, INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities.
The overall goal of the INTERACT program is to improve care and reduce the frequency of transfers to the acute hospital setting. Such transfers are often avoidably, and can be emotionally and physically difficult for residents as well as result in numerous complications of hospitalization, which can be costly.
Covenant Care adopted the INTERACT program so that any changes in a resident’s condition are identified as early as possible. This allows the team to reassess the resident’s condition, determine if a treatment intervention is necessary, and modify the treatment plan accordingly.
Components of the INTERACT program include:
Stop and Watch Tool: Used to assist identifying early and subtle changes promptly. This tool is a part of our facilities’ culture.
Care Paths: Nurses follow these to step-by-step, detailed algorithms developed by medical experts to treat complex clinical conditions such as chronic heart failure, pneumonia, dehydration, urinary tract infection, and fever.
Change-of-Condition File Cards: Used to help “triage” symptoms so that those requiring immediate attention are taking care of first.
Situation Background Assessment Recommendation (SBAR) Assessment Tools: Condition-specific tools that prompt proper assessment, effective communication among the medical team, diagnostics, and treatment; incorporates CP guidance for properly managing condition. Exclusive to Covenant Care!
Advanced Care Planning Tools: Facilitate crucial conversations regarding the intensity of care.
In keeping with our commitment to provide the most advanced treatment options possible, we are proud to use PointClickCare. This cutting-edge, state-of-the art voice recognition system allows our nursing staff to spend more time with you or your family members.
Here are just a few of the benefits of PointClickCare:
- Empowers our care team to provide more individualized quality care for each of our residents. Our care team can hear any resident’s personalized care plan at any time, discreetly page fellow staff members for assistance and document care activities at the point-of-care without ever needing to access cumbersome paper records
- Enables our care team to communicate more efficiently and streamline their daily workflow.
- Headset technology is utilized for direct care staff which provides immediate access to patient care information so that services provided are based on the patients current and specific needs.
- The system allows for point in time documentation of patient status thereby capturing and communicating any changes in abilities to perform activities of daily living to the IDT.
- PointClickCare gives our care team immediate access to accurate, updated records and care plans. Along with the benefits to our residents, this also allows us to maintain compliance with the ever-changing federal and state regulations.
At Covenant Care, we engage and empower our patients and their families at all stages of care. Beginning on, or sometimes even before, the day of admission, we emphasize the importance of taking ownership in the rehabilitation and recovery processes.
Within 72 hours of admission the IDT meets to assess the patient status and identify initial goals, as well as provide any necessary educational needs to the patient & family to support and prepare for a safe discharge to a lower level of care. During this invaluable face time, the team will do a thorough review of your progress and discuss your expected goals and discharge plans .
Our education also extends from our doors to yours: we want to be sure that you are aware of and prepared for what type of monitoring (ie, blood pressure, pulse rate, blood glucose testing) and resources you will need when you return home.
Our family works with your family, from before you ever cross our threshold until you return safely home.
Our interdisciplinary Discharge Wellness Program actually begins upon admission to provides patients with the necessary knowledge and skills needed to manage their conditions and transition successfully back into the community.
Preparing in Advance for Elective Surgery or Therapy
If you or a loved one will be going into the hospital for an elective surgery such as a knee or hip replacement, we can help you coordinate the entire process so that the transition from that acute care setting to ours is smooth and stress-free.
Prior to your scheduled surgery, we will work with you to verify your insurance and assist you in completing your initial paperwork regarding your stay in our rehabilitation facility. Once the necessary paperwork is complete, we will coordinate with your physician and the hospital social worker to ensure that the transition of care runs smoothly.
There are multiple benefits of “planning ahead” for both the patient and their family. Having things in place for treatment after surgery helps make the entire process easier and less stressful for everyone involved.
By “pre-registering,” you can establish your treatment plan with the team of professionals who will be working with you on your road to recovery. This will let you know what to expect, to understand what programs and services you will be receiving, and give you confidence that your needs are being met even before you arrive!
This peace of mind can make your road to recovery easier and even potentially decrease your length of stay.
You can even arrange to stay the night before, making the transition to surgery and back a smooth continuum of care.
We believe that your focus should be on getting well and being able to return home, not on transitioning from surgery to a rehabilitation facility.
Pre-registering for your stay with us before your surgery will allow you to:
- Develop a partnership with your physician and rehabilitation team
- Customize your postoperative recovery protocols
- Tour the facility and the rehabilitation department
- Get acquainted with your therapist and nursing staff
- Establish a presurgery exercise program
- Become familiar with adaptive equipment and assistive devices
- Complete admission paperwork prior to admission
- Select your room preference in advance
At Covenant Care, we offer admissions 24 hours a day, 7 days a week so that no one is ever without a place to go.
This service, although it seems simple, is vital to the continuum of care often needed, but is not always available at other facilities.
However, at Covenant Care facilities, we are prepared and available 24/7 to accept a patient. Whether being discharged from an acute care stay, or directly from the Emergency Department, patients will receive the attention and care needed to make the return home as quick as possible.
In addition to providing an immediate solution while a longer-term plan of care is being developed, we can often begin the recovery process sooner than even a hospital could.
As a partner to our hospitals, physicians, and the communities we serve, Covenant Care now offers Centralized Placement as a resource for convenient one-stop communication and 24/7 coverage.
Our placement and insurance specialists work with Medicare, Medicaid, managed care plans and supplemental insurance companies to verify benefits and obtain pre-authorizations. This allows for quicker response times and a smooth transition for our patients and their families.
Centralized Placement enhances our ability to coordinate long- and short-term skilled nursing, therapy, outpatient services, hospice, and respite needs by placement in one of our specialized facilities, which also offer memory care and assisted living options.
Please contact us for availability and placement in any of our locations.