Author(s): Scott Campea, MD, Ian Joungouk Kim, MD
Originally published: September 11, 2015 Last updated: March 11, 2024
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Overview and Description

Description

Since World War 1, the team approach to patient care has been a hallmark of the medical specialty of Physical Medicine and Rehabilitation, also called Physiatry. Care of soldiers during and after World War II formalized comprehensive rehabilitation and fostered the team approach in the specialty care of individuals with temporary or permanent disabilities.

Rehabilitation team care of patients is effective in the inpatient or outpatient setting. Inpatient rehabilitation facilities (IPR) provide inpatient medical care while simultaneously providing intensive rehabilitation. A team approach to these inpatients is critical. Collaboration and communication are essential to the patient team approach. Together, the health care professionals focus on the patient’s specific medical rehabilitation and psychological care to achieve the goal of increased function and quality of life.

A physiatrist, a physician specialist trained in Physical Medicine and Rehabilitation, leads the rehabilitation medicine team. Because many inpatients are complex and require care from multiple disciplines, physiatrists need to understand the role of each of the members of the patient care team. Additionally, the physiatrist must utilize the leadership skills necessary to build and maximize the team’s specialized function in patient care. This article provides an overview of rehabilitation team function, considers its clinical applications, and discusses emerging topics and gaps in our knowledge. 

Overview of Rehabilitation Team Function 

What is a rehabilitation team? 

A rehabilitation team is a group of healthcare professionals with distinct training and backgrounds who collaborate with each other to help the patient and their family achieve attainable short- and long-term goals of maximal restoration of physical and cognitive function while receiving necessary medical care.

In the IPR setting, the physiatrist leads the inpatient rehabilitation team, which is composed of nurses, physical therapist (PT), occupational therapist (OT), speech language pathologist (SLP), rehabilitation psychologist, and social worker. Additional team members can include a recreational therapist, dietitian, vocational therapist, orthotist, prosthetist, respiratory therapist, chaplain, or other medical physician specialist. Table 1 outlines the titles and roles of the most common core and potential additional team members.

Table 1: Inpatient Rehabilitation Team Members

Rehabilitation-Team-Table-1-1

These specialized treatment teams are a classic feature of inpatient rehabilitation. These specialized treatment teams, for example in the case of stroke rehabilitation care, have been shown to be more effective than clinicians working independently from each other.1

In the case of inpatient rehabilitation facilities (IRF), the rehabilitation teams are defined by regulatory organizations, such as the Centers for Medicare and Medicaid (CMS) and the Commission on Accreditation of Rehabilitation Facilities (CARF). According to CMS, for example, interdisciplinary teams in IRFs must meet every seven days and be explicitly led by a PM&R physician and include appropriately credentialed and licensed PT, OT, and SLP professionals. Patients must have medical needs that require inpatient medical care.

All team members implement the patient specific coordinated treatment plan which addresses the patient’s health conditions, impairments, activity limitations, participation restrictions, and the environmental and personal contextual factors. Regular formal communication and team goal setting improve patient care and discharge planning. Utilizing a standardized format for weekly interdisciplinary team conferences, focusing on recovery and discharge barriers, enhances home discharge rates and reduces transfers to acute care and long-term care.3

A team-based approach is beneficial in outpatient rehabilitation as well. This setting, however, has less regulation defining membership or manner of communication. While not ideal, physician participation is not always required or present. Despite these challenges, clinical success using a team approach in outpatient settings is documented, including patients with chronic pain3 or those at home with stroke.5 

Underlying team management principles 

As the rehabilitation team leader, the physiatrist plays a crucial role in ensuring seamless patient care through effective management principles. The level of engagement and support from the physiatrist in the rehabilitation care team is associated with improved patient-focused team cohesiveness6. As such, higher physiatrist supervision can enhance team member engagement by instilling professional standards that bolster team processes. To achieve this, one requires a nuanced understanding of internal team dynamics, the ability to recognize team strengths, and areas for improvement. Then by outlining clear rehabilitation goals of care, the physiatrist not only encourages shared leadership but also motivates the team by maximizing their diverse expertise.

Overall, the physiatrist’s leadership has a direct impact on patient rehabilitation progress and quality of care. When leading rehabilitation team members, striking a balance between task-oriented and relationship-oriented functions fosters a positive team atmosphere.8 Delegating tasks through open and respectful communication further promotes positive team dynamics and conflict resolution. Also, the physiatrist should be aware of external factors that also influence team processes and function. These encompass the culture within healthcare facilities, the administrative hierarchy at the hospital level, and supervisory expectations. For a detailed overview, refer to Table 2 below, which highlights key aspects of multiple rehab team dynamics.7 

Table 2: Team Models

Rehabilitation-Team-Table-2

Relevance to Clinical Practice

Clinical outcomes and patient satisfaction 

Improved clinical outcomes have been associated with certain team characteristics. Within Veterans Affairs rehabilitation units, greater team structure, use of feedback to improve treatment process, less focus on discipline-specific task and greater focus on cross discipline activities were associated with better patient functional outcomes.9 Similarly, patient satisfaction has been shown to improve with implementation of team-based care.10 

Clinical team interprofessional relationships 

The effectiveness of interpersonal communication and team function is complex, non-linear, and difficult to measure. Interpersonal communication skills are important for all team members. These are critically important for the team leader to foster and assure effective interprofessional team relationships.

