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Rehabilitation Matters

About all rehabilitation

Capability 4: cross-boundary working

This page sets out what behaviours someone with capability four would show, and the knowledge and skills needed. The capability is: “Able to work across all organisational, geographic and time-based boundaries, collaborating actively with other professionals, teams, and organisations.” The discussion about teams undertaken when considering capability three (here) emphasised that a patient will be involved with many services and teams and that it was necessary to recognise this. These teams may be located anywhere geographically, in any organisation, in different funding systems etc. It is vital that the network of teams involved with a patient collaboratively, just as team members need to work together closely. Rehabilitation teams are often at an interface, (see here) and need to become adept at bringing the disparate team together. A Mind-Map of the capability is here.

Context – part of a journey

Rehabilitation is sometimes conceived of as part of a pathway, where the term carries with it an implication of being part of a predictable route such as acute care, to early rehabilitation on an acute ward, to rehabilitation service, to community service, to discharge. Moreover, each step is envisioned as have entry and exit criteria, and limited duration stays. All this is predicated on every patient having similar needs, and similar responses to offered input, and, last, it is assumed that the criteria are congruent, such that patients will automatically flow, and it is assumed that the capacity is such that patients can transfer exactly when needed.

Every one of these assumptions is wrong, there is no coordinated planning of service criteria or capacity; patients differ greatly in their needs; and responses to offered treatments vary greatly. In reality, patients in one setting are moved to the place or service that is least inappropriate, even if that place is sometimes unable to meet any actual rehabilitation needs. It is almost a random journey, like Brownian movement, bouncing from service to service. To add to this, often a service cannot meet all a patient’s needs alone. This is becoming very obvious with patients with Long Covid, where pulmonary rehabilitation services cannot meet, for example, neurological needs. This has been the case for several decades and is particularly obvious after major trauma.

So, whether it is after an acute onset where an expectation of improvement is normal, or rehabilitation concerns a more gradual onset and progressive onset disorder, a patient in rehabilitation is always on a journey. The journey often extends over long periods of time, sometimes a lifetime, and most patients will move through and be in contact with innumerable services. Rehabilitation is the bridge, or more accurately, a network of bridges between disease-focused services and social integration, between health and social services, between a past and a future and so on.

Rehabilitation services should take on the role of supporting the patient in their journey for several reasons. Rehabilitation teams are more expert at taking an overall and patient-centred view than many other services; they acquire and have a better insight into and understanding of the other services that most other services do, and rehabilitation services can assist a patient in their use of other services, for example giving advice to housing agencies about adaptation, to equipment suppliers about needs, and to patients about how to use the equipment.

In summary, although this capability may seem removed from rehabilitation itself, it is a set of knowledge and skills that no other service has, and it is one that can give the patient help that is otherwise unavailable, and it can enable the patient to use the skills learned in rehabilitation. Just as rehabilitation takes a holistic view of the patient, it also needs to take a holistic view of the myriad of available services to form a suitable ‘team of services’ for the individual patient.


The attitudes needed for this capability are:

  • adaptability, altering approach to meet the needs of the patient in their context as the context alters
  • acceptance of change and constraints associated with new situations, while remaining focused on the patient’s goals
  • focus on priorities, ensuring that high priority long-term patient goals are retained, but recognising need to leave or alter lower-level and short-term goals
  • willingness to negotiate and explain, to achieve the best for the patient


There are four general behaviours that facilitate and demonstrate collaborative, cross-boundary working.

The first is that the professional actively thinks about, looks for, and makes contact with teams and services that can help the patient. The professional has to recognise that the patient probably already has, and almost always will have, needs that will need involvement from other services. The commonest example, usually acknowledged though not necessarily acted on, is ongoing support from a disease-specific service. It is not sufficient for the professional simply to identify only problems that the team can help with. It is equally inappropriate to identify problems that the team cannot help and then to fail to look for and seek help from a service that can help.

The three specific behaviours associated with this are that the professional:

  • explicitly looks for problems that may need help, now or in the future, from another service;
  • if some are identified, then looks for services able to meet the identified needs;
  • refers the patient early, specifying the need, and providing focused relevant information.

The second general behaviour is that the professional shows respect for the other organisation whenever in contact with them. This needs the professional to know important information such as their purpose (as they see it), their culture and values, how they are funded, how they work, what their priorities are, and similar information that is not always easy to find. Having this information, and showing that you know it and appreciate its significance will greatly increase the likelihood of forming a good, productive and lasting relationship.

The three specific behaviours associated with this are that the professional:

  • demonstrates an awareness of the team’s expertise, and the expertise of the different professions within the team or service;
  • ensures that all communication, and especially initial referral information, is set out in line with the purpose, priorities, expertise and policies (if any) of the service being asked to help;
  • shows an awareness of the limitations and constraints that the other service has to work within.

The third general behaviour is that the professional communicates pro-actively with all other teams and services involved, without being asked. This extends to teams who were recently involved, so that they remain aware of the patient, and learn what has happened.

The two specific behaviours associated with this are that the professional:

  • copies all relevant letters, summaries and reports routinely to other teams: any from the recent past, those currently involved, and any likely to be involved in the future;
  • writes all documents clearly and without using rehabilitation jargon, so that it can be understood by all recipients easily.

The fourth and last type of general behaviour is that the professional engages cooperatively with all other involved teams and services.

The three specific behaviours associated with this are that the professional:

  • responds quickly and constructively to any requests for help or information, not only giving what is requested but also, if appropriate, making further suggestions or giving additional information;
  • offers to set up and host a meeting to increase collaborative working, inviting people from any relevant services;
  • attends any meetings set up by other organisations or services, contributing constructively.

Knowledge and skills

Working together with other teams and services forms, in some ways, a ‘super-team’; the knowledge and skills needed has much in common with the knowledge and skills needed to perform effectively within the ‘home team’. The extra features are (a) being able to work outside the normal ‘comfort zone’ and (b) being able to work as a full member of a new, limited duration team set up around a single patient immediately.

The knowledge needed covers three main aspects of other teams. The expert rehabilitation professional will know:

  • The expertise of professions working in other services or teams, for example social workers, community psychiatric nurses, and social service community occupational therapists;
  • The purpose and priorities of, the constraints on, and the practices and policies of the services and teams commonly worked with, so that the rehabilitation suggestions are understood by and are likely to be acceptable to the team and its members;
  • How to present information in a referral or when responding to a request so that it is relevant and informative to the recipient.

The skills needed are also similar to the skills needed to participate in ‘the home team’. The particular overarching skill is that the professional can operate outside his or her own comfort zone. Most members of a rehabilitation team take time to bed into team working. Here the professional has to fit into a new ‘team’ at short notice, and possibly only in relation to this patient.

The skills needed cover three main aspects of the other services. The expert rehabilitation professional will be able to:

  • adapt easily and quickly to the different culture, language, priorities and goals of another service, working as a member of a larger team possibly only for a single patient. Put another way, the professional must work in a new context using all the skills underlying teamwork already learned.
  • communicate rehabilitation formulations, plans, and suggestions effectively without using jargon. It is quite likely that the other teams will use their own jargon, and the professional must ask them to explain it.
  • work willingly and collaboratively with any other service from any other organisation. This concerns ensuring that an attitude of willingness and enthusiasm, not reluctance, is transmitted at all times.

To conclude, this capability can be considered as having the ability to join a new, possibly short-term larger team concerned only with a single patient from the person’s full case-load. The behaviours, knowledge and skills are all similar to those concerned with multi-professional teamwork, with an additional over-riding ability to participate in this new team fully from the outset, and in a different environment.

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