1. OVERVIEW AND DESCRIPTION
The team approach has been a hallmark of rehabilitation since the creation of rehabilitation professionals prior to and during 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 participation 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.
Rehabilitation usually denotes that multiple disciplines engage with patients and their families to determine and work toward attainable short and long term goals. In particular, treatment teams are classically a characteristic of the inpatient rehabilitation setting, although outpatient settings and programs now may also use this treatment management strategy. A team is composed of different professional disciplines that are needed to provide comprehensive rehabilitation care; some teams, specifically inpatient rehabilitation facility (IRF) teams, are defined by regulation. All teams employ goal setting techniques and regular formal communication for coordination. Because of this, teams are felt to be more productive than isolated individual clinicians. There are multiple team models, described in Table 1.
Table 1: Team models
The team-based approach can be found in outpatient rehabilitation as well, although there is no regulation to define membership or manner of communication. Some voluntary accreditation agencies may use the presence of a team, physician involvement, and evidence of communication as measures of quality. Outpatient team programs 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. Physician participation is not always required or present, other than to refer or write prescription for patient participation. Publications support a team approach in community-based outpatient rehabilitation programs.2,3,4. Team approaches can also 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. There are no regulations for membership or specifics of communication, although expert opinion-based standards may offer guidance.
While most emphasis is placed on professionals within the team, patients and their families are also members of the team and must participate in team decision making related to goals and discharge planning.
Underlying Management Principles
Understanding the factors that will lead to the development of a successful team is of vital importance to the physiatrist. There are both internal and external environments with which to contend. Within team environments include leadership, communication, and effective goal attainment. Team leadership typically is the responsibility of the physiatrist, but there may be shared leadership related to a specific patient issue or program focus. 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, showing behaviors that focus on patient services.5 Not all teams are successful or effective. Successful team functioning requires skillful leadership and knowledgeable team members; most teams have varying degrees of skill, experience, and knowledge. Team leaders should be mindful of both task-oriented (e.g., organization, practical and concrete tasks, decision-making) and relationship-oriented functions (e.g., nonjudgmental communication, respect, consensus building, conflict resolution).6,7 Rehabilitation teams tend to mostly engage in task-orientated processes. A recent report noted that following a team meeting template in an IRF stroke rehabilitation program led to an increase in home discharge rate and a decrease in acute care discharge and long-term placement, compared with the previous team meeting organization.8
External environments that influence team processes and functions are health care facility cultures, hospital-level administration and hierarchy, and supervisory expectations.5,9Disciplined supervisors can improve team member participation through development of professional standards that support team processes. Teams can also transcend bureaucratic cultures.5
Recent healthcare changes and programs have accepted many rehabilitation principles. 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 to address process improvement projects.
2. RELEVANCE TO CLINICAL PRACTICE
Patient outcomes and satisfaction
Characteristics of team functioning may be associated with rehabilitation outcomes. Within a VA stroke rehabilitation program, 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).10 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).
A German study suggests that high patient satisfaction and treatment acceptance is better predicted by positive team interactions, in addition to good physician-patient communication.11Survey data used to identify important physiatrist qualities in an IRF setting noted that caring and competency were important to patients, although collegiality and caring were valued by the rehabilitation staff.12
Research of team characteristics and measurements remain in the early stages of development, despite the acceptance of rehabilitation teams as the standard of care for many years.
Team interprofessional relationships
Strasser et al suggest 5 central components of inpatient rehabilitation team functioning: physician support, shared leadership, supervisor team support, team cohesiveness, and team effectiveness.13 While innovation may not be emphasized, it should not be stifled. In general, team members tend to endorse the team approach.12,14 A “team culture” is developed through collaborative leadership, care philosophy, relationships, environmental contexts, and communication.15 Team members often develop alliances within the team, usually among those engaged in the physical needs of the patients or 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.15
Communication within teams is a required interpersonal skill for all team members, especially the team leader. Research suggests that communication within and from well functioning interdisciplinary teams results in high levels of patient and family satisfaction, improved symptom control, and reductions in LOS.16 Kuziemsky et al identified 6 team processes that were a key part of communication within a design for health information systems: care planning, information exchange, teaching, decision-making, negotiation, and leadership.16Communication is usually complex and often non-linear, which requires both formal and informal communication among team members.15
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 (17). 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.6,14,16 Interprofessional difficulties appear not to be related to specific team membership or perceived status in the team, experience in rehabilitation, or professional training.6 Individual teams likely differ in their perceptions of the team process, and different treatment environments will also play a role. Team members have reported “a delicate balance between shared decision-making and top-down decision-making”.15 Open communication and other mechanisms for airing disagreements should be a part of team processes. Further education for team members about conflict management skills and their application to conflict dynamics should be considered.
