At Pleasant Manor Senior Community, we are committed to ensuring our patients are engaged and prepared to succeed when they leave our community. We have integrated a state-of-the art solution called Engage that allows our staff to easily track the progress of each patient, provides management intelligence to our team, and ensures each patient has the tools, resources, and support necessary to self-manage at home.
While providing the highest quality of clinical care is always forefront, we recognize that the ability to self-manage after discharge is dependent upon several key factors:
We actively engage the patient and the family early in the stay.
- Preparation for transition begins at admission.
- The engaged patient takes an active role in their recovery process.
We learn as much as possible about the patient, their prior living situation, and their expectations.
- Having a clear understanding of the expectations of the patient and the family paves the way for productive communication.
- Closing expectation gaps to the greatest extent possible sets the stage for successful transitions.
We listen to our patients ‘In the Moment’.
- We use ‘In the Moment’ conversations during the course of each stay to listen to our patients while they are with us.
- Their feedback gives us the opportunity to address any issues immediately so that by the time they leave us they feel well prepared to self-manage.
We provide each patient with timely, relevant education.
- Providing relevant education is a cornerstone for successful patient outcomes.
- Engage’s Accelerated Patient Learning provides customized, patient-centered education paths.
Upon discharge, each patient receives a customized, comprehensive set of transition instructions for managing their care.
- The transition (discharge) plan is written for the patient and outlines a clear program to help them or their family members manage their care.
- Patients are encouraged to take the transition plan with them to follow-up appointments with health care professionals following them after discharge.
Active, ongoing post-transition follow-up with each patient is a priority.
- We understand that follow-up after discharge is critical to our patient’s ability to successfully manage their own care.
- We are able to connect with patients actively and provide early intervention on issues that may lead to readmission through Engage’s Continuum Manager.