Rehabilitation Team Function and Prescriptions, Referrals, and Order Writing
John C. King
Karen J. Blankenship
William Schalla
Amit Mehta
Patients undergoing comprehensive rehabilitation require the services of multiple health care providers who possess unique skills, training, and expertise that are employed for the full restoration of these patients’ function and their optimal reintegration into all aspects of life. The competent physiatrist must be able to communicate in an optimal fashion with all these providers to meet the many needs of the patient. Prescriptions, referrals, and orders are basic tools by which the physiatrist may communicate the desired involvement of other rehabilitation or medical specialties in assessment, treatment planning, treatment delivery, provision of equipment, and fitting of adaptive devices. Medical specialties that are commonly involved with the rehabilitation patient include neurosurgery, neurology, geriatrics, primary care (including family practice, internal medicine, and pediatrics), psychiatry, urology, and orthopedics. Many other medical and surgical specialties are consulted as needed. Assessment, treatment planning, and therapy are often provided by rehabilitation clinicians specializing in occupational therapy, physical therapy, kinesiotherapy, prosthetics and orthotics, psychology and neuropsychology, recreational therapy, speech and language pathology, rehabilitation nursing, social work, dietary science, case management, and others (Fig. 13-1, Table 13-1) (1, 2). Which professions are involved with a particular patient and the extent of those involvements are largely determined by the nature of the patient’s deficits and the structure of the setting in which rehabilitation is being conducted. As indicated by an initial comprehensive physiatric assessment, the physiatrist requests the participation of other rehabilitation specialists for their assistance in determining the appropriate rehabilitation services and level of care, as well as for comprehensive rehabilitation planning, conduct, and monitoring of treatment, discharge planning, and patient and family education.
The health care team is a group of health care professionals from different disciplines who share common values and objectives (3). Halstead performed a literature review, covering the years 1950 to 1975, on team care in chronic illness and concluded that a coordinated team care approach appears to be more effective than fragmented care for patients with long-term illness (3). More recently, the efficacy and efficiency of team care has continued to be lauded (1, 4, 5, 6, 7, 8, 9).
Writing physical medicine and rehabilitation (PM&R) therapy referrals, equipment prescriptions, and coordinating care requires the skills of a well-rounded clinician who is adept in both therapy and patient interactions to form an effective health care team individualized to the needs of that particular patient. Deficits in knowledge base or team and patient interaction skills lead to suboptimal treatment plans and care. The well-trained rehabilitation medicine specialist is able to develop comprehensive PM&R treatment plans of substantial detail when warranted. The degree of documentation and specification required depends on the mode of team interaction and treatment adopted by the professionals involved. Effective participation in treatment planning, nevertheless, requires the ability both to generate and to support the rationale behind multiple interventions as well as a thorough knowledge of the methods and systems required to achieve a particular rehabilitation goal, within each of the disciplines involved. These interventions must be appreciated in terms of their impact on function as well as on each patient’s pathophysiologic processes.
Treatment plans are generated from goals that arise from the problem list developed during evaluation. The evaluation (see Chapters 1, 2, 3, 9 and 18) results in a set of identified problems that can be classified in various ways but typically are organized as medical, rehabilitation, and social problems. A set of goals or desired treatment outcomes is generated, along with an initial estimate of the duration of therapy necessary to accomplish each. Such goals assist the treating professionals in establishing therapeutic, discipline-specific goals that serve to support the overall medical rehabilitation plan, assist in identifying target skills that will be required to reach these goals, and serve as the foundation of a comprehensive treatment plan. This plan is a tool that patients, families, therapists, and other treating professionals examine for prognosis and expectations. It forms the basis from which all team members may suggest additions, deletions, methods of achievement, or modifications. The treatment plan is not a static document but rather remains dynamic as goals are accomplished, new goals are
identified and added, or some goals, which become irrelevant or unachievable, are eliminated.
identified and added, or some goals, which become irrelevant or unachievable, are eliminated.
