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Scope of Services, Persons Served & Resources

Referral Sources:

We receive referrals from the geographic area of predominately Palm Beach, Broward, and Dade County, FL. These referrals usually come from acute hospitals and long term acute care hospitals (LTAC); however a referral can be made

by a skilled nursing facility, home health agency, outpatient center, worker’s compensation case manager, physician, as well as a self referral.

Methods Used to Assess and Meet Patient’s Needs:

Pre-admission screenings are completed prior to admission, during which current functional status is evaluated and discharge goals are determined. A comprehensive assessment of each patient’s medical, physical, and cognitive condition including psychosocial and cultural preferences is a prerequisite for the formation of your rehab program and to determine possible benefit from admission. The Rehabilitation Medical Director will review the pre-admission assessment in order to make a decision to approve or deny the referral prior to admission and the decision will be communicated to the referral source, patient and family/support system. If a referral is determined to be ineligible, recommendations can be made for alternative services in a more appropriate setting along with applicable resources.

Patients Served:

The rehabilitation program serves patients with a variety of medical, physical, and functional needs. Some of the conditions treated in the program are as follows:

  • Stroke
  • Spinal Cord Injury
  • Amputation
  • Brain Injury
  • Guillain-Barre
  • Hip Fractures
  • Joint Replacements
  • Multiple Trauma
  • Cardiac or Pulmonary Disorders
  • Myopathy
  • Progressive or Degenerative Neurological Disorders:
    • Multiple Sclerosis
    • Muscular Dystrophy

Admission and Continued Stay Criteria:

  • Patient must be medically stable
  • Patient must be able to tolerate an intensive rehabilitation therapy program consisting of three hours of therapy per day at least five days per week or consist of at least 15 hours of intensive rehabilitation therapy within a seven consecutive day period upon physician order, beginning with the date of admission
  • Nursing care must be required 24 hours a day
  • Patient must require two or more therapies one of which will be physical or occupational therapy as well as a coordinated interdisciplinary approach to their rehabilitation
  • Patient must have experienced a functional decline
  • Patient must have potential for improvement
  • Patient must be cooperative and motivated to fully participate in the rehab
  • Patient must require physician supervision by a rehabilitation physician to access the patient both medically and functionally as well as to modify the course of treatment as needed to maximize the patient’s capacity to benefit from the rehabilitation process
  • Patient must have a pay source or an arrangement with our financial department prior to admission.
  • Patient must be expected to realistically discharge back to the

Discharge and Transition Criteria:

Our team works with you, the patient, and your family to ensure the most appropriate placement following discharge from the Acute Rehabilitation Unit. When the patient’s medical condition allows, the patient and family will be notified in order to plan for the pending discharge by the Rehabilitation Team. Discharge from the program shall be considered when one or the following criteria occurs:

  • A patient has reached rehabilitation potential and no longer qualifies for this intensity of therapy services
  • A patient has plateaued in the rehabilitation process and no longer qualifies for this intensity of therapy services.
  • A patient is medically unstable requiring more intensive medical
  • A patient is behaviorally unable to cooperate with the demands of the program and or is jeopardizing his/her own safety or that of other patients and or staff
  • A patient refuses to participate in the program, despite being medically stable, and there is no evidence of progress, resulting in a discharge to appropriate level of care.

Alternative Resources:

A Transition Coordinator/case manager will facilitate your discharge from inpatient rehabilitation. The Transition Coordinator will help identify and arrange for any individualized services that may be required upon discharge. These may include:

  • Durable medical equipment (DME) and prosthetics and orthotics
  • Home health services
  • Outpatient therapies
  • Skilled nursing services where therapy regime is less intense level and there is 24 hour nursing care
  • Community resources
  • Transportation or accessibility needs

Non-Voluntary Discharge:

  • If you are unable to complete the intensity of service, minimum of three hours of combined therapy at least five days per week, our discharge planning staff will assist in finding placement in a less intensive setting to continue services.
  • Circumstances have changed and you are no longer expected to return to the

Services Provided Directly or By Referral May Include:

  • Rehabilitation Medicine
  • Specialty consults as necessary
  • Rehabilitation Nursing
  • Physical Therapy
  • Occupational Therapy
  • Speech Language Pathology
  • Activity Programs
  • Social Work/Case Management
  • Therapeutic Recreation
  • Psychology or Neuropsychology
  • Orthotics & Prosthetics
  • Visual Assessment
  • Respiratory Services
  • Dietary Services
  • Renal Dialysis
  • Wound Care
  • Chaplaincy
  • Home Evaluation

Medical, diagnostic, laboratory, and pharmacy services are also available here at Delray Medical Center. The response time is specific to each of these services.

It is the expectation, however, that the vast majority of orders or consultations will receive some level of response within 24 hours of a department/ or medical

consultant receiving the order excluding critical orders, which take precedent. That initial response will then be conveyed to the appropriate clinician(s) as soon as possible.

SCOPE OF SERVICES:

Comprehensive inpatient rehabilitation services are provided to adult and adult geriatric patients with neurological and other medical conditions of recent onset or regression and who have experienced a loss of function in activities of daily living, mobility, cognition, or communication. This program serves persons 18 years and older and accepts persons served of varying cultural backgrounds and of all payer sources. All patients are medically stable but have sufficient medical acuity to warrant an ongoing hospital stay.

Persons served will receive 24 hour rehabilitation nursing and a minimum of three hours a day of therapy a day, no less than five out of seven days in the week. Your therapy program, including the frequency, intensity and length of stay, will be designed according to your needs after you have been fully evaluated. Hours for therapy services are normally provided within the hours of 7:30 am to 5:00 pm Monday through Saturday. Our patients receive at least 3 hours of individualized, therapy at least 5 days per week during their stay.

The team will work with you and your family to help determine the best discharge environment for you based on your needs at the time of discharge. If you are unable to return home, the team will assist you and your family in making other arrangements.

Rehabilitation Services