Author(s): Kathlin Ramsdell, MD, Andreea D. Nitu-Marquise MD, Margaret A. Turk, MD
Originally published: September 11, 2015 Last updated: September 26, 2020
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Overview and Description

Description

The team approach has been a hallmark of rehabilitation since the creation of rehabilitation professionals prior to World War I, and was further advanced with the inception of formalized comprehensive rehabilitation associated with World War II.1 Now, comprehensive care teams and the coordination and communication they foster are being promoted as a necessity for quality healthcare. Comprehensive rehabilitation requires the collaboration of multiple healthcare providers, each with unique skills and training, to optimize function and improve the quality of life for people with temporary or permanent disability.

The field of physical medicine and rehabilitation (PMR) is uniquely equipped for comprehensive rehabilitation. By definition, the primary focus of this specialty is maximal restoration of physical and psychological function. This is achieved through a patient centered approach with teams of multiple professional disciplines working with patients and their families to reach attainable short and long-term goals. Table 1 outlines essential team members as well as more specialized team members that are often integral parts of inpatient rehabilitation facilities (IRFs). 

Table 1: Rehabilitation Team Members

Rehab-Team-Table-1Download

Patients and their families are integral members of the team and must participate in team decision making related to goals and discharge planning. This is vital to the success of the rehabilitation program.

Specialized treatment teams are classically a characteristic of the inpatient rehabilitation setting. Some teams, specifically IRF teams, are defined by regulation. For example, according to the Centers for Medicare and Medicaid Services (CMS), interdisciplinary teams in an IRF must meet every seven days, be explicitly lead by a rehabilitation physician, and also include a registered nurse who is trained as a social worker or case manager as well as licensed or certified physical therapists, occupational therapists and speech and language pathologists.3 All teams utilize goal setting techniques and regular formal communication for coordination and improved patient care. Because of this, teams are felt to be more productive than isolated individual clinicians. There are multiple team models, as described in Table 2.

Table 2: Team Models

Rehab-Team-Table-2Download

The team-based approach can be found in outpatient rehabilitation as well. However, there is often little regulation to define membership or manner of communication, and while not ideal, physician participation is not always required or present, other than to refer or write prescription for patient participation. Despite these challenges, publications support a team approach in community-based outpatient rehabilitation programs.4,5,6 Team approaches can be found in outpatient evaluations of complex patient conditions, such as traumatic brain injury, spina bifida, cerebral palsy, neuromuscular conditions and spinal cord injury. Often the teams are composed of physician specialists and other health care professionals. Outpatient team programs also include a variety of condition-specific programs: cardiac and pulmonary rehabilitation, stroke rehabilitation, chronic pain programs, brain injury day programs, and early intervention programs for children identified as having developmental delays. The American Association of Cardiovascular and Pulmonary Rehabilitation is one example of an organization that supports team work under the supervision of a physician in an outpatient setting. Some voluntary accreditation agencies may even use the presence of a team, physician involvement, and evidence of communication as measures of quality.

Underlying Management Principles

Physiatrists are the physicians who specialize in rehabilitation; they are the team leaders and are responsible for coordinating patient care services with the other team members. Understanding the factors that lead to the development of a successful team is of vital importance to the physiatrist. There are both internal and external environments to consider. Within team environments, effective leadership, open communication, and appropriate goal setting are most essential. Team leadership typically is the responsibility of the physiatrist, but there may be shared leadership with other team members depending on the specific patient issue. Shared leadership is vital to the success of the team, but ultimately it is the physician’s responsibility to oversee all aspects of the team. There are many skills required to successfully lead teams, and setting expectations and knowing how to delegate are important to highlight. Interdisciplinary teams with strong physiatrist leadership and involvement have been associated with high team cohesiveness,7 and this model may be the best strategy for IRFs. Successful team functioning requires skillful leadership and knowledgeable team members, and physiatrists will lead most effectively if they are aware that team members have varying degrees of skill, experience and knowledge. Team leaders should be mindful of both task-oriented functions (e.g., organization, practical and concrete tasks, decision-making) and relationship-oriented functions (e.g., nonjudgmental communication, respect, consensus building, conflict resolution).8,9 Rehabilitation teams tend to primarily engage in task-oriented processes. Following a team meeting template in an IRF stoke rehabilitation program can lead to an increase in home discharge rates and a decrease in acute care discharges and long-term placement, as noted in a report related to stroke rehabilitation programs.10 External environments that influence team processes and functions include health care facility culture, hospital-level administration and hierarchy, and supervisory expectations.7,11 Disciplined supervisors can improve team member participation through the development of professional standards that support team processes. Excellence in care now requires attention to coordination of care, communication (among professionals and with patients using shared decision making), and achieving measurable quality, within both inpatient and outpatient settings. Relating team functioning to patient outcomes may be useful in helping to address future process improvement projects.