 FIGURE 13-1. Multiple caregivers that may be required in comprehensive rehabilitation. |
Treatment strategies are developed to accomplish the identified goals. The specific strategies can be physician-directed, therapist-directed, or, ideally, mutually derived by the patient and team through the interdisciplinary process. The rehabilitation medicine specialist should be knowledgeable about all pertinent therapies, their methods and modalities, and the potential benefits and risks of each, in order to optimally apply the specific interventions desired from each therapy specialty that will help to accomplish the desired patient goals. The availability, benefits, and risks of adaptive equipment and their use to facilitate independence in activities of daily living (ADL), improve mobility, improve communication, maintain leisure activities, and decrease pain must be well understood to be prescribed and proscribed appropriately. A knowledge of expected effects and potential side effects, as well as a pathophysiologic and pharmacologic knowledge base, allows therapeutic interventions to be made with the least possible morbidity. This occurs when treatment is supervised by a physiatrist who can offer appropriate precautions and monitoring of referrals and prescriptions. The comprehensive treatment plan is initiated by referrals, prescriptions, and direct physician interventions. Factors that influence the form and details of the written therapy referral or equipment prescription include team communication needs, styles of interaction, and need for ongoing quality control.
TABLE 13.1 Rehabilitation Team Members Associations, Organizations and Journals as of April 2008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Health care teams may be classified into one of four groups: the traditional medical model, the multidisciplinary model, the interdisciplinary model, and the transdisciplinary model. These will be discussed in detail later, along with pertinent regulatory issues, within the context of the communication styles and needs of these differing team interactions.
TABLE 13.2 McGregor’s Characteristics of an Effective Work Team | ||||||||||||||||||||||||
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TEAM DYNAMICS
The focus of the comprehensive rehabilitation team is the well-being, quality of life, and functional reintegration of the patient into all aspects of life. An effective team is efficient in reaching its goals and creates an exciting and stimulating work environment for its members. Douglas McGregor developed one of the first descriptions of an effective team, noting that it must have the 11 characteristics outlined in Table 13-2 (6). When a team exhibits McGregor’s characteristics, it has a
built-in feedback mechanism through which it constantly monitors itself and maintains its effectiveness. When a team is not functioning well, effective function can be developed or restored through the process of team building (6). Team building requires commitments of time and energy, but the rewards of improved patient outcomes and satisfaction of the team members are worth the effort (6, 10, 11).
built-in feedback mechanism through which it constantly monitors itself and maintains its effectiveness. When a team is not functioning well, effective function can be developed or restored through the process of team building (6). Team building requires commitments of time and energy, but the rewards of improved patient outcomes and satisfaction of the team members are worth the effort (6, 10, 11).
A newly formed team, or a team with several new members, faces several major tasks if the team is to function effectively (6, 11). The members must build a working relationship and establish a facilitative climate. This is particularly challenging in training atmospheres, since new members are frequently being added or removed for new rotations, and new trainees must learn and adapt to the culture of the permanent team in which negotiated roles have already been established. New teams must work out methods for setting goals, solving problems, making decisions, ensuring follow-through on task assignments, developing collaboration of effort, establishing lines of open communication, and ensuring an appropriate support system that will let team members feel accepted yet allow open discussion and disagreement. In a newly formed team, it is advisable to designate meetings in which members can share personal expectations and develop working policies.
CONFLICT AND DISAGREEMENT
Conflict is a normal, necessary, and not necessarily destructive part of team development (7, 10). The potential for conflict is high in health services organizations (12). How it is handled will determine its effect on team objectives and the group process. A good rehabilitation team creates an atmosphere in which members can agree to disagree without making personal accusations or faulting each other’s personalities. In this atmosphere, conflict can be used as a vehicle for growth and innovation.
