The interdisciplinary team consists of
every staff member who interacts with
patients, including physicians, nurse
practitioners, social workers, nurses,
receptionists, pharmacists, dieticians,
physical therapists, home health nurses,
chaplains, and librarians.
The entire team meets for hour-long
weekly care conferences to discuss
high-risk, complex patients.
For all patients seen in the SHWC, health
status is assessed using standardized
tools for health data such as mental
status, risk for falls, depression, nutrition,
and others.
Medical practice guidelines for pain, falls,
diabetes, urinary incontinence, dementia,
and osteoarthritis are used. An electronic
medical record houses patient's medical
records from hospitalizations and visits to
the clinic. Weekly reports identify patients
who go to the emergency room, hospital,
or outpatient surgery.
Click here to download below chart in printable PDF format
Click here to download chart in printable PDF format
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