The complexity of team decision-making is described in the literature. While team goals should be based on medical management, patient functional capabilities, and social support, other factors can distract rehabilitation teams from their focus on clinical care. Diversions, either internal or external to the team, can include: 

  • organizational and political forces (e.g., hospital cultures, insurance carriers) 
  • diverse personal and professional backgrounds or philosophies among team members 
  • group dynamics (group solidarity vs. polarization)11 

These diversions may lead to conflicts within the team. For example, an inpatient physiatrist might have to balance discrepancies in recommendations regarding length of stay between therapy assessments and an insurance carrier’s approved and compensated length of stay. Open and respectful communication and other mechanisms for airing disagreements should be part of team processes to resolve disagreements. The rehabilitation team may need training, individually and as a group, in these critical skills.

The physiatrist needs to be attuned to their team’s perspectives and recognize the impact of the work environment on both efficiency and individual team members’ effectiveness. While prioritizing team member satisfaction is valuable, it should not overshadow the primary objective of excellence in patient care. Equally, if not more crucial, is grasping the intricate interplay between team dynamics, rehabilitation efficiency, and the resulting outcomes and satisfaction of the patients. 

Attempts to create a framework for team communication and function have also been described in the literature. For example, team communication structure, process and outcome have been categorized into the following six core concepts:  

  • care planning 
  • information exchange 
  • teaching 
  • decision-making 
  • negotiation 
  • leadership12 

Similarly, attempts have been made to describe the central components of inpatient rehabilitation team functioning, and include the following: 

  • physician support 
  • shared leadership 
  • supervisor team support 
  • team cohesiveness 
  • team effectiveness13 

Educational issues 

Given the importance of team function in PM&R, it is an essential aspect of residency training. The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for graduate medication education in PM&R state that a resident must work in an environment that promotes interprofessional and team-based care. Additionally, the ACGME requirements state that the resident physician must learn to work effectively as a member and/or leader a health care team.14 The ACGME PM&R Milestones includes team-based skills in multiple competencies including the Milestone: Interpersonal and Communication Skills 2: Interprofessional and Team Communication which focuses specifically on interprofessional and team communication.15 

Interprofessional collaborative practice is increasingly incorporated into health care curricula across many disciplines. Separate from the ACGME, The Interprofessional Education Collaborative, which represents 21 national health professions associations, has proposed four core competencies related to interprofessional collaborative practice: 

Competency 1 – Work with individuals of other professions to maintain a climate of mutual respect and shared values. 

Competency 2 – Use the knowledge of one’s own role and that of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. 

Competency 3 – Communicate with patients, families, communities and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. 

Competency 4 – Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.16 

Successful approaches to education about team functioning are summarized in Table 3. 

Table 3:  Educational Approaches

Rehabilitation-Team-Table-3

Cutting Edge/Unique Concepts/Emerging Issues

The Rehabilitation Treatment Specification System (RTSS) 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, clinical education, translation of research findings to clinical care but may also help justify appropriate reimbursement.21

Gaps in Knowledge/Evidence Base

Though the team approach to patient care is a well-known established and 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. While there appears to be a strong connection between team effectiveness and patient outcomes, a definition of team functioning, the necessary characteristics of a team, team members and leaders, and the determination of modifiable factors have not been clarified. With more specialty care services adopting a team approach, this information is becoming increasingly critical. 