The interactionist perspective is one current view toward conflict. According to this view, a certain level of conflict is healthy and leads to a group that is viable, self-critical, and innovative. A group can have too little conflict. Without conflict, it may be viewed as harmonious, cooperative, and tranquil, but the team may become apathetic, noninnovative, and nonresponsive to needs for change and may show low productivity. Team members may leave the apathetic team because they are bored. If this occurs, then it becomes the responsibility of team leaders to stir up enough conflict or tension to promote creativity, innovation, and productivity among the team members. The manager who creates conflict must use great skill to see that the conflict does not accelerate to the point where it becomes disruptive, divisive, or chaotic. If conflict is not controlled, then communication suffers, cooperation ceases, and the quality of patient care decreases (7). When conflict repeatedly occurs with no resolution, action must be taken to restore the team’s effectiveness. An appropriate setting for conflict resolution is a team-building session.
TEAM BUILDING AND DEVELOPMENT
A group of professionals brought together for the purpose of helping a particular patient or set of patients will not automatically form the most efficient and effective force to accomplish that purpose. Understanding the factors that lead to the development of a team in which members are synergistic in their care of patients is of paramount importance to the physiatrist. To make interdisciplinary rehabilitation teams effective, Rothberg believes the following functions must be performed (13):
Show/teach team members how to work together and provide sufficient practice time in teamwork.
Ensure that all members learn, understand, and respect the knowledge and skills of others.
Develop clear definitions of the roles and behaviors expected of team participants and lessen ambiguities regarding expectations of others.
Encourage use of the full potential of each member.
Direct attention to initiation and maintenance of communication and to the breaking down of barriers to interdisciplinary communications.
Attend to the maintenance of the teams in the same way that other organizations engage in activities that strengthen their cohesion and offer satisfaction to their personnel.
Acknowledge that leadership should shift as necessary in terms of the patients’ needs.
Ensure that the person in the leadership role respects the other members, as evidenced by consultation, active listening, and their inclusion in planning.
Develop an internal system for demonstrating the accountability of each team member to the group, as well as to the institution in which the team practices.
Develop a process to acknowledge conflict as it arises and to address it in a manner that strengthens the group and its members.
Table 13-3 lists individual characteristics that help one integrate into an interdisciplinary health care team. A professional who is unwilling to accept such roles cannot participate in a significant way in the interdisciplinary health care process.
TABLE 13.3 Personal Characteristics of Successful Interdisciplinary Team Participants | ||||||||||||||||||
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New Team Development
Initiating an effective team is a particular challenge. No matter what type of team is being developed, whether formal or informal, multidisciplinary, interdisciplinary, or transdisciplinary (as defined later), or a business group or committee, five basic stages of group development are encountered (Fig. 13-2). These are (a) forming, (b) storming, (c) norming, (d) performing, and (e) adjourning (14).
During the forming stage, initial entry and identification with the group are the primary concerns. Group members are interested in what the group can offer them and what they can offer the group. During this stage, individuals are usually on their best behavior and may temporarily overlook conflicts for the good of the group.
Storming is the most difficult stage and is characterized by high emotional tension. The level of trust becomes low during this phase. Team members tend to pressure the rest of the group to accept their preferences. Status and control in the group may become an issue during this phase. Cliques and coalitions may form here, and “hostility and infighting” (14) are common. During this phase, members begin to understand one another’s interpersonal styles and learn to interact within those parameters (15). Team members also attempt to find ways to work toward the team’s goals while they seek concurrently to meet their individual needs.
The norming phase is a transition to more comfortable and stable interaction and is referred to as initial integration. Balance begins to emerge during this phase, and the team begins to function more as a unit. This initial balance is not completely stable and can give way at any time, but balance and focus are usually reestablished fairly quickly. The newfound harmony usually comes as a great relief after the storming and may become the primary objective of the team for a period of time. Trust improves; however, the group has not yet matured, and the balance between group needs and individual needs is precarious.
Performing, also referred to as complete integration, is characterized by maturity and a high level of functional efficiency. Complex tasks and disagreements no longer suspend or preoccupy the group. They are quickly resolved, often creatively, and the group moves on toward goal accomplishment. Trust is a key component of the successful team and becomes very high during this phase.