Relevance to Clinical Practice

Patient Outcomes and Satisfaction

Certain characteristics of team functioning are associated with rehabilitation outcomes. Within a Veterans Affairs stroke rehabilitation program, for example, key characteristics associated with better patient functional outcomes were 1) greater team structure and formality, 2) use of quality information for feedback to improve treatment processes, and 3) less discipline-specific task orientation (i.e., more in-context cross discipline activities).12 This same study showed an unexpected outcome of longer length of stay (LOS) for teams with greater managerial effectiveness (e.g., possibly better ability to effectively advocate for increased time) versus shorter LOS with better team cohesiveness (e.g., possibly recognizing pressures for shorter LOS). Additionally, a German study suggests that improved patient satisfaction and treatment acceptance is predicted by positive team interactions, in addition to good physician-patient communication.13 Survey data used to identify important physiatrist qualities in an IRF setting noted that caring and competency were important to patients, while collegiality and caring were valued by rehabilitation staff.14 Such research of team characteristics and measurements are still in the early stages of development, despite the fact that rehabilitation teams have been the standard of care for many years. Research about team characteristics and associations with effectiveness measures remains limited. Patient satisfaction has been shown to be positively affected by team processes, although the relationship to outcomes across health care settings is unclear.15

Team Interprofessional Relationships

Strasser et al. suggest five central components of inpatient rehabilitation team functioning: physician support, shared leadership, supervisor team support, team cohesiveness, and team effectiveness.16 While innovation may not be emphasized, it should not be stifled. In general, team members tend to endorse the team approach.14,17 A “team culture” is developed through collaborative leadership, care philosophy, relationships, environmental contexts, and communication.18 Team members often develop alliances within the team, usually among those engaged in the physical needs of the patients and those supporting psychosocial needs. Nurses may also be less integrated, usually because of the separation of the living area from the rehabilitation therapy areas and different staffing patterns or shifts.18 However, when an organized team communicates effectively and works toward a common goal, patient outcomes improve.This includes increased survival to hospital discharge, fewer readmissions, fewer adverse events, higher patient satisfaction and health-related quality of life, and higher staff satisfaction.19

Good communication is a required interpersonal skill for all team members, especially the team leader. Research suggests that communication within well-functioning interdisciplinary teams results in high levels of patient and family satisfaction, improved symptom control, and reduction in LOS.20 Kuziemsky et al. identified six team processes that were a key part of communication within a health information systems:

  • care planning
  • information exchange
  • teaching
  • decision-making
  • negotiation
  • leadership20

Overall, communication is usually complex and often non-linear, and requires both formal and informal communication among team members.18

Unsworth described the complexity of team communication, decision-making, and goal determination. While team goals should be based on patient functional capabilities, social supports, and need for medical management, other factors often distract rehabilitation teams from their focus on patients’ health and functional needs. Diversions are external and internal to the team, and include: 1) organizational and political forces (e.g., hospital environments or cultures, insurance carriers), 2) diverse personal and professional backgrounds and philosophies among team members, and 3) group dynamics that may result in group solidarity or polarization to extremes.21 These may lead to conflicts within the team. Team members have expressed concerns over professional boundaries, and may be defensive about their professional judgments or the acceptance of their judgments.8,17,20 Interprofessional difficulties appear not to be related to specific team members or perceived status in the team, experience in rehabilitation, or professional training.8 Individual teams likely differ in their perceptions of the team process, and different treatment environments can also play a role. Team members have reported “a delicate balance between shared decision-making and top-down decision-making.”18 Open communication and other mechanisms for airing disagreements should be part of team processes to help resolve disagreements. Further education of team members about conflict management skills and their application to conflict dynamics should be considered. Additionally, the physiatrist should be aware of their team’s views and how the environment affects efficiency. Achieving full team member satisfaction, while important, should not be the ultimate goal. More important is the understanding of the relationship between team characteristics, the efficiency of rehabilitation, and ultimately, patient outcomes and satisfaction.

Social Policy and Legislation

The Patient Protection and Affordable Care Act (ACA) has been changing health care financing and delivery since it was signed into law in March, 2010. There is a promise for improved insurance coverage for many, but also the concern for cost limiting measures. In particular, there is a call for altering Medicare and Medicaid and for projects to monitor cost effectiveness in the name of improved quality care. This is of particular interest to Medicare since between 2001 and 2013, Medicare post acute care (PAC) (i.e., IRF, skilled nursing facility [SNF], long-term care hospitals, outpatient services, home health agencies) spending grew annually at a rate of 6.1% and doubled to $59.4 billion while, in comparison, payments to inpatient hospitals grew only at an annual rate of 1.7 during this same time period.22 PAC is one of the fastest growing expenditures within Medicare, and PAC systems vary widely from state to state.22,23,24 Rehabilitation services and devices are one of the 10 essential health benefits that are covered under the ACA; however, individual states define that coverage. For example, state Medicaid coverage plans focused on people with stroke and IRF utilization in all but 4 states.25 Rehabilitation teams continue to be the mainstay of PAC as existing quality measures for IRFs depend on teams for increased functional gains, medical stability and discharge to home within a relative short time frame. In fact, the ACA promotes coordination of care and communication among providers to improve quality of care through Accountable Care Organizations (ACO). Yet, teams and coordination of care are expensive propositions, in large part because of the number of personnel involved. Making decisions about LOS, equipment, or ongoing rehabilitation services may be biased by imposed “report cards” based on inadequate quality proxies such as LOS, total cost, or discharge destination. Inpatient rehabilitation programs and services are likely to be further affected by the ACA24: according to the 2015 Comprehensive Error Rate Testing (CERT) Report, the denial rate for SNFs increased from 6.9% in 2014 to 11% in 2015 due to missing or incomplete certification.26

