Chapter 6 Community Physiotherapy
Introduction
• Community physiotherapy can be offered to people who are likely to benefit most from treatment in their own environment.
• Those who are housebound or have a long-term condition are examples of where this may be more appropriate than seeing them in a formal setting.
• A community physiotherapist can work in many different capacities, as a single-handed domiciliary physiotherapist, part of a multidisciplinary multiagency intermediate care team (ICT) or in one of the many other community teams.
• The assessment can take place in a variety of settings, from privately owned housing, rented accommodation, Council or Housing Association accommodation, supported housing (sheltered or special sheltered), a caravan, hostel, residential/nursing home or a day centre.
• Careful consideration must be given to the patient’s choice (DOH 2001a), culture (CRE 2002), privacy, dignity and confidentiality (DOH 2003) (this includes never leaving messages on an answer-phone without the patient’s permission).
• To ensure a safe interaction for the patient and physiotherapist a risk assessment needs to be carried out to cover the physiotherapist entering a person’s home environment alone, with the difficulties this brings in terms of the potential for providing treatment in the space available (CSP 1998, 2002, 2009a,b).
• The environmental constraints where treatments take place could include the room being confined by furniture and general clutter such as piles of old newspapers or magazines. The room may be generally unkempt or even unclean and may be completely unsuitable for hospital equipment that requires space and a smooth clear floor to operate safely.
• Community physiotherapy is a speciality which requires ‘core’ physiotherapy assessment and treatment skills, with the additional focus on home-based functional goals.
• The functional goals are related to the patient’s specific needs and their environment. If appropriate this can involve family members or carers to ensure that as much information as possible is obtained in order that the intervention will provide maximum benefit for the patient.
• Some physiotherapists find adjusting to this non-traditional approach frustrating or difficult, as there can be a considerable reduction in the time that they are able to use their ‘pure’ physiotherapy skills. The different working practice involves the development of new skills in holistic assessment, a more functional approach to treatment, the ability to set goals with the patient, that may be biased towards the patient’s needs rather than the desired physiotherapy outcomes. The role may even involve the physiotherapist being an advocate for the patient.
• Where consent is required for involvement with carers, either formal (through an agency) or informal (family or friends) this must be clarified as part of the assessment process (CSP 2004, DOH, 2001b,c,d).
• When visiting the patient in their home environment the physiotherapist may encounter issues around the patient being a vulnerable adult and these issues need to be identified and addressed appropriately (DOH, 2001a). Potential protection of vulnerable adults and safeguarding issues need to be identified and addressed appropriately (DOH 2006, ISA 2010). There are many types of abuse that may be encountered in the community setting, for example; neglect, physical, emotional, psychological and financial abuse (DCA 2005).
• A thorough assessment may need to take place over several visits; this will depend on the patient’s ability to engage in the process. The limitations could be due to concentration span, exercise tolerance, mental state or other factors.
• Some community therapy teams may only be able to offer a brief intervention, consisting of assessment and advice. This will involve the physiotherapist undertaking a more specific, but superficial assessment to determine a patient’s problems.
• If more complex issues are identified and a comprehensive assessment is required, this may need to be discussed within the team resulting in a request for a further referral or intervention by another team with a particular expertise.
• It is helpful for the physiotherapist to have an understanding of how teams in the community may differ in their roles. Social services teams will need to follow their directive regarding the types of issues they can deal with. If a patient has substantive needs then this becomes a priority for the service. Decisions need to be made about the referral of a patient with moderate needs and whether they will be able to access the service.
• It is important to be aware of other services that are available in the local area, statutory, voluntary organisations, charities and self-help groups (Appendix 6.1).
Referrals
• Depending on the criteria for each particular service, the referral could originate from any of the following: primary, secondary or tertiary care, social services, the voluntary sector or in some instances self-referral. With this in mind it is essential that the reason for referral is clear, realistic and has been agreed with the patient.
• In addition to the required standard data the referral form should include information about the social history of the patient, access to the property and any known risks to staff.
