Teamwork Makes the Dream Work

Submitted by Aaron De La Torre, Therapy Resource, Keystone Borderstone Market, TX
Having a decline in health can be an extremely challenging time for the individual and their family members. Typically, individuals who are admitted to the hospital can expect to be discharged to a skilled nursing facility, where they will receive therapy and nursing care and then be discharged home, where they will be serviced by a new set of therapists at home. At McAllen Transitional Care Center, the team has specialized in helping individuals receive an excellent continuity of care to assist them in their journey to return to their prior level of function. Jennifer Ybarra, DOR, and Ediel Barrera, ED, have worked hard to create a culture where patients are cared for from the time they are referred to McAllen Transitional Care Center until they have returned to their desired environment.

Upon admission into the facility, the evaluating therapists start discharge planning from day one. Once the patient has met all of the inpatient goals and is ready to go home, the physician and team determine the need for continued services. If outpatient services are indicated, the team starts the planning to ensure continuity of care.

Every individual who serves the patient at the facility plays an important role in ensuring that the patient receives the highest continuity of care possible. The patients are excited to discharge home and continue services with the therapists they have made strides with to return to their prior functional level. Below are pictures of the amazing team at McAllen Transitional Care Center that goes above and beyond to make the outpatient dream work!