Rehabilitation Teams

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Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Ashmita Patrao, Kim Jackson, Jess Bell, Oyemi Sillo, Wanda van Niekerk, Ewa Jaraczewska, Admin, Tarina van der Stockt, Vidya Acharya, Lucinda hampton and Stacy Schiurring      

Introduction

Cohen and Mohrman define a team as ”a group of individuals who work together to produce products or deliver services for which they are mutually accountable”.  The shared goals of the team are made manifest by mutual and cordial interaction by team members, and the roles of each professional in the team are mutually interdependent and accountable to enable achievement of set goals. Similarly, Eduardo Salas defines a team as a “distinguishable set of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal, objective or mission, who have been each assigned specific roles or functions to perform, and who have a limited life-span of membership.”  Basically a team consists of a group of people with complementary skills who are committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable.

"The premise underlying team care has always been that assorted professionals, each contributing their own discipline's expertise and closely cooperating through oral (team rounds, informal hallway discussions etc.) and written communication (medical record entries, reports etc.) are able to achieve outcomes that are superior to those of a lone clinician, or of a number of different clinicians each practising independently of all others."  Reliance on multifaceted team-based care enables an evolving health care system to address the changing patient needs with regard to physical, psychological, and social aspects of health. 

Types of Teams

The terms “multidisciplinary,” “interdisciplinary,” and “transdisciplinary” are increasingly being used interchangeably to define health and social care and rehabilitation teams and outline the various degrees of involvement of the multiple disciplines within the team environment, but there are clear differences between these different approaches to care.

Multidisciplinary

According to Jefferies & Chan (2004), multidisciplinary team working is described as the main mechanism to ensure truly holistic care for patients and a seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary and tertiary care. The Multidisciplinary Team (MDT) is a team of professionals that includes representatives of different disciplines e.g. Physiotherapy, Occupational Therapy etc., who coordinate the contribution of each discipline with little overlap to assess and treat the patient separately with discipline specific goals. There are different definitions and descriptions which capture important features of multidisciplinary work. Each discipline could function autonomously, working in parallel towards a shared goal; acknowledging one other’s contributions and sharing successes. The patient’s progress within each discipline is communicated through written documentation and regular team meetings and as such does not emphasize an integrated approach to care. This type of team approach is predominantly what we see in an acute hospital setting.

• Each discipline works in parallel with clearly defined roles with the team
• Each discipline sets their own individual, specific goals with the patient and communicates these goals and outcomes with the team through written documentation or within team meetings where appropriate 
• In most cases within an Acute Setting the team is Consultant / Physician led 

Interdisciplinary

Interdisciplinary teams differ from multidisciplinary teams in that they overlap practice with shared goals coordinated into a unified management plan, rather than working individually, allowing for group decision making and group responsibility, with the patient considered an active member of the team. Each team member in an interdisciplinary team build on each other’s expertise to achieve the common, shared goals. Patient progress is communicated through written documentation and regular team meetings as in the multidisciplinary approach but reports tend to focus more on the common overall patient goals rather than on discipline specific goals.  According to Fergusson (2014) an interdisciplinary care plan generally is developed by considering the following questions:

• What are the issues?
• Who will be involved?
• What will the interventions be?
• What are the goals of the intervention?
• When will re-evaluation occur? 

The interdisciplinary team is very common in inpatient spinal cord injury rehabilitation centers. Interdisciplinary teams involve: 

• Professionals involved in joint problem solving
• Overlapping, patient focused treatment goals
• Collaboration with other disciplines
• Regular communication between team members
• Active involvement of the patient 

Transdisciplinary

Transdisciplinary teams share roles across disciplinary boundaries so that communication, interaction, and cooperation are maximised among team members with an overlap of responsibilities that allows flexibility in problem solving and produces closer interdependence of team members. Team members jointly communicate, exchange ideas and work together to come up with solutions to problems from day one of working with the individual. In this approach, there is no hierarchy among the disciplines, and there is a higher level of communication and cooperation among the individual members of the organisation.   Flexible boundaries and interchangeable roles and responsibilities encourage the exchange of information, knowledge and skills.The interwoven nature of transdisciplinary teams broaden the skill sets of each therapist due to their exposure and substantial interaction with others outside their discipline, but it also allows the team of professionals to work together to reinforce and maintain goals not normally monitored. With a truly transdisciplinary team, the typical boundaries of each professional discipline tend to disappear.

