Gottlieb's Transitional Care Team physicians work with residents to achieve positive outcomes through emphasis on rehabilitation, respect, dignity and compassion to guide our interactions.
Our goal is to assist our residents to function at their optimal level, whether that is independence in the community, functioning in an assisted care setting or comfort at the end of life.
Our interdisciplinary team provides skilled services to assist our residents to achieve mutually agreed upon goals during their short-term stay. We provide these services through timely, appropriate and cost-effective utilization of our resources.
We are dedicated to providing quality, personalized care incorporating a team approach. Residents, their families, physicians, nurses, social workers, therapists, registered dietitians and pastoral care staff work together focusing on each person as a whole. During their stay, residents remain under the care of their personal physician. The team's objective is to assist the resident throughout the recovery process so that he or she can return to an independent lifestyle.
- Nursing: Our licensed certified staff will provide skilled services 24 hours a day. Examples of these services include: wound care, intravenous therapy, antiobiotic therapy, assessment and care plan development, education and tube feedings.
- Nutrition: Our dietitian will assess your nutritional needs upon admission and throughout your stay. Your weight will be monitored as well as your food likes and dislikes. We will work with you to address your special dietary needs and collaborate with you to develop your plan of care. Substitutions may be ordered for any meal.
- Social Services: Our social worker will meet with you during your stay to coordinate your discharge plan. By working on your discharge plan from day one of your stay, our interdisciplinary team can help you work toward your goals. You will receive assistance with setting up medical equipment when needed, transportation, community services and referrals.
- Rehabilitation Services: Our interdisciplinary care planning includes physical, occupational and speech therapists who will work with you to meet your needs. Your therapist will work with you to design an individualized treatment plan that will help you meet your optimal level of function to facilitate your discharge.
- Activity Therapy: Our activity staff will visit you to discuss your life patterns, hobbies and interests. They will orient you to the types of daily activities we offer as well as our special interest and dining groups. The staff will develop a care plan to meet your needs. We encourage you and your family to attend these recreational therapy activities, which are an important part of your recovery.
- Respiratory Therapy: If your physician orders a treatment to assist with your breathing, our respiratory therapist will provide services to support and improve your condition.
- Pharmacy: A registered pharmacist will review your medications to ensure that they won't interact in a harmful way with each other or with food.
Additional Services Available
- Hospice Services: Gottlieb's Transitional Care Unit, in conjunction with Gottlieb's Hospice Team, can provide hospice care in a home-like environment. Each resident has a private room with overnight accomodations for family, including a refrigerator and microwave. Staff is trained in symptom and pain management.
Leaving the TCU
When you are preparing for discharge, we offer a variety of resources including the following:
- Referrals and Medical Services: Your physician may order services to help you after you leave the Transitional Care Unit such as Home Health Rehabilitation, Durable Medical Equipment, Hospice, or referral to a Nursing Home, Assisted Living Center or Independent Living
- Community Services: The Social Services department is available to help set up or refer you to additional services such as Meals on Wheels.
- Follow-Up Tests or Treatments: If your physician orders follow-up tests to monitor your progress, the orders will appear on your discharge form.
- Prescriptions: If your physician prescribes medications for you to take at home, you will receive them prior to discharge.