The physiatrist should be aware of her/his team’s views and how the environment affects efficiencies. Achieving full team member satisfaction, while important, should not be the ultimate goal. More important is the understanding of the relationships between team characteristics and the efficiency of rehabilitation.
The Patient Protection and Accountability Care Act (ACA) is changing health care financing and care delivery since it was signed into law in March, 2010. There is the 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 demonstration projects to monitor cost effectiveness in the name of improved quality care. This is of particular interest to Medicare since an estimated 11% of Medicare expenditures have been allotted to postacute care (PAC) (i.e., IRF, SNF, Long-term care hospitals, outpatient services, home health agencies) in 2012,18 PAC is one of the fastest growing expenditures within Medicare, and PAC systems have wide variation geographically related to spending.18,19 Rehabilitation services and devices are one of the 10 essential health benefits that are covered; however, individual states define the coverage and possible expansions of coverage. State Medicaid coverage plans developed through the ACA were studied using 2010 data and focused on people with stroke and IRF utilization; 4 states (TN, TX, SC, WV) did not cover IRF services.20Rehabilitation teams are the mainstay of PAC, providing coordinated care and safe discharge planning. Existing quality measures for IRFs depend on teams for increases in functional gains, medical stability, and discharge to home within a relatively short time frame. In fact, the ACA promotes coordination of care and communication among providers, both concepts within the definition of teams, 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 more biased by imposed “report cards” based on quality proxies such as LOS, total cost, or discharge destination. Inpatient rehabilitation programs and services are likely to be further affected by the ACA.19
Since teams are at the foundation of PM&R, resident education in team functioning is an essential part of training. ACGME PM&R Program Requirements note that residents must work within effective interprofessional teams and maximize communication.21 The ACGME Milestones recognize the team approach within 4 of the 6 reportable competencies, with Systems-Based Practice devoting an entire milestone to participation in and leadership of team functioning.22 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. Strasser, et al. developed a training program for stroke rehabilitation teams, consisting of an off-site workshop focusing on team dynamics and use of program evaluation data, action plans for process improvements, and periodic consultation over a 6 month period. Patients treated by those teams who had participated in formalized training were more likely to make functional gains than those treated by staff receiving information only.23 Wheelan identified 5 stages of team development (dependency and inclusion; counter dependency and fight; trust and structure; work and productivity; termination). From this, a group development questionnaire (GDQ) was developed which can provide the developmental stage of a team, and then allow a process improvement project to improve effectiveness.24 Identification of strengths and weaknesses in an objective manner may allow focus on goal achievement, structural approaches, and clarity of roles to enhance effectiveness.
3. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES
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. The program recognizes the increasing complexities of medical care requiring integration with social, financial, educational and vocational resources, the need to engage families as a part of the team, and coordination of care through team processes across diverse and multiple medical centers and programs in both inpatient and outpatient settings. Strasser et al advocate for further evaluation of complex care coordination and geographic dispersion of care,25 with possible replication in the private sector.
Quality improvement projects are now required for hospital programs and physicians participating in Maintenance of Certification. Projects can be focused on measurements of team member behaviors, team education, and team effectiveness and assessment of effect on patient outcomes.26
4. GAPS IN KNOWLEDGE/EVIDENCE BASE
While teams are integral to rehabilitation, there is a paucity of research and publications related to the rehabilitation interdisciplinary team process, functioning, and effectiveness. There appears to be a connection between team effectiveness and patient outcomes. However, a definition of team functioning, the needed characteristics of a team or team members and leaders, or determination of modifiable factors have not been clarified. Teams continue to be promoted in healthcare as a solution to improved coordination of complex care, despite the lack of science that defines team functioning, cost, or cost effectiveness.
