What Is a Care Team?

What Is a Care Team?

The purpose of a care team is to provide patients and their families with an interdisciplinary approach. Each team member offers insight from their area of expertise and works in collaboration with the other team members, the patient, and their family to determine goals, develop a customized care plan, and ensure each resident or patient achieves the best quality of life possible.

The Benefits of a Care Team

At Christian Health, every one of our residents and patients in long-term care or short-term rehabilitation has an interdisciplinary care team. Each care team includes the following:

• A social worker
• A nurse
• A rehab professional (physical, occupational, and speech therapy)
• A chaplain
• An activities professional
• A dietician

“The beauty of an interdisciplinary approach is that everyone brings their expertise to the family and patient,” said Teresa Durantino, MSW, LSW, CDP, Director of Social Services at Heritage Manor.

Care teams meet regularly to discuss their residents and patients and any progress or new diagnoses, adjust medications, and make any plans for discharge. Residents, patients, and their families are invited and encouraged to attend these meetings to stay in the know about their loved one’s care and give them agency over any important decisions.

“Interdisciplinary collaboration improves the patient’s satisfaction and engagement by involving them in decision-making,” said Marie Ubiadas, PACU Assistant Director of Nursing. “When we have that meeting, we have open communication with the family and patient to collect and share information, set up a successful care plan for the patient, and promote awareness of the patient’s individual needs with the team. This improves the quality of care for the patient.”

“Everyone has input here,” said Teresa. “We’re all in this together.”

Involving residents, patients and their families in their own treatment plans is important because it allows them to have all the information available to make decisions about the care they want – now and in the future. If a patient is in short-term rehabilitation, they may need help planning their discharge and determining what they will need moving forward – whether that be assisted living or home health services.

“The patient has a right to say what happens in their life,” said Reverend Dawn Rivers, DMin, Heritage Manor Chaplain. “We inform them and help them make their decisions so they, too, become a part of the care team. They still have a sense of control and independence based on the information we supply them with.”

“It’s a significant change, not just for the patient, but for the family,” said Marie. “Keeping them aware really alleviates their anxiety and helps them plan ahead for their care.”

The Different Disciplines of a Care Team

Nursing

A nurse assesses the resident or patient’s medical needs and directly collaborates with the physicians to determine the resident or patient’s progress or relay any new challenges or diagnoses. The nurse will update the rest of the care team, the resident or patient, and the resident or patient’s family about any medication recommendations or changes, lab results, or other health-related developments.

Rehabilitation

Whether a patient is in short-term rehab or long-term skilled nursing, a rehabilitation therapist will evaluate their functionality and mobility when they are admitted and determine a care plan for the patient that may include physical, occupational, or speech therapy. “The treatment goal is to get them to their prior level or highest level of function possible,” said Carla Moldes Gustilo, PT, Director of Rehabilitation Inpatient Services. For short-term patients, the rehab therapist will also communicate with the team about what equipment the patient may need upon discharge and help them ensure their home is safe and accessible for their return.

Social Work

A social worker addresses the psychosocial needs of every patient in short-term or long-term care. If a discharge is planned, a social worker will make referrals for resources in the community for their needs, such as home care services. For long-term patients, the social worker’s role is to ensure they’re achieving the best quality of life, recommending any mental health services if necessary, and helping their family deal with various aspects of care planning. “We are patient advocates,” said Teresa. “We also offer a lot of support to family members when struggling with new diagnoses or end-of-life issues. Our job is to deliver patient- and family-centered care because that is our mission every day.”

Pastoral Care

At Christian Health, we believe in not only nurturing physical health but spiritual health as well. That’s why a chaplain from Pastoral Care plays an important role on our care team. The chaplain is available to offer spiritual guidance to the resident or patient and their family and help them on their healing journey. “For some patients, it’s the first time they’ve experienced illness on a large scale, and they’re questioning their faith,” said Rev. Dawn. “We work with them to understand their faith journey and to see how we can support them. For family members, it may be the first time that they’re caregivers or making decisions for their loved one’s health or well-being. We offer a safe place to express their thoughts, needs, disappointments, and fears.”

Activities

In long-term care, a robust activities program is essential for residents and patients to stay engaged, healthy, and socialized. As part of an interdisciplinary care team, an activities professional can provide updates on a long-term resident’s engagement and work with the rest of the team to ensure they are participating in activities that best foster their physical and mental wellness and provide them with the richest quality of life possible.

Dietary

Diet has a huge effect on health, and providing nutritious, healthy meals is a significant part of delivering excellent care. The dietician’s role on the care team is to monitor a participant’s diet and how it relates to their health, ensure they are getting proper nutrition and all dietary needs or restrictions are being met, and make dietary recommendations.

Learn More About Skilled Nursing and Rehabilitation at Heritage Manor

Our center for long-term skilled-nursing care and short-term post-acute rehabilitation, Heritage Manor, provides compassionate interdisciplinary treatment, with an individualized care plan to meet each patient or resident’s unique needs. To learn more, please call (201) 848-5855 or visit ChristianHealthNJ.info/HeritageManor.