Capability 6: support team treatments

One way to define this capability is that it encourages and enables a ‘personal rehabilitation environment‘ to be created, whereby all the people involved with the patient support and reinforce those patient behaviours, increasing autonomy. There are two reasons for building a rehabilitation environment around the patient.

First, it is well established that direct face-to-face therapeutic contact rarely exceeds 10 hours a week, even in well-staffed inpatient rehabilitation units. There are 112 waking hours a week. This capability will increase the practice and feedback given in those 10 hours. It could and should also add additional training and feedback throughout the rest of the day. In inpatient settings, nursing and care staff will play a central role; families may also contribute. Family members and carers will be much more critical in other locations.

Second, it is also well established that a stimulating and challenging environment increases learning and recovery, provided the person can explore it. Part of this environment concerns objects that may facilitate or hinder the person from exploring the environment. However, the social environment has the more significant impact: do other people provide support and encouragement while also allowing the patient to face some risks, or do they suppress patient activity, perhaps because they wish to avoid trouble?

The social environment is complex. Most patients receiving multi-professional, team-based rehabilitation in the hospital will be in contact with between 10 and 20 individuals over a week. Most therapists are assisted by therapy assistants and often share responsibility for expert professional input; nurses (for in-patients) inevitably work in teams; doctors work as a group. In the community, the patients are still seen by many people from several or many different agencies and organisations.

What the patient needs is continuity and consistency of care. A Kings Fund research paper, ‘Continuity of care and the patient experience‘, has examined this problem in the context of people in the community. (here). Though the context differs from the hospital, much of the discussion and ideas are relevant.

The research paper makes an important conceptual distinction between two aspects of continuity of care. The first aspect is management continuity. This is better termed management consistency because it refers to everyone doing and saying the same thing, sharing an agreed understanding of the situation and having a uniform approach to its management. The paper adds that this includes information continuity, which refers to consistency in the information given by different parties.

The second aspect is relationship continuity – the same person or people seeing the patient over time. This is of great importance but is not part of this capability.

This capability addresses the matter of management consistency. The King’s Fund report suggests that general practitioners should and could lead on this in the community. However, the solution primarily focuses on case management – identifying organisations needed and getting them involved – and coordinating work through careful planning. There needs to be more discussion of how, in reality, any of the ideas proposed can be achieved. Furthermore, the report hardly considers the consistency of management for an individual patient.

Although outside the scope of this capability, the idea of relationship continuity is essential and possibly an even more powerful component of rehabilitation. It is tangentially related to capability five. In complex cases managed over time by the rehabilitation service, the team’s continued commitment to the patient (not necessarily one person) helps the patient the most. They do not need to go through the assessment, formulation, and planning processes repeatedly.

I initially imagined this capability applying to the constrained situation of an inpatient rehabilitation team. This capability applies to the rehabilitation team, including nurses and care staff, and might extend to family members and frequent visitors.

However, as I wrote this, I realised (a) that most rehabilitation should occur in the community and (b) that creating a rehabilitation environment was not only essential, but it was also achievable as part of this capability. The key is for an expert rehabilitation team to engage with the family, friends, and other closely involved people, teaching and training them to create and sustain ‘the rehabilitation environment’. The people involved might include carers paid for by social services, individual therapists working in the community who are not part of an expert team (but many will be), and others, as well as family and friends who visit regularly; this is discussed in a post on nursing homes (here) and one on the importance of social care in rehabilitation (here).

The capability has three components. First, an expert rehabilitation team should have or develop team policies for managing specific challenging problems and common problems. The professional needs to engage in the development and implementation of these policies. Second, In all their contacts with a patient, the professional needs to use and reinforce any treatments or approaches that can be used or supported safely. Third, the professional needs to teach both team members and others (e.g. family, community carers, and community rehabilitation staff) the techniques needed to continue patient learning skills.

In summary, this capability involves a mixture of learning basic approaches to a patient’s problems that lie outside the normal range of the issues managed by the professional and teaching both team members and other people living with or caring for the patient techniques they can use to maximise the patient’s learning and recovery. It involves enriching the patient’s environment so that more people become involved in training the patient as a natural part of day-to-day life, replacing an emphasis on ‘going to have treatment’ with a focus on ‘using the activity I need or wish to undertake as an opportunity to learn’.