The adjourning phase occurs when the team disbands. The ability to do this and reconvene in the future as needed is the true test of a team’s integration, maturity, and ultimate success.
 FIGURE 13-2. Phases of new team development. (Modified from Schermerhorn JR, Flint JG, Osborn RN. Organizational Behavior. 7th ed. Philadelphia, PA: John Wiley & Sons; 2000:178-181.) |
The physiatrist, as a team leader, must appreciate that these phases of team development are normal, realizing that to some extent they are inevitable, are acceptable, and represent progress toward the desired goals of an effective and efficient team (14). Leading the team through these tumultuous times takes calm, steady leadership, and the leader must have the ability to remind the members of the group of these normal phases as they pass through them, with the goal of something better resulting eventually. The team must be reminded that complete integration is the goal, but this may not necessarily occur without first going through these other, less effective and efficient phases of negotiation. The leadership qualities defined by Lundberg should be cultivated by rehabilitation team leaders approaching this task (Table 13-4) (16). During the storming and early norming
phases, extra care needs to be taken to avoid the appearance of selling out for personal gain during this time of naturally high distrust. Emphasizing the value and importance of each member will help to establish trust and facilitate progress through these tumultuous phases of team development.
phases, extra care needs to be taken to avoid the appearance of selling out for personal gain during this time of naturally high distrust. Emphasizing the value and importance of each member will help to establish trust and facilitate progress through these tumultuous phases of team development.
TABLE 13.4 Some Qualities of a Leader | |||
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Established Team Complacency
Another factor that may be detrimental to the team’s effectiveness is complacency among established teams (2, 6, 7). Whereas much transitional energy is present on initial team development and negotiation of roles, a mature team may lose its edge by accepting routine patterns of behaviors even when change is indicated. A complacent team may be recognized by one or more of the following characteristics: the same members seem to be doing the same things the same way year after year despite advances in the field; products prescribed are predictable; new members transfer out of the team because of the lack of challenge; there is a fear of, or resistance to, risk taking; and the rewards go to team members with average performance. These characteristics are especially detrimental to the rehabilitation team because external conditions that define the team’s direction and individual patient’s needs are always changing.
Despite similar diagnoses, each patient presents a unique picture; thus, treatment goals and procedures should always vary in some customized way. Treatment techniques should change in response to new research finding, and creativity and problem solving should be important to the operation of a rehabilitation team. Steiner has identified the following characteristics of a creative team: unusual types of people, open channels of communication, interaction with outside sources, openness to new ideas, freedom (i.e., not run as a “tight ship”), an atmosphere in which members have fun, rewards go to people with ideas, and risk taking occurs (2, 6).
Barriers to Communication
Communication networks associated with rehabilitation are complex, and there are many potential barriers to effective communication (2). Understanding flows of communication, natural barriers to effective communication, and strategies to overcome communication barriers can improve internal communication within the rehabilitation team and health care organization, and thus improve patient care. Communicating well in a rapidly changing health care market, especially external communication with stakeholders outside the rehabilitation facility, can benefit the health care organization in ways that ensure the health, or even survival, of the organization. For example, the rehabilitation organization that communicates well may benefit in terms of being selected as the firstchoice provider of rehabilitation services, obtaining contracts at favorable reimbursement levels, or helping to establish favorable regulatory policies (17). Communication skills enhancement is also important for marketing to external stakeholders, as emphasized by CARF (Commission on Accreditation of Rehabilitation Facilities) (18).
An important issue in facilitating rehabilitation team communication is the identification and resolution of barriers to communication. Given and Simmons have identified communication barriers that can interfere with the achievement of treatment goals (11):
Autonomy
Individual members’ personal characteristics that may contribute to personality conflicts
Role ambiguity
Incongruent expectations
Differing perceptions of authority
Power and status differentials
Varying educational preparation of the patient care team members
Hidden agendas
These barriers stem from interpersonal, interprofessional, and practice issues, and these are not intrinsic defects of the team concept (11).
