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Is A Team Approach to Community-Based Rehabilitation Really Possible?

Is a team approach really possible in community rehabilitation?The effectiveness of multi-disciplinary teams is well evidenced in the rehabilitation literature. In fact, in an overview of 14 systematic reviews, the Journal of Rehabilitation Medicine found support for multi-disciplinary teams in 10 different populations including adults with acquired brain injury, multiple sclerosis and stroke, as well as for chronic pain, low back pain and fibromyalgia (Momsen et al, 2012).

The evidence tells us that working in teams provides the best outcomes for clients. But what does this approach to care really look like? It is easy enough to imagine in the hospital setting: members of different health care professions sharing offices, sharing ideas in rounds, having conversations at the nurses’ station, etc. Imagine a client on an acquired brain injury floor of a rehab hospital. In addition to a nursing and medical team, he or she likely also has an occupational therapist, physiotherapist, speech-language pathologist and a social worker. The OT and SLP might both be working on cognitive strategies and would reinforce each other’s strategies with the client. The nursing team, OT and PT might work together to ensure that the client is safe with bed mobility and transfers. The social worker will work closely with the client’s family and will collaborate with the team to facilitate a discharge plan. Everybody is on the same page. Miscommunications are avoided and ultimately (and most importantly) the client benefits from the care team working so closely together.

And then the client is discharged home. Then what happens?

Unfortunately, what sometimes happens is that the team-based approach ends. The client might have an OT working on home safety strategies and increasing participation in meaningful activity. He or she may be attending physiotherapy at a community clinic. Perhaps there is also a social worker involved who is providing counseling around adjustment to illness. While each professional may be providing excellent care, the communication and collaboration to achieve the client’s goals is often lost. This can result in uncoordinated care and can delay recovery time and goal achievement for the client.

At GLA, we work to integrate our clients’ care. We have in-house occupational therapists, physiotherapists, social workers as well as highly trained rehabilitation support workers all working closely together. Therapists at GLA collaborate in teams to ensure coordination of client care. Many of our clients receive services from two or more disciplines and ongoing communication between therapists is viewed as an essential component of the client’s care plan. From phone calls and emails between treating therapists to formal team meetings held at the client’s home or in our offices, we believe that this evidence-based approach to care provides the best outcomes for our clients.

Momsen, A.M., Rasmussen, J.O., Nielson, C.V., Iverson, M.D., Lund, H. (2012). Multidisciplinary team care in rehabilitation: an overview of reviews. Journal of Rehabilitation Medicine, 44(11), 901-12. doi: 10.2340/16501977-1040.