- Turk MA & Mudrick N. Rehabilitation Interventions, Volume 6. In SAGE Reference Series on Disability: Key Issues and future Directions. Albrecht GL (Series Editor). SAGE Publications Inc., 2013.
- Mosleh SM, Bond CM, Lee AJ, Kiger A, Campbell NC Effects of community based cardiac rehabilitation: Compatison with a hospital-based programme. Eur J Cardiovasc Nurs 2015 14(2):108-116. doi:10.1177/1474515113519362
- 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
- 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
- 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.
- 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.
- 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
- Savage TA, Parson J, Zollman F, Kirschner KL Rehabilitation team Disagreement: Guidelines for Resolution. PM R. 2009 Dec;1(12):1091-7. doi:10.1016/ j.pmrj.2009.09.017
- 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.
- Quaschning K, Körner M, Wirtz M Analyzing the effects of shared decision-making, empathy and team interaction on patient satisfaction and treatment acceptance in medical rehabilitation using a structural equation modeling approach. Patient Educ Couns. 2013 May;91(2):167-75. doi: 10.1016/j.pec.2012.12.007. Epub 2013 Jan 11.
- Moroz A, Prufer N, Rosen Z, Eisenberg C Important Qualities in Physiatrists: Perceptions of Rehabilitation Team Members and Patients. Arch Phys Med Rehabil. 2000;81:812-6. doi:10.1053/apmr.2000.6272
- 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
- Sivaraman Nair KP, Wade DT, Satisfaction of Members of Interdisciplinary Rehabilitation Teams With Goal Planning Meetings. Arch Phys Med Rehabil. 2003;84:1710-3. doi:10.1053/S0003-9993(03)00313-7
- Sinclair LB, Lingard LA, Mohabeer RN. What’s so great about rehabilitation teams? An ethnographic study of interprofessional collaboration in a rehabilitation unit Arch Phys Med Rehabil 2009 90(7): 1196-1201.
- 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
- Unsworth C. Team decision-making in rehabilitation: a commentary. Amer J Phys Med Rehabil 1996 75(6):483-486.
- Skolarus LE, Jones DK, Lisabeth LD, Burke JF The Affordable Care Act and Stroke. Stroke. 2014 Aug;45(8):2488-92. doi: 10.1161/STROKEAHA.114.005315. Epub 2014 Jul 1
- Boninger JW, Gans BM, Chan L. Patient Protection and Affordable Care Act: potential effects on Physical Medicine and Rehabilitation. Arch Phys Med Rehabil 2012 93(6): 929-934.
- Skolarus LE, Burke JF, Morgenstern LB, Meurer WJ, Adelman EE, Kerber KA, Callaghan BC, Lisabeth LD Impact of state Medicaid Coverage on Utilization of Inpatient Rehabilitation Facilities Among Patients With Stroke. Stroke. 2014 Aug;45(8):2472-4. doi: 10.1161/STROKEAHA.114.005882. Epub 2014 Jul 8.
- ACGME, Program Requirements for Physical Medicine and Rehabilitation. Last accessed 4-6-2015.
- ACGME, PMR Milestones. Last accessed 4-6-2015.
- 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
- Wheelan SA, Hochberger JM Assessing the Functional Level of Rehabilitation Teams and Facilitating Team Development. Rehabil Nurs. 1996 Mar-Apr;21(2):75-81.
- Strasser DC, Uomoto JM, Smits SJ The interdisciplinary Team and Polytrauma Rehabilitation: Prescription for Partnership. Arch Phys Med Rehabil. 2008;89:179-81. doi:10.1016/j.apmr.2007.06/774
- Strasser DC, Burridge AB, Falconer JA, Uomoto JM, Herrin J Toward Spanning the Quality Chasm: An Examination of Team Functioning Measures. Arch Phys Med Rehabil. 2014;95:2220-3. doi:10.1016/j.apmr2014
Margaret A. Turk, MD
Nothing to Disclose
Andreea D. Nitu-Marquise MD
Nothing to Disclose