Customized Restorative Care Plans 

Transitional Care  

All-American Care is known for its transitional care model and goals of sending patients back to their home, or moving a patient who is functioning at their highest level to a lower level of service. Over 40 years of expertise in the Long Term Care field enables us to assess each patient's unique needs and develop a Restorative Care Plan to advance his or her improvement to the highest level of functioning possible.

This is done through a combination of deductive processes and computerized technology which allow us to obtain full Medicare, and other applicable insurance coverage, for the number of days (up to 100 for each episode of illness) required to restore the patient. Our system, the Caregiver Management System of Care Models and Customized Care Planning is the only one of its kind.

We take great pride in offering you our 4Rs of Transitional Care for the post hospital treatment of any illness or injury. The 4Rs approach has a high degree of success in reintegrating a patient back into the community, or continuing with a high quality of life in a lower level service. This is an effective approach because we assess all patients upon admission for physical, emotional, spiritual and social problems in order to develop individualized care plans that work! These individualized care plans are then implemented, and interventions are tracked using a computerized system that methodically carries our team through all the proper steps to restore the patient, then preserve their health and improve their quality of life.

Our 4Rs Patient Assessment  

All-American Care’s 4Rs – recuperation, restoration, rehabilitation and reintegration – set us apart from all other long term care facilities:

  • Medical diagnosis is the basis for determining a patient's recuperative medical needs
  • Nursing diagnosis and MDS are the basis for defining the patient’s daily skilled restorative nursing, nutrition and medication needs
  • Therapy diagnosis is the basis for treating skilled rehabilitation needs
  • Social histories and family input determine a discharge plan for reintegration back into the community and includes social likes and dislikes

Restorative Programs  

All-American Care patients are guided through a comprehensive Restorative Care Plan by our capable team. Every step of the way is designed to develop improvement in Activities of Daily Living. As patients graduate from direct therapies and low rehabilitation programs, they advance to appropriate restorative nursing and/or retraining programs such as bathing, grooming, eating, ambulating, dressing and toileting.

Each Restorative Care Plan is carefully developed after assessing the patient by professional nurses and therapists, and approved by the physician. All-American Care patients will remain in the program for the length of time necessary to achieve their highest level of functioning.

Skilled Rehabilitation  

All-American Care has a tradition of providing a full range of therapy services that work toward restoring patients to their highest level of functioning in accordance with their Restorative Care Plan, and sustaining that level. Our licensed therapists provide a full range of physical, occupational and speech services. All-American Care therapists preserve the patient’s dignity throughout treatment, while encouraging each patient to achieve their goals. Progress is closely monitored and compared to the care plan goal for each patient problem.

The All-American Care record speaks for itself. A high percentage of All-American Care patients return home or move to a lower level of care.  

Skilled Nursing Programs  

All-American Care medical directors and nursing directors are available 24 hours a day, seven days a week. All American Care patients begin their program with a careful assessment and development of a Restorative Care Plan. Each day, the patient is re assessed to determine progress or deterioration using the PIE methodology – Problems, Interventions, Evaluation. All-American Care skilled nursing services include, though are not limited to:

  • PIE assessment based on patient diagnosis and Care Plan
  • Monitoring of physical, emotional, social and spiritual patient problems, using a variety of techniques such as vital signs, weight changes, skin condition, and effectiveness of interventions
  • Restorative classes in activities of daily living
  • Supervision of Certified Nurses Aide assignments
  • Supervision and coordination of Care Plan implementation
  • Medication management including IV therapy and patient teaching
  • Nutrition management and patient teaching
  • Wound Care
  • Evaluation of outcome level for each problem
  • Consultation with physician, therapist, social worker and family to coordinate and manage patient care