A special barrier to effective communication on rehabilitation teams is the presence of many professional disciplines in rehabilitation, particularly the differing perspectives of professionals with a physical background (e.g., physiatrists and physical therapists) and a psychosocial background (e.g., psychologists and social workers) (19). This adds strength to the holistic assessment and consideration of all aspects of the individual patient’s life needs but can permit a frustrating set of varying backgrounds, priorities, and initial perspectives that may not be well understood by other team members of a differing discipline. A portion of this barrier can be varying definitions and understanding of rehabilitation-related terminology by different members of the rehabilitation team. A recent study provided objective evidence that members of rehabilitation teams have “a disturbing lack of common understanding for some basic rehabilitation terminology” and that “only about half of the personnel providing rehabilitation services are currently sensitive to this issue” (20). The authors suggested several courses of action for this problem: alert rehabilitation professionals that it exists, adopt a standardized rehabilitation glossary for the team, avoid the use of vague terms, define terms operationally, and express descriptions of patients and their progress objectively using standardized functional assessment instruments (20). The use of a communication instrument to help keep the information comprehensible, relevant, and compact can help improve discussion between professionals with different backgrounds (19).
Lack of effective communication can be detrimental to the rehabilitation process and uncomfortable for team members. Time must be designated to maintain an effective team process and to help overcome any existing communication barriers. When a team is functioning suboptimally because of conflict, complacency, or poor communication, the problem can be resolved through the team-building process (6). Dyer cites three prerequisites for conflict negotiation:
All parties must agree to come together and work on the problems.
Members must agree that there are problems that need to be solved and that solving them is everyone’s responsibility.
Members accept the position that the end result is that the team will communicate better, thus enhancing the rehabilitation process (6).
Once these prerequisites have been met, the team identifies the conflicts or barriers in need of resolution. It is important that concrete suggestions be made for the resolution of these problems and that the team agrees on the solutions. This creates a problem-solving session rather than a detrimental process in which the members attempt to determine fault or place blame. Once solutions are agreed on, each member has the responsibility to follow through according to his or her role.
An outside consultant may be extremely helpful, since some signs of poor team function are more easily discerned by an outsider (6). Other symptoms are more easily observed by team members, but an outside consultant can help interpret and resolve these symptoms. The consultant can guide the team away from interpretations of problems that are not likely to lead to resolution, such as erroneously labeling incomplete or inadequate conflict resolution as personality conflict, or placing blame rather than finding effective solutions (6). Consultants can guide the team toward constructive ways to resolve problems such as appreciating the expectation theory, which simply states that negative reactions can be predicted whenever the behavior of one person violates the expectations of another (15). A vicious cycle of escalating conflict can result when the negative reaction itself violates the expectations of the first person. However, because this theory focuses on behavior rather than personality, it allows a greater possibility for conflict resolution. If the parties involved, or even one of the parties, can identify the behaviors that violate expectations, then behaviors can be changed or agreements can be reached. Team members can then reward one another’s behaviors rather than negatively reinforce them (6, 15). Appreciating our differences and anticipating how others desire to be treated, including how they prefer to communicate, has been called the Platinum Rule (15). A consultant can help the team learn to sustain healthy communication by developing its own internal mechanisms for problem identification and diagnosis, planning remediation, implementing changes, and evaluating its own results in a healthy feedback loop. The beneficiaries of healthy communication on the rehabilitation team are both the patients and the team members.
It is especially important that health care teams and organizations be able to manage a particular type of conflict—the conflict that arises when something goes wrong. Even in the best-managed organization, things will go wrong. In a healthcare organization, the result of mistakes can be injury, pain, suffering, or even death. In such cases, the rehabilitation team and the organization also experience distress. There are always ripple effects that can affect multiple stakeholders inside and outside the organization. Excellent communication skills in this situation can contain the damage and may help to redress the consequences, the most difficult step. Healthy communication can help to build trust and even strengthen future relationships with affected stakeholders, and demonstrate a proactive approach toward helping to prevent recurrences of similar mishaps (2, 17).
