Your parent or spouse was just transferred from the hospital to a short-term rehabilitation center. You survived the initial 48 hours upon admission, in which it seemed like a myriad of health care professionals, such as nurses, certified nursing assistants, the social worker, the registered dietician, physical therapist, occupational therapist, speech therapist, activities director or aide, dietary director or aide, and doctor, introduced themselves to you and performed their own assessment of your loved one’s current level of care.
In addition to feeling emotionally overwhelmed about your loved one’s current illness or injury, how could anyone process and remember who’s who or who is responsible for what?
That is when the care conference comes in. The social worker at each short-term rehabilitation center is responsible for scheduling mom or dad’s care conference within 14 days of their admission to the facility. The care conference gives you the opportunity to express your concerns, ask questions, and meet the individuals responsible for your loved one’s care.
Here is a rundown as to who generally attends these meetings:
- Doctor – Upon admission to the short-term rehabilitation center, the facility either assigns one of their attending physicians to your spouse’s care or you may have the opportunity to choose one. The doctor may or may not attend the care conference. The doctor is responsible for approving any medication changes, consultations with other specialists (such as the facility’s attending psychiatrist), or ordering any lab works, X-Rays, or other exams.
- Nurses – They administer your loved one’s medications on a daily basis, attend to any wounds or other health issues, and work with the certified nursing assistants in ensuring that your family member’s personal care needs are met. The preceding sentence doesn’t even begin to capture how nurses manage almost every aspect of your elderly loved one’s care. They are an integral part of the interdisciplinary team, and their attendance is crucial to the care conference. Medication-related questions or questions related to your spouse’s daily hygiene regimen can be directed to the nurse(s) present at the care conference.
- Certified nursing assistants – Many facilities understand that the certified nursing assistants (since they are the individuals providing your loved one with the daily 1/1 care) are often the first staff members to notice behavioral changes or increased care needs. Their attendance to the care conference is helpful in that they provide insight on your family member’s daily routine or improvements in their ability to perform their activities of daily living.
- Social worker – The social worker is ultimately responsible for planning your spouse’s discharge home from the short-term rehabilitation center. Most importantly, during your loved one’s stay at the facility, they are responsible for educating and connecting you to any outside community resources that would be helpful in assisting you with your caregiving duties. Questions related to community resources can be directed to the social worker during the care conference.
- Physical/occupational therapist – Depending on your parent’s specific treatment plan, both the physical and occupational therapists may be in attendance to the care conference. They would provide you with a comprehensive report as to how your spouse is progressing in therapy, and how long Medicare or the Medicare HMO would continue to pay for your family member’s therapy needs at the facility.
- Speech therapist – The speech therapist would monitor your mom or dad’s ability to tolerate and swallow different textures of food. In addition, they would assist in helping your parent re-learn how to verbalize words after a stroke. During the care conference, the speech therapist would also provide updates on your family member’s progress in these areas.
- Registered dietician – The dietician is responsible for assessing mom or dad’s nutritional needs, and evaluating and reporting any changes. They may or not be in attendance to the care conference. Any questions related to your family member’s feeding tube or nutritional supplements (such as nutritional shakes) should be directed to the dietician.
- Activities director – The activities department is an integral member of the care planning and care conference team. Many studies show that patients’ involvement or participation in facility activities could impact the outcome of their recovery. Therefore, during the care conference, activities personnel offer insight on how they could meet your family member’s social and care needs from a non-medical and non-invasive perspective.
Depending on the items that need to be addressed during the care conference, these meetings could run anywhere from 15 to 45 minutes. More often than not, they are held in a conference room. But I have also attended care conferences that are held and facilitated in the resident’s room.
I recommend bringing another family member or your parent’s private social worker or geriatric care manager to the care conference with you. Your loved one is always invited to attend these meetings, but depending on your loved one’s level of cognitive impairment or dementia, it is always helpful to bring another family member or outside professional who could assist in advocating for your loved one’s current and future long-term care needs.