The individual and family are central to this type of team and are respected as equal, and valued team members, often the final decision makers in the team. As such this model is an extension of the interdisciplinary team and seen as a family friendly approach, operating within a family centred practice model. This model is frequently used in environments where there are inadequate numbers and / or unavailability of specific disciplines e.g developing countries, rural or isolated communities, leading to other team members taking on these missing roles. 

• Professionals have an overlap of responsibilities
• Flexibility in problem solving 
• Closer interdependence of team members
• Active involvment of the patient and family

Comparison of Teams

According to Kirshblum (2013) and Fergusson (2014) the collaborative approach is the fundamental difference between both the interdisciplinary and transdisciplinary team approach in comparison to the multidisciplinary team, which does not emphasise an integrated approach to care. In the multidisciplinary approach each discipline approach a situation or problem from their own perspective and then share findings, often presenting problems with development of a cohesive management plan. This interdependance is also seen with interdisciplinary teams, but efforts are much more collaborative and team members work together toward a resolution, building on each other’s expertise to achieve common, shared goals. While with a transdisciplinary teams the lines are more blurred, and the typical boundaries of each professional discipline tend to disappear.  The interdisciplinary approach to patient care has shown better results for team effectiveness in comparison with a multidisciplinary approach. 

Team Members

Team composition will vary depending on the type of team structure used, the phase of treatment, the environment and specific resources available. Exactly who is included in the team will vary through each of the different phases of management, with the roles often dependent on the specific health system set up and resources available locally. The clinical role of team members as health providers is hugely diverse within the varying areas of care giving (primary, secondary and tertiary care) and a variety of subspecialties.

For example, during the acute phase following a spinal cord injury the team members may include a spinal surgeon, a general physician or neurologist / spinal cord injury specialist, an anesthesiologist, intensive care nurses, specialist respiratory and acute neurology physiotherapists, occupational therapists, speech and language therapists, dieticians, social workers, and trauma psychologists. While during the rehabilitation phase of treatment, the team members might include a rehabilitation physician with specialism in spinal cord injury, urologist with an interest in neurourology, specialist spinal cord injury rehabilitation nurses, physiotherapists who have skills in motor learning, balance, strength, cardiovascular, gait and wheelchair mobility, rehabilitation therapists who have an interest in disability sport and recreation programs, occupational therapists who have skills in facilitating independence in self-care, seating prescription and adaptive aids, social workers who work with families as well as patients, dietitians, clinical psychologists and neuropsychologists, peer counselors, family members and care support workers and, most importantly, the patient. 

Individual

The individual accessing rehabilitation services are and always should be a key member of the team throughout each phase of the rehabilitation process. They are key in the development of goals and should have the opportunity to question the process and / or the goals, and direct their rehabilitation needs in order to optimise their function.

Family & Friends

Family members, friends and caregivers play an essential role and provide key emotional support to the individual and is an important and integral part of any rehabilitation program.

Physiotherapist

Physiotherapy is treatment to restore, maintain, and make the most of a patient’s mobility, function, and well-being. Physiotherapists help people affected by injury, illness or disability through physical rehabilitation, injury prevention, and health and fitness. They helps to encourage development and facilitate recovery, enabling people to stay in work while helping them remain independent for as long as possible.

Occupational Therapist

Occupational therapy focuses on maximising a person’s ability to perform a wide range of activities of daily living and are responsible for assessing the impact of the illness or injury on these activities. They provide strategies and environmental adaptations to facilitate independence and build on skills.

Speech and Language Therapist

Speech and language therapy enable people with communication disorders and swallowing disorders to achieve their maximum potential. They are involved in assessing their clients’ communication and swallowing difficulties, and developing treatment programmes to meet their needs.