REHABILITATION TEAM COMMUNICATION METHODOLOGY
Comprehensive medical rehabilitation requires the interactions of multiple caregivers to provide the breadth of services needed by people with physical and cognitive impairments (3, 4, 21, 22). Patient needs range from acute and chronic medical problems to physical impairments, their complex interactions, and the impact each has on the patient’s psychological, vocational, and social integration. The primary goal of interactions between care providers is communication of the patient’s needs and coordination of his or her efforts in a synergistic manner (23). Physician-initiated prescriptions, referrals, or orders are written communications that are intended to provide for patient needs by initiating the services to be provided by multiple caregivers. The form such written communications take depends in part on the style of interaction adopted by involved professionals. Redundant, poorly coordinated, or incomplete care can occur when a patient’s desires and needs are addressed from multiple vantage points without effective communication and coordination among the different caregiving professionals. Despite the widespread perception that a coordinated team effort enhances the effectiveness of such complex patient care, definitive studies are not available to prove this point. The results of the available studies have varied outcomes related to different measured variables (4, 5, 7).
Accrediting agencies such as CARF, and, more recently, The Joint Commission (TJC, formerly know as The Joint Commission on the Accreditation of Health care Organizations/JCAHO), and federal regulations in certain instances, require “interdisciplinary teams” (5, 9, 24, 25), yet many styles of interaction exist that are influenced in part by the practice environment (26). Four general styles of interaction between physicians and other professional caregivers will be discussed: the traditional medical model without a formal team; the multidisciplinary team, which some call the traditional medical model of team interaction; the interdisciplinary model; and the transdisciplinary model. Each model’s advantages and disadvantages are outlined, and its impact on prescriptions, orders, referrals, and treatment plan writing is discussed. These four models of interaction are described in pure form, though features of each are often combined to take the greatest advantage of the benefits each model’s features may offer for a particular practice setting. Effective team dynamics and communication discussed earlier are always important, but they are especially necessary for successful implementation of the interdisciplinary and transdisciplinary models.
STYLES OF INTERACTIONS
Medical Model
Traditional medical care results in a model in which a physician attends to the patient’s needs. If services of another discipline are desired, that professional is consulted and given either specific or general requests for assistance to meet the needs of the
patient as determined by the attending physician. The quality of the service rendered by the consultant, and thus future consultations, depends on meeting the needs of the patient and the attending physician. The consultant identifying additional needs would usually discuss them with the attending physician before proceeding with the additional treatment, in recognition of the fact that the attending physician may have additional information and insight not available to the consultant. This traditional system results in a clear chain of responsibility that continues to be well respected and is reinforced medicolegally. This traditional autocratic model of leadership, in which the physician assumes an authoritarian role and other team members obey, is not effective in the rehabilitation setting (10). Multiple consultations may result in many professionals doing multiple tasks. Coordination of these efforts by the attending physician or among the involved professionals can often be difficult or incomplete, resulting in less efficient and sometimes redundant patient care. This is one of the major disadvantages to the medical model of patient care (21, 23, 27).
patient as determined by the attending physician. The quality of the service rendered by the consultant, and thus future consultations, depends on meeting the needs of the patient and the attending physician. The consultant identifying additional needs would usually discuss them with the attending physician before proceeding with the additional treatment, in recognition of the fact that the attending physician may have additional information and insight not available to the consultant. This traditional system results in a clear chain of responsibility that continues to be well respected and is reinforced medicolegally. This traditional autocratic model of leadership, in which the physician assumes an authoritarian role and other team members obey, is not effective in the rehabilitation setting (10). Multiple consultations may result in many professionals doing multiple tasks. Coordination of these efforts by the attending physician or among the involved professionals can often be difficult or incomplete, resulting in less efficient and sometimes redundant patient care. This is one of the major disadvantages to the medical model of patient care (21, 23, 27).
