The Initial Evaluation and Assessment Phase:
After admission, the first step in the “Rehab” process is to thoroughly evaluate each client to determine individual strength and needs.  Every client is unique; each has their own personal history, personality, learning style and personal goals.  For rehabilitation treatment strategies to be successful, they must meet the client’s individual needs at that particular time.

This initial phase involves a comprehensive evaluation within the first 7-10 days of admission to the program.  The physician completes a History & Physical exam and report.  Licensed therapists - Physical Therapy (PT), Occupational Therapy (OT), and Speech Pathology (SLP) complete discipline specific evaluations.  Behavioral information and data are recorded in ½ hour intervals, 16 hours a day.  Both pro-social behavior (desirable, functional behavior) and maladaptive behavior (behaviors that put client at risk or risk to others) are collected in order to qualify and quantify baseline behaviors.  The baseline data points are used to help determine the effectiveness of medication trials and individual behavioral intervention plans.  By Day 10, a Master Treatment Plan (MTP) based on the discipline specific evaluations, client/family statement of goals, and goals as stated by the funding source is completed.  The MTP is a working document which structures, coordinates and guides the team toward the overall goals and objectives. The MTP also provides a basis for evaluation of the effectiveness of treatment strategies; identifies perceived barriers to treatment, and helps project length of stay and outcomes.

The Structured Rehabilitation Phase:
As the Master Treatment Plan and evaluative process are completed, the client enters the Structured Rehabilitation Phase.  This phase is defined by highly structured and coordinated therapeutic activities. Each client’s daily schedule consists of 3-5 hours of a combination of licensed therapies and volunteer work activities.  These activities are performed on campus or at off campus volunteer sites under staff supervision.  Therapeutic sessions begin upon awakening and conclude following the group sessions held after the evening meal.  Medication trials are initiated and closely monitored by the physician/pharmacologist team. A review and comparison of behavioral data is completed weekly in order to assess the effectiveness of the treatment program. Changes in medication and/or treatment programs occur based on success in achieving the desired changes in cognition, function, and behavior, as well as a guard against adverse side effects.  Family Education is emphasized during the Structured Rehabilitation Phase as well.

Discharge Planning
Though discharge planning is often considered the final phase of the rehabilitation process, it actually starts at the time of admission, when the question “Where do you see yourself returning at the completion of this rehabilitation stay?” is asked.  Depending on the personal circumstances of each family in terms of supportive resources and practical issues, responses vary.  Often the answer is “To return home, if …..can be accomplished”.  However this question is answered, the answer is integrated as a key treatment goal and component of the discharge plan from the very beginning of treatment. Re-evaluation of this goal occurs at specific intervals throughout in order to assess the initial plan’s feasibility.  As the Structured Rehabilitation phase progresses and desired improvements emerge and stabilize, the discharge plan becomes more concrete. 

Home and community assessments are often included in the discharge plan to identify physical barriers that may be present at the discharge site. Coordination with essential support services and community resources is implemented to facilitate success at home.  More frequent family education and counseling sessions are conducted to help assure a successful discharge.  Supervised therapeutic home visits ranging from a few hours to overnight or to multiply overnights are planned and incorporated into treatment solidifying a smooth transition. 

Post discharge follow up plans are scheduled and coordinated with local support systems in order to support gains achieved during treatment.  Referrals for ongoing therapeutic services and continuation of volunteer/work in the respective community are included and are critical to a sustainable and successful discharge.