Educational Issues

Since teams are at the foundation of PMR, resident education in team functioning is an essential part of training. ACGME PMR program requirements note that residents must work within effective interprofessional teams and maximize communication.27 The ACGME milestones recognize the team approach within four of the six reportable competencies, with system-based practice devoting an entire milestone to participation in leadership of team functioning.28 All milestones relate to communication and coordination to ensure high quality and safe patient care.

However, education about team functioning is usually not structured or formalized. This is true not only for resident physicians, but also for other members of the rehabilitation team. More and more, programs are incorporating interprofessional education into health care curriculums. Table 3 outlines existing publications about successful approaches to education about team functioning.

Table 3: Educational Approaches

Rehab-Team-Table-3Download

Team Approach Applications in Other Disciplines

In the field of palliative care, it was found the interdisciplinary teams have the ability to significantly improve patient and team experiences during the process of caring for the terminally and seriously ill.33 They found that patients were most satisfied when individuals were self-aware, humble, and had a comfort with dying and when the team was coordinated with a shared purpose, respected patient autonomy, trusted in the process and were thinking holistically.33

Patient-centered approaches are also becoming more widely used. In a study by Ianova et al., the introduction of a patient-centered, problem-oriented, multidisciplinary rehabilitation program (in comparison to a linear model with each therapist working separately without group discussion) led to increased independence of stroke patients. Improvements in their outcomes were attributed to improved organization, increased focus on functional outcomes, and greater involvement of the patient and their relatives in the rehabilitation process and therefore greater patient interest.34 Additionally, cancer patients now often require rehabilitation prior to discharge, and it has been shown that patient-centered rehabilitation in the field of oncology improves cancer-related symptoms, treatment related side effects, and the quality of life of both the patient and the caregiver.35 Multidisciplinary approaches are also now being incorporated into treatment and prevention of obesity,36 and Rytter et al. demonstrated that a specialized, interdisciplinary rehabilitation program was effective at reducing post concussive symptoms in physical, emotional and cognitive areas.37 It is clear that interprofessional and multidisciplinary rehabilitation is translatable to multiple specialties and can make significant improvements inpatient care.

Cutting Edge/Unique Concepts/Emerging Issues

Many specialty care services, within and outside of PMR, are adopting the concepts of team functioning, and sometimes modifying implementation strategies to meet specific patient needs or outcomes. The Department of Veterans Affairs Polytrauma System of Care is an integrated network of specialized rehabilitation programs that serve Veterans and Service Members with both combat and civilian related traumatic brain injury and polytrauma. This program recognizes the increasing complexities of medical care, which now requires integration with social, financial, educational and vocational resources, engagement with families as a part of the team, and coordination of care across multiple medical centers and programs in both inpatient and outpatient settings. Quality improvement projects are required for hospital programs and physicians participating in maintenance of certification. Projects are being focused on measurements of team behaviors, team education, and team effectiveness on patient outcomes.32 Strasser et al. advocate for further evaluation of complex care coordination and geographic dispersion of care31, with possible replication in the private sector. Additionally, Zanca et al. describe the Rehabilitation Treatment Specification System (RTSS) that provides a universal framework and language for rehabilitation interventions that allows clinicians to see the connection between their intervention and functional outcomes, which will not only improve patient care but may also help justify appropriate reimbursement.38 Table 4 outlines the principles of the system.

Table 4: Rehabilitation Treatment Specification System Principles

Rehab-Team-Table-4Download

Gaps in Knowledge/Evidence Base

While it is well known that teams are integral to rehabilitation, there is a paucity of research and publications related to the rehabilitation interdisciplinary team process, functioning, and effectiveness across health care settings. There appears to be a strong connection between team effectiveness and patient outcomes. However, a definition of team functioning, the necessary characteristics of a team or team members and leaders, and the determination of modifiable factors have not been clarified, especially now with more specialty care services adopting a team approach. Teams continue to be promoted in health care as a solution to improved coordination of complex care, despite the lack of science that clearly defines team functioning, cost, or cost effectiveness.

References

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Original Version of the Topic

Margaret A. Turk, MD, Andreea D. Nitu-Marquise MD. Rehabilitation team functioning. 9/11/2015

Author Disclosure

Kathlin Ramsdell, MD
Nothing to Disclose

Andreea D. Nitu-Marquise, MD
Nothing to Disclose

Margaret A Turk, MD
Elsevier Inc, Honorarium, Co-Editor-in-Chief; Center for Disease Control and Prevention (CDC), National Center for Birth Defects and Developmental Disabilities (NCBDDD), Cooperative agreement/research grant 1U19DD001218, Co-PI/Researcher; National Institutes of Health, National Institute on Aging, Research grant 1R03AG065638-01, Consultant