Type of service: Short-Term, Complex Medical Management meets needs of patients with multiple medically complex chronic diseases such as neuromuscular and renal disease and/or who have had a traumatic injury that requires unique care programming.
Admission criteria: Age 16 years or older, acute medical needs stabilized, yet medically complex with long-term illnesses/disabilities and/or disabilities and comorbidities typically requiring daily physician/medical care, and ongoing skilled nursing and technology based care that cannot be provided by community programs/services. On admission, may have limited physical and/or cognitive capacity due to medical complexity but believed to have restorative potential.
Meets needs of patients with multiple medically complex chronic diseases such as neuromuscular and renal disease and/or who have had a traumatic injury that requires unique care programming. Some distinct cohorts will include, but are not limited to: ventilator dependent, dialysis, stroke, complex wound care and longer term rehabilitation. Stroke patients with an alpha FIM score of <40 will be considered for admission with regular assessment for transition to inpatient rehabilitation.
Patients must demonstrate a need and ability to participate in a minimum weekly therapy plan supporting functional progression. Functional objectives include stabilization and progression to avoid further loss of function, increase activity tolerance and progress to safely transition home or appropriate destination within the community. Target LOS 90 days
