Professionals That Make a Difference

When a patient leaves the hospital, what type of healthcare will they receive? Is the medical team qualified to address the patient’s needs? Will they support the patient’s transitions?

These are some of the questions that challenge physicians, caregivers, discharge managers and case workers as the patient transitions from the intense hospital environment to a post acute, sub acute or transitional care facility. At Kissito Post Acute, we acknowledge this challenge and immediately create a feeling of trust, security and open communication between the medical team and caregiver/patient.

Hospitalization and post acute (hospital) care are stressful and challenging for families and caregivers. Because the patient is likely to be seriously ill or experience a significant decline in function, there may be a great deal of uncertainty involved with his/her prognosis. Often, the caregiver feels helpless and out of control with little communication or input to the medical team.

Kissito Post Acute focuses the care on the patient’s needs by building an interactive, collaborative relationship between the patient, caregiver and its Total Care Medical Team. Together with input from the patient and family, the team determines the most effective and efficient treatment plan, based on Best Practices to help maximize the patient’s independence and return home safely.

As Post Acute Care is often clinically complex, our Team is interdisciplinary and comprehensive. It offers 24/7 care with medical professionals including Nurse Practitioners, RNs, therapists, social workers, and case workers.  In fact our Nurse: Patient Ratio exceeds the national average.

After the patient’s admitting diagnosis and assessment, our Team utilizes one of our 23 Collaborative Care Pathways to guide the care plan. The Team members collaborate to develop clear objectives and then deliver care using Evidence Based Medicine. Team members keep one another, as well as patients and their loved ones, informed every step of the way to improved health and functioning.

Based on the traditional teaching hospital of Grand Rounds, the Total Care Medical Team has evolved Collaborative Care Rounds for the Post Acute patient.  On a regular basis the Team provides Rounds to each patient.  This provides an opportunity for both the patient and caregiver to interact with team and for the team to track the progress of the patient and address their needs.