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NeuroRehabilitation 34 (2014) 655–669 DOI:10.3233/NRE-141080 IOS Press

Team models in neurorehabilitation: Structure, function, and culture change Robert L. Karola,b,∗ a Welcov b Karol

Healthcare, Minneapolis, MN, USA Neuropsychological Services & Consulting, Minneapolis, MN, USA

Abstract. INTRODUCTION: Neurorehabilitation requires a team effort. Over time the nature of teams has evolved from single discipline work through multi-disciplinary and inter-disciplinary teams to trans-disciplinary teams. However, there are inconsistencies in the literature and clinical practice as to the structure and function of these team models. Each model engenders advantages over its predecessor and unless the models are well understood clinicians may labor in a model that is less efficacious than the most transcendent model. OBJECTIVES: To define and examine the models of single discipline care, multi-disciplinary teams, inter-disciplinary teams, and trans-disciplinary teams and to review in depth trans-disciplinary teams as the most advanced team model. This paper will also consider professional roles and integration across disciplines as well as the crucial topics of staff selection, attendance in rounds and the nature of rounds, staff physical plant assignments, and leadership responsibilities. Leadership responsibilities that will be addressed include scope of practice and role release, peer pressure, and culture change issues. CONCLUSIONS: The trans-disciplinary model is the gold standard for teams in neurorehabilitation because they entail more integrated service delivery than do other teams. Trans-disciplinary teams also represent a more persons-centered approach. To initiate a trans-disciplinary model, team members must have excellent communication and shared decision making including persons with brain injury. Leadership must address staff selection, scope of practice and role-release. Otherwise, the model will fail due to peer pressure and institutional or program cultural variables. Keywords: Team models, rehabilitation teams, multidisciplinary, interdisciplinary, transdisciplinary, role release, scope of practice, culture change

Neurorehabilitation is built upon the dual foundations of team work and a process model (Barnes, 1999). In contrast with medical interventionalist approaches where individual procedures are utilized, from injections to surgery, neurorehabilitation operates from a frame work of a multi-pronged approach and graduated change. It is multi-pronged in that numerous providers facilitate change simultaneously, rather than sequentially, and often target closely related or similar deficits (e.g., aspects of cognition treated by speech-language ∗ Address

for correspondence: Robert L. Karol, 9637 Anderson Lakes Parkway, #162, Minneapolis, MN 55344, USA. E-mail: [email protected].

pathologists, occupational therapists, and psychologists). It is graduated in that improvement occurs progressively compared with, for example, the robust changes that often occur quickly following surgery. To achieve this, multi-pronged, graduated intervention requires a coordinated team effort. Individual therapeutic intervention that is uncoordinated is insufficient to optimize improvement (Sinclair, Lingard, & Mohaber, 2009). The team approach arose following World War II. The concept was to provide comprehensive and collaborative care for soldiers with complicated injuries who had survived the war, but may have died in previous wars (Strasser, Uomoto, & Smits, 2008).With

1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved

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such teams, providers can simultaneously address medical, psychological, and social needs: a biopsychosocial approach (Smits et al., 2003). In fact, the broadest of teams include professionals who consider needs outside traditional health care. These teams dissolve the wall between health and daily life. Once this artificial difference is dispelled, teams can help not just with traditional health concerns (e.g., medical, physical, psychological functioning) but a broader array of issues such as vocational, recreational, and spiritual needs. A team approach is necessary to successfully return persons with brain injury to the community by facilitating function across all of their needs. Without a team, isolated therapists may only help people reach partially useful goals (Ponsford, 2004). Imagine a physical therapist who helps someone learn to walk, but does not tackle training whether socks or shoes go on the feet first or if there is motivation to actually walk instead of using the wheelchair. If the therapist collaborated with a team to teach the person dressing skills and to motivate the person to walk, accomplishment of walking would not be a hollow victory. Most rehabilitation goals necessary for community re-entry cannot be reached in isolation since the real world requires complex skills. In addition, community re-entry entails diverse skills. Hence, teams and comprehensive neurorehabilitation are strongly linked. It is hard to conceive of a sole professional conducting a comprehensive treatment plan with complex goals that has multiple intervention targets. Moreover, neurorehabilitation places high demands on professionals necessitating a team to distribute the workload (Ponsford, 2004). Effective neurorehabilitation intervention requires professionals to impart coordinated knowledge, skills, and motivation, and not just complete tasks for individuals receiving such services. It is far easier for skillful, experienced professionals to do something for persons with brain injury, than to have them acquire the capacity to do something for themselves. Neurorehabilitation requires participation by the persons involved in the services; they must be active, participating learners rather than passive recipients (Niemeier & Karol, 2011) and they must do this with cognitive impairment.

