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 geographically anywhere, in any organisation, in different funding systems etc. The network of groups must be involved with a patient collaboratively, just as team members must work together closely. Rehabilitation teams are often at an interface (see here) and must become adept at bringing disparate groups together. A Mind-Map of the capability is below and can be downloaded here.

Table of Contents

Cross-boundary working, rehabilitation capability 4

Context: is rehabilitation a journey?

Rehabilitation is sometimes conceived as part of a pathway.  The term implies being part of a predictable route such as acute care, early rehabilitation on an acute ward, rehabilitation service, community service, and discharge. Moreover, each step is envisioned as having entry and exit criteria and a limited duration stay. All this is predicated on every patient having similar needs and similar responses to offered input. 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 precisely when needed.

Every one of these assumptions is wrong. There needs to be coordinated planning of service criteria or capacity; patients differ significantly 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.

Additionally, a service often needs help to meet all a patient’s needs. 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 standard 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, 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 advising housing agencies about adaptation, to equipment suppliers about needs, and to patients about how to use the equipment.

Working across all boundaries should improve the continuity of care, especially provider continuity meaning stable personal relationships between the patient and the professionals providing rehabilitation. Carl van Walraven and colleagues undertook a systematic review which found evidence that provider continuity of care was associated with better outcomes. Merethe Hustoft and colleagues studied 701 patients in rehabilitation services in Norway. They found that “better personal, team and cross-boundary continuity of rehabilitation care was associated with better patient health after rehabilitation at 1-year follow-up.”

In summary, although this capability may seem removed from rehabilitation, it has knowledge and skills that no other service has. It can give the patient help that is otherwise unavailable. 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 available services to form a suitable ‘team of services for the individual patient. This capability improves patient outcomes.


The attitudes needed for this capability are:

  • adaptability, altering the 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 the need to leave or alter lower-level and short-term goals
  • willingness to negotiate and explain to achieve the best for the patient


Four general behaviours 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 must recognise that the patient probably already has, and almost always will have, needs that need involvement from other services. The most familiar example, usually acknowledged though not necessarily acted on, is ongoing support from a disease-specific service. It is not sufficient for the professional to identify only problems the team can help with. It is equally inappropriate to identify issues that the team cannot help and then 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 respects 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 can be challenging to find. Having this information and showing that you know and appreciate its significance will significantly increase the likelihood of forming a good, productive, 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 group 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 proactively with all other teams and services without being asked. This extends to recently-involved groups, so 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, 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 required to perform effectively within the ‘home team’. The extra features are (a) being able to work outside the normal ‘comfort zone’ and (b) working 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 following:

  • The expertise of professionals working in other services or groups, 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 similar to those required to participate in ‘the home team’. The particular overarching skill is that the professional can operate outside their 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, possibly only concerning 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 another service’s different culture, language, priorities and goals, 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. The other teams will likely use their vocabulary, 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 always transmitted.


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 involved with multi-professional teamwork, with an additional over-riding ability to fully participate in this new team from the outset and in a different environment.

Cross-boundary rehabilitation working

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