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The patient journey

Step 1

Assessment and personalised care plan


Once the patient has been admitted, they are assessed by each member of Senso Health’s multidisciplinary team. They conduct an in-depth medical and functional assessment to measure all areas that are relevant to the patient’s daily life.


Once completed, an in-depth team review is conducted and a set of medical, physical, cognitive and psychosocial treatment goals are set. These goals, and anticipated length of stay, are discussed with the patient and their family as part of a formal meeting.


All assessments, documentation and treatments plans are also shared with the patient’s referring provider team.

Step 2

Ongoing therapy and progress updates


Patients receive daily therapy based on their care plan. This typically includes ongoing interactions with a multidisciplinary team, as well as nursing care. The sessions are closely monitored to track patient progress, which is also formally scored on a weekly basis.


To facilitate the process, the multidisciplinary team meets on a weekly basis to discuss each patient and their respective progress. All monitoring is evidence-based with the team using Beta Scale Tools as developed by the South African Database for Functional Medicine. These regular discussions and ongoing monitoring enable proactive changes to the patient’s care plans for optimal recovery outcomes.


Regular updates are shared with the patient, their family, referring providers and medical funder (if applicable). Should an extended length-of-stay be required, this is also immediately discussed, and coordinated, with the patient’s medical funder.

Step 3

Patient discharge and return to home


The discharge planning process is done well in advance and the patient’s home needs are thoroughly assessed by the treating team. If required, a social worker will conduct a home visit to further facilitate the process.


Informed recommendations are made, including equipment needs and possible home modifications. The Senso Health team is able to facilitate all requirements, including equipment arrangements with suppliers, liaising with home-based nursing agencies and appointing caregivers as needed.


Once a patient is ready for discharge, a final update is sent to the patient’s primary physician, family and medical funder. If needed, follow-up appointments are also arranged with the patient’s Senso Health team.

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