1. Team design It is evident in discipline specific documents that rehabilitation professionals acknowledge the importance of teams. For example, the work of psychologists is partially explained as follows: “The rehabilitation

Fig. 1. Continuum of Team Models. Trans-disciplinary teams represent the most transcendent team model being the most integrated and person focused.

psychologist consistently involves interdisciplinary teamwork [emphasis added] as a condition of practice and services within a network of biological, psychological, social, environmental and political considerations in order to achieve optimal rehabilitation goals.” (American Board of Professional Psychology, 2013, para. 3). Similarly, for physical therapists: “Members of inter-disciplinary teams [emphasis added] also need to interact with each other and with patients/clients/family and caregivers to determine needs and formulate goals for physical therapy intervention/treatment.” (World Confederation for Physical Therapy, 2011, p. 4) Unfortunately, while rehabilitation professionals recognize the central tenant of teamwork, there is little agreement regarding definition of team models or their constitution. Still, there are essential aspects of each of the three most common team models, though the literature historically has lacked precision, especially in consistently labeling and defining each model. Moreover, across authors, different proponents of the same model may use different names for it. Beyond the historical single discipline treatment precursor to team models, there are three main team models: multi-disciplinary, inter-disciplinary, and trans-disciplinary service delivery (Malec, 2013). One can view the progression from multi-disciplinary to inter-disciplinary to trans-disciplinary as an evolution in how teams are conceptualized. In concert with the degree of integration is a progression from being profession-oriented to being persons served-oriented (see Fig. 1). The best teams are person-centered considering the person’s strengths, deficits, competencies, and goals (Butt & Caplan, 2010). Person-centered approaches acknowledge that individuals respond uniquely to injury or illness and that this should inform rehabilitation (Smithson & Kennedy, 2012). A holistic approach integrates individuals into health care and makes them a central player (Umphred & El-Din, 2001). Trans-disciplinary teams re-conceptualize the role of persons with brain injury.

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Multi-disciplinary teams provide care primarily based upon the discipline of each professional. Interdisciplinary teams acknowledge that care does not occur exclusively within disciplinary boundaries and that such boundaries are somewhat artificial; there is overlap between the traditional turf of various disciplines. Trans-disciplinary teams break down boundaries further and focus on the issues persons with brain injury face and help people tackle problems regardless of discipline identification, bringing to bear each discipline’s expertise to any presenting problem. Hence, trans-disciplinary teams represent the most integrated model and the one that is least oriented toward professional identification, and the most persons-focused. As will be seen trans-disciplinary teams are essential for the provision of superior neurorehabilitation treatment because of the complex, multi-determined, and chronic nature of neurorehabilitation conditions.

2. Team models 2.1. Single discipline care The traditional medical model of single discipline care was the prevailing mode of care prior to World War II (Strasser, Uomoto, & Smits, 2008). Being a successful single discipline provider – one could label this uni-disciplinary – necessitates either limited scope of practice or extraordinary range of ability. Unfortunately, the increasing complexity of health conditions makes maintaining a narrow focus or broad knowledge challenging. A narrow practice is difficult because it has become unusual for someone to present a clean case without complications. Simultaneously, the expansion of health care knowledge makes it more difficult to be a “Renaissance Man” of health knowledge. Of course, the single discipline practitioner continues to succeed, but typically establishes an extensive network of referral contacts, essentially creating a team-without-walls. Typically, treatment for brain injury entails a team at all points along the continuum of care (Ivanhoe, DurandSanchez, & Spier, 2013). 2.2. Multi-disciplinary teams Upon discovery of the need for teamwork, rehabilitation practitioners began to create multi-disciplinary teams that involved coordination of care by providers from different disciplines. Turner-Stokes, Nair, Sedki,

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Disler, and Wade (2011) defined multi-disciplinary rehabilitation as “any intervention delivered by two or more disciplines working in coordinated effort to meet these objectives” (p. 4). However, that definition is broad and would encompass all three team models reviewed here. So, the actual function of true multidisciplinary teams bears attention. The hallmark of true multi-disciplinary teams is the simultaneous contribution of team members to neurorehabilitation hurdles that fall within their traditional disciplinary scope of practice (see Fig. 2). This division of a person into disciplinary component problems of the whole person occurs via team decision making about staff assignments and typically without input from the individual receiving services. Each discipline carves out its” turf” which it guards from intrusion from other disciplines, as is evident in rounds where disapproval is voiced about the expertise of other providers who comment on the findings of another provider. Such turf battles can occur in regard to assessment or treatment. This can be voiced in statements such as “You do not know about that since you are not a .” A crucial functional aspect of multi-disciplinary teams is that communication usually goes through the physician (see Fig. 3). Disciplines receive orders from the physician and report their findings to the physician. There is often little cross comparison of results between team members. Rounds are usually conducted by the physician and each discipline reports their findings to the physician who then makes decisions and issues further directives regarding assessments, care, or discharge. Discharge arrangements are usually assigned to the social worker with little ownership by other team members, mobility to the physical therapist, etc. 2.3. Inter-disciplinary teams The hallmark of inter-disciplinary teams is the recognition that disciplines overlap in their expertise and clinical focus (see Fig. 4). While each discipline still reserves exclusive competencies in this model, each concedes that elements of its knowledge and skill sets are shared by other disciplines. This contrasts with past dogmatic territorial boundaries (Umphred, Byl, Lazaro, & Roller, 2001). The concession that rehabilitation approaches can overlap is not trivial in light of historical and ongoing turf battles between disciplines – one need merely follow various list-serves to see such concerns contemporaneously articulated. The sentiments are typically expressed both at clinical sites

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Fig. 2. Graphic Representation of Multi-disciplinary Teams. The circle represents the person with brain injury. Disciplines carve up the person by their areas of expertise without overlap between disciplines. Not all disciplines are represented in this figure. Note. This figure is an adaptation from Karol (1986).

