2.2 The team around the person

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In addition to considering the type of rehabilitation the service supports, teams need to consider strengthening the team and the person’s experience by incorporating the ‘team around the person’ (figure 5). This model was developed from the original project Team Around the Child.1

Venn diagram with person in the middle. Overlapping circles of rehab team, family and environment.
Figure 5: The team around the person

In this model the person and their family are part of the team. Together, they develop and understand the rehabilitation plans and contribute to the person’s work towards their goals.

In some contexts, peers can be a valued member of the team around the person. Peer support programs may be offered by the rehabilitation team. They are noted here to recognise the unique contribution peer support can make to the experience of the person.

Principles

Regardless of team type, there are some key principles for a well-functioning rehabilitation team which optimises the persons experience.

  • The person and their family remain at the centre of everything the rehabilitation team do. They are engaged in every stage of the rehabilitation process. Their goals and aspirations direct the services provided by all team members.
  • Communication and teamwork are underpinned by mutual trust and respect. They are characterised by collaboration and negotiation.
  • Ensuring the person’s goals are known to all team members and inform all discipline-specific actions and interventions.
  • Regular collaboration to complete joint planning, shared monitoring and joint evaluation of progress and outcomes.
  • Reducing the person’s experience of repetition. Nominate a primary point of contact (e.g. the rehabilitation coordinator, care coordinator or case manager) for the person and their family. Use this role to identify pre-health event lifestyle, social and personal factors, aspirations, fears, preferences, communication needs and cultural considerations.
  • Where access to a specialist health intervention is required, this is engaged from within the health service or brokered into the team from other sources.

References

  1. Limbrick-Spencer G. The keyworker: a practical guide. Birmingham: WordWorks; 2001.
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