Rehabilitation professionals have recently favored the concept of “client-centered therapy.” This is not meant to trivialize the patient’s needs, as physicians may suppose, but rather to emphasize the patient as the director and arbiter of the interventions according to the patient’s own desires (28). The term client is used in the place of patient in order to indicate that the role is an active one. The client, his or her caregivers, and the service providers enter into a collaborative relationship with the assumption that the client is the most knowledgeable about his own functional needs. The professionals advise and educate and assist in creating an optimal environment for the client to achieve independence in those areas that the client has identified as being important. Some advantages of this approach include empowerment and decreased dependency for the client, and a truly individualized treatment program, since each patient identifies the issues that he or she wishes to master. However, client-centered care is challenging to provide within the structure of current health care systems, which emphasize professional assessment and medical necessity over patient desires in establishing allowed treatment interventions. It also assumes a fluid interaction that can be problematic within the bounds of the medical model in which a particular attendingdefined problem was the cause for the initial referral and for which authorization for treatment was received.
 FIGURE 13-3. Multidisciplinary team conference structure. Vertical communication (solid lines) may serve to limit horizontal communication (dotted lines) between team care providers. |
Medical ethics in recent decades has prioritized patient autonomy over attending beneficence (paternalistic actions deemed by the practitioner to be in the patient’s best interest), which is also consistent with patient-centered care (2, 29, 30). The medical model, as compared with more team interactive models in which the patient is part of the team, is not particularly well suited for patient-directed care because of the additional effort required of the physician in this system. This is because all therapies and consultant plans are coordinated by the attending, and not by the patient. For patient autonomy to have priority, the full weight of patient education, including advice regarding all possible interventions and their respective risks and potential benefits, and recommendations is borne by the attending physician. This has become more difficult in an era of time-limiting managed care. Indeed, much of the decision making over what is best for the patient’s health care is defined by what the patient’s health insurance is willing to cover and is frequently removed from both patient and attending preferences by the coverage certification mechanisms of managed-care systems. These decisions are based more on economic considerations than on considerations of optimal health benefit.
Multidisciplinary Team Model
The multidisciplinary team model provides a means for multiple professionals who require frequent interactions to meet and coordinate efforts on a consistent basis. The multidisciplinary model is analogous to the classic pyramid-shaped model of management, which features vertical communication between supervisor and subordinates. It typically remains an attending physician-controlled team in which most interactions are between consultants and the primary attending. Discussion between consulting professionals is held to a minimum or, when necessary, directed by the attending physician. This emphasis on vertical communication (Fig. 13-3) is
evolved from the medical model attending physician’s role and relationship with consultants (26).
evolved from the medical model attending physician’s role and relationship with consultants (26).
Team conferences can be conducted efficiently with such clear lines of authority and control, but lateral communication may suffer (27, 31) (see Fig. 13-3). This tendency to impede the free, horizontal flow of communication between the team members is recognized as an obstacle to the optimal use of each participant’s specific expertise and problem-solving skills. This may negate the possible group synergism that can create a product greater than the sum of its parts; or, in clinical terms, a care plan better than any one participant could have developed alone (26, 32). The interdisciplinary team model does attempt to improve this communication and enhance group synergism, thus fostering a sense of mutual authority and responsibility (22, 31, 32).
Interdisciplinary Team Model
Interdisciplinary teams benefit from lateral communication flow that occurs as easily as vertical communication in the multidisciplinary team. Because the interdisciplinary model is designed to facilitate such lateral communication, it is theoretically better suited for rehabilitation teams (34, 35, 36). The expected norm is group decision-making and group responsibility for developing optimal care planning (31). The problem orientation and ease of flow of lateral communication in the interdisciplinary team processes are similar in function to the project orientation and communication patterns of matrix organization (33, 34). The patient is considered part of this planning group and has a central role in the team’s considerations (see Fig. 13-1) (23, 37
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