Fig. 3. Communication and Decision Making on Multi- and Inter-disciplinary Teams. Communication and decision making are centralized passing through the physician who coordinates all information and issues orders.

between providers and in national maneuvering in terms of billing code usage, right to diagnose, freedom to practice independently, concerns about other disciplines’

Fig. 4. Graphic Representation of Inter-disciplinary Teams. The circle represents the person with brain injury. Disciplines carve up the person by their areas of expertise with overlap between disciplines. The striated areas represent “inter” areas of overlap. Not all disciplines are represented in this figure and not all areas of overlap are represented in this figure. Note. This figure is an adaptation from Karol (1986).

assessment tools, prescription privileges, restraint of trade, job security, etc. Given these pressures, it may be remarkable that disciplines acknowledge that there is any common turf. As shown in Fig. 4, the shortcoming of the interdisciplinary model is the continuation of assigning clinical issues by discipline, albeit with overlap. Nevertheless, there is recognition of common ground. There are numerous areas of overlap and one figure cannot illustrate them all. Examples can be cited, however. Speech-language pathologists and psychologists might both work on language disturbances, memory deficits, or social skills. Social workers and psychologists might both work with family members, or on behavioral disturbances in collaboration with nurses. There is a continuing shifting of joint responsibilities for both assessment and treatment depending upon the talent, experience, and desire of particular staff and the needs and restrictions of their work setting. The actual application of overlapping disciplinary expertise results in teams that are better coordinated than multi-disciplinary teams. Clinicians must work together on clinical hurdles in those areas where overlap is recognized. The model incorporates treatment plans, teaching approaches, educational initiatives, and

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Fig. 6. Communication and Decision Making on Trans-disciplinary Teams. Communication and decision making are decentralized. All disciplines communicate with each other and decision making is a joint exercise. The physician is a team member as is the person with brain injury. Not all disciplines are represented in this figure.

Fig. 5. Graphic Representation of Trans-disciplinary Teams. The circles do not represent the person with brain injury, but rather represent a sequence of issues to be addressed by the whole team beginning in the center on basic, foundational issues. Note. This figure is an adaptation from Karol (1986).

interventions that are at least compatible and preferably similar. Within areas of overlap, providers in the interdisciplinary model have the same playbook. Chaos ensues if two, or more, providers simultaneously working on a given issue fail to do so in an integrated fashion. When care is coordinated the benefits of this model include clearer communication, more consistent treatment techniques, and more uniform implementation of adaptive compensation tools. This leads to enhanced response to treatment and better outcomes. 2.4. Trans-disciplinary teams 2.4.1. Description Trans-disciplinary teams are the current exemplar of team integration. However, while the progression from multi-disciplinary teams to inter-disciplinary teams represents a significant change in thinking, the jump to trans-disciplinary teams is a true quantum leap. Trans-disciplinary teams epitomize an advanced way of conceptualizing treatment roles, although the basic model under the term “supra-disciplinary” was

described some time ago (Karol, 1986). The transdisciplinary team model changes the relationship between the disciplines and clinical issues. Transdisciplinary teams do not divide up the person based upon discipline specific areas of expertise as do multi-disciplinary teams (without overlap – Fig. 2) or inter-disciplinary teams (with overlap – Fig. 4). Instead, the sine qua non of trans-disciplinary teams is that all disciplines are responsible for every clinical concern. They are transcendent and as Malec (2013) points out the integration and role flexibility in such teams is characteristic of high performance teams (e.g. Special Forces military teams). Trans-disciplinary team members create a hierarchy of issues that they need to address (see Fig. 5), but the hierarchy is usually in flux as new issues arise or as care progresses. Team members determine how each discipline will contribute to the amelioration of every problem. Of course, some disciplines may have more input than others into a given problem. However, no one opts out of contributing to the treatment of any problem. Although varied concerns can be treated simultaneously, staff typically must address certain concerns sequentially. For example, a team might work on dressing skills before path finding during an outing, behavioral dyscontrol before home passes, selftransfers before walking, or balance before ambulatory self transport to treatment. No problem is owned by particular disciplines in a trans-disciplinary model.

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Using dressing as an example, occupational therapy might design a methodology for getting dressed, nursing works on practicing them, psychology assists with motivation when the person struggles or provides praise when the person succeeds, physical therapy works on balance while dressing, recreational therapy targets insight into appropriate dress for social situations, speech-language pathology designs reminders about how to communicate the right steps to getting dressed, and social work obtains actual clothes of the person from the family that would be used at home to practice with in therapy. Hence, everyone contributes to the hurdle of re-learning