• To supplement the referral information the GP can supply other medical records (hard copy or electronic), which can include medical history, details of next of kin, name of preferred contact, current medication as well as any previous interventions or other referrals.
• For patients referred following an acute episode of care in hospital, for example, following surgery or a fracture fixation, it is essential to confirm relevant dates for fracture healing times, or precautions following joint replacement surgery.
Knowledge for the community
Patient choice
• Many patients choose to request physiotherapy, but referrals made solely to satisfy the patient (or their carers), when the proposed goals are not realistic, can be frustrating for both sides. On occasions a referral can give the patient a false expectation of the potential benefits that can be gained from physiotherapy intervention.
• Some patients will have been seen previously by other services, including community physiotherapy and it is important to be aware of previous treatment approaches and the outcome of these as it may be possible to use the information as a basis for deciding the best intervention for the patient’s current episode.
• Some patients may chose not to engage with the intervention and this must be respected, documented and reported back to the referrer.
• If, on assessment, it becomes apparent that the patient is not willing to continue with the proposed intervention, e.g. home exercise programme, then this decision must be explored further with the patient and the potential issues that may arise must be clearly outlined to them. The content of the discussion and the agreed outcomes must be documented.
Culture
• Develop an awareness of cultural requirements of patients to ensure the treatment is appropriate to their lifestyle.
• The choice of the individual to carry out a task in a specific way that might not be in accordance with the therapy plan must be acknowledged.
• Do not make assumptions, ask the patient about their preference for treatment that is appropriate to their culture and lifestyle. For example, if there is need to wash under running water it is inappropriate to set the goal for strip-washing at a basin. If it is not culturally acceptable to access the kitchen, then this needs to be taken into account when planning treatment interventions.
Confidentiality
• It is not appropriate to leave a message on an answerphone when attempting to make a first appointment to visit a patient.
• During the assessment confirm with the patient that it is acceptable or practical to leave messages on an answerphone or mobile phone. In addition clarify if a third party is involved in listening to messages, such as a family member, neighbour or warden.
• Privacy must be respected. As a community physiotherapist you will be working as a guest in someone’s home and as such you must respect their wish for privacy and lifestyle choices.
• It is necessary to explain to the patient what the assessment process will involve and if the patient wishes to have others present, either their family or friend or another member of staff during the consultation then this wish must be respected.
• Just as you would close curtains around a patient’s bed on the ward or in the department for privacy, remember bedrooms and living rooms may be overlooked by other houses or even be on a bus route, where passengers may be able to see into the accommodation.
• Respect a patient’s dignity at all times. A patient may feel more relaxed in their own surroundings, but may need more time to complete tasks. A physiotherapist should be conscious of not rushing a patient, to maintain the dignity of the patient an assessment may need to be spread over several sessions.
• Others present during assessment and subsequent treatment should only be there with the consent of the patient.
Risk assessment
• It is essential that there are effective risk management procedures in place to ensure that personal safety, lone working, moving and handling, environmental and other risks are assessed and appropriate action plans identified.
• Therapists should ensure that they are familiar with and adhere to local policies and procedures (CSP 1998, 2002, 2009a,b).
Lone working and personal safety
• Often staff will be working alone for at least part of the day.
• If there are electronic community records it is important that these are accessed to establish if there are any noted concerns regarding the patient before the initial visit.
• If possible, telephone the patient prior to visiting to confirm the address, any parking restrictions, access to the property and whether the patient will be alone or have family or friends present.
Moving and handling
• Statutory training provided annually by employers or universities covers the basic legal requirements for you to ensure your safety and that of the patient.
• Equipment is available and must be used if indicated as a result of the risk assessment.
• Techniques used by the family and/or patient must be reviewed and if unsafe or inappropriate techniques are being used these must be addressed and safer alternatives agreed and documented. If agreement cannot be reached with the patient and/or carers, then it is essential to record this.
• A physiotherapist must never put themselves at risk of injury or harm.
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