Psychologist

Clinical psychology aims to reduce distress and to enhance and promote psychological well-being, minimise exclusion and inequalities and enable individuals to engage in meaningful relationships and valued work and leisure activities. They work with individuals, families and groups of different ages experiencing psychological distress or behavioural problems which disrupt their everyday functioning and wellbeing

Dietician

Dieticians translate the science of nutrition into everyday information about food and advise people on their food and nutrition choices. They assess, diagnose and treat dietary and nutritional problems with their overall aim to promote good health and prevent disease in individuals and communities.

Podiatrist

Podiatrists specialise in the diagnosis and treatment of lower limb conditions, common foot ailments and chronic medical conditions that affect the feet and lower limbs.

Orthotists

An orthotist is a healthcare professional who makes and fits braces and splints (orthoses) for people who need added support for body parts that have been weakened by injury, disease, or disorders of the nerves, muscles, or bones.

Prosthetists

A prosthetist is a healthcare professional who makes and fits artificial limbs (prostheses) for people with disabilities. This includes artificial legs and arms for people who have had amputations due to conditions such as cancer, diabetes, or injury.

Assistive Technologist

Assistive technology and adaptive devices, both low tech and high tech, are key for many people to assist with independence in daily living activities i.e. pressure relief mattresses, moving beds, switches and controllers, computers and power wheelchairs. Assistive technologists often play a key role in rehabilitation at all phases. These individuals tend to have a background in either rehabilitation engineering and/or occupational therapy. The solutions provided are usually designed to enhance communication, mobility and access to computers, educational materials and environmental control, thus promoting greater independence by enabling the person to perform tasks that they were previously unable to accomplish or had great difficulty accomplishing. 

Social Worker

Social workers work in partnership with individuals, families and groups experiencing marginalisation, disadvantage, social, and or emotional difficulties. The aim of social work is to facilitate and enable individuals to identify options and make decisions for themselves so that they may develop strategies to solve problems and to effect improvement in the quality of their own lives.

Audiologist

Audiologists identify, assess and manage disorders of hearing, balance and other neural systems. Audiologists are trained to diagnose, manage and treat hearing or balance problems for individuals from birth through adulthood.

Optician, Optometry and Ophthalmology

Opticians are technicians trained to design, verify and fit eyeglass lenses and frames, contact lenses, and other devices to correct eyesight. They use prescriptions supplied by ophthalmologists or optometrists, but do not test vision or write prescriptions for visual correction.

Optometrists are healthcare professionals who provide primary vision care ranging from sight testing and correction to the diagnosis, treatment, and management of vision changes, which primarily involves performing eye exams and vision tests, prescribing and dispensing corrective lenses, detecting certain eye abnormalities, and prescribing medications for certain eye diseases.

An ophthalmologist is a medical doctor who specializes in eye and vision care. Ophthalmologists differ from optometrists and opticians in their levels of training and in what they can diagnose and treat. An ophthalmologist diagnoses and treats all eye diseases, performs eye surgery and prescribes and fits eyeglasses and contact lenses to correct vision problems.

Peer Support Worker

Peer support workers are individuals who have lived experience of the specific illness or injury who use their own experiences and empathy to support other people and their families receiving rehabilitation services. Peer support workers join other members of someone’s care team to help support their wellbeing and provide inspiration for their recovery.

Nurse

Nurses have a broad role covering a range of rehabilitation issues including personal care, activities of daily living, short and long term health, social, independence issues and emotional support. They also facilitate other discipline rehabilitation activities outside therapy time as they are present “24-7,” thus allowing and even encouraging the patient to practice what they have been learning in their therapy sessions.

Physician

The physician role and type of physicians involved will vary hugely depending on the type of illness or injury and phase of management i.e. acute, rehabilitation or post discharge. Types of physicians involved include Emergency Medicine, Anaesthesiologist, Orthopedist, Neurologist, Neurosurgeon, Respiratory, Urologist, Physiatrist or Rehabilitation Medicine. Diagnosis and management of underlying pathology and impairments through medical assessment, treatment whether conservative or surgical, including prescribing pharmacological and non-pharmacological, and rehabilitation planning are key roles of the physician. They have an important role in ensuring that the individual is well enough to participate in rehabilitation.  

Community Health Worker

Community health workers are frontline public health workers who have a close understanding of the community they serve. This trusting relationship enables them to serve as a liaison/link/intermediary between health services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

Community health workers also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.

Resources

References