References

  1. Miller EL, Murray L, Richards L, Zorowitz RD, Bakas T, Clark P, Billinger SA; on behalf of the American Heart Association Council on Cardiovascular Nursing and the Stroke Council. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010; 41:2402–2448. doi: 10.1161/STR.0b013e3181e7512b.
  2. Turk MA, Mudrick N. Rehabilitation Intervention, Volume 6. In SAFE Reference Series on Disability: Key Issues and Future Directions. Albrecht GL (Series Editor). SAGE Publication Inc., 2013. 
  3. Kushner DS, Peters KM, Johnson-Greene D. Evaluating use of the siebens domain management model during inpatient rehabilitation to increase functional independence and discharge rate to home in stroke patients. PM R 2015 Apr;7(4):354-64. doi: 10.1016/j.pmrj.2014.10.010 
  4. Stanos S. Focused Review of Interdisciplinary Pain Rehabilitation Programs for Chronic Pain Management. Curr Pain Headache Rep 2012; 16:147-152. doi:10.1007/sl1916-012-0252-4 
  5. Allen L, Richardson M, McIntyre A, Janzen S, Meyer M, Ure D, Willems D, Teasell R. Community Stroke Rehabilitation Teams: Providing Home-Based Stroke Rehabilitation in Ontario, Canada. Can J Neurol Sci 2014 Nov; 41(6):697-703. doi:10.1017/cjn.2014.31 
  6. Smits SJ, Falconer JA, Herrin J, Bowen SE, Strasser DC. Patient-focused Rehabilitation Team Cohesiveness in Veterans Administration Hospitals. Arch Phys Med Rehabil. 2003 Sep;84(9):1332-8. 
  7. Howard I, Potts, A. Interprofessional care of neuromuscular disease. Curr Treat Options Neurol. 2019:21-35.
  8. Strasser DC, Falconer JA, Martino-Saltzmann D. The Rehabilitation Team: Staff Perceptions of the Hospital Environment, the Interdisciplinary Team Environment, and Interprofessional Relations. Arch Phys Med Rehabil 1994 75(2): 177-182.Strasser DC, Smits SJ, Falconer JA, Herrin JS, Bowen SE. The influence of hospital culture on rehabilitation team functioning in VA hospitals. J Rehabil Res Dev. 2002 Jan-Feb;39(1):115-25 
  9. Strasser, DC, Falconer JA, Herrin JS, Bowen SE, Stevens AB, Uomoto J. Team Functioning and Patient Outcomes in Stroke Rehabilitation. Arch Phys Med Rehabil 2005 86(2): 403-409. 
  10. Will KK, Johnson ML, Lamb G. Team-based care and patient satisfaction in the hospital setting: a systematic review. J Patient Cent Res Rev. 2019; 6:158-71. doi: 10.17294/2330-0698.1695 
  11. Unsworth C. Team decision-making in rehabilitation: a commentary. Amer J Phys Med Rehabil 1996 75(6):483-486. 
  12. Kuziemsky CE, Borycki EM, Purkis ME, Black F, Boyle M, Cloutier-Fisher D, Fox LE, MacKenzie P, Syme A, Tschanz C, Wainwright W, Wong H. Interprofessional Practices Team An interdisciplinary team communication framework and its application to healthcare ‘e-teams’ systems design. BMC Med Inform Decis Mak. 2009; 9:43. doi:10.1186/1472-6947-9-43 
  13. Strasser DC, Burridge AB, Falconer JA, Herrin J, Uomoto J. Measuring Team Process for Quality Improvement. Top Stroke Rehabil. 2010 Jul-Aug;17 (4):282-93. doi: 10.1310/tsr1704-282 
  14. ACGME, Core Program Requirements. Last accessed 10-23-2023. cprresidency_2023.pdf (acgme.org) 
  15. ACGME, PMR Milestones. Last accessed 10-23-2023. pmrmilestones.pdf (acgme.org)  
  16. Interprofessional Education Collaborative. Last accessed 10-23-2023. IPEC Core Competencies (ipecollaborative.org)  
  17. Blue DJ, Fike GC, Escalante G, Kim Y, Munoz JA. Simulation as a Multidisciplinary Team Approach in Healthcare Programs in an Urban University Setting. International Journal of Social Science Studies. 2018 Dec; 6(12):61-66. doi: 10.11114/ijss.v6il2.3749. 
  18. Fox L, Onders R, Hermansen-Kobulnicky CJ, Nguyen TN, Myran L, Linn B, Hornecker J. (2018) Teaching interprofessional teamwork skills to health professional students: A scoping review, Journal of Interprofessional Care, 32:2, 127-135, DOI: 10.1080/13561820.2017.1399868 
  19. Strasser DC, Falconer JA, Stevens AB, Uomoto JM, Herrin J, Bowen SE, Burridge AB. Team Training and Stroke Rehabilitation Outcomes: A Cluster Randomized Trial. Arch Phys Med Rehabil. 2008 Jan;89(1):10-5. doi: 10.1016/j.apmr.2007.08.127 
  20. Wheelan SA, Hochberger JM. Assessing the Functional Level of Rehabilitation Teams and Facilitating Team Development. Rehabil Nurs. 1996 Mar-Apr;21(2):75-81. 
  21. Zanca JM, Turkstra LS, Chen C, Packel A, Ferraro M, Hart T, Van Stan JH, Whyte J, Dijkers MP. Advancing Rehabilitation Practice Through Improved Specification of Interventions. Archives of Physical Medicine and Rehabilitation. 2019:100:14-71.

Original Version of the Topic

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

Previous Revision(s) of the Topic

Kathlin Ramsdell, MD, Andreea D. Nitu-Marquise MD, Margaret A. Turk, MD. Rehabilitation team functioning. 9/26/2020

Author Disclosure

Scott Campea, MD
Nothing to Disclose

Ian Joungouk Kim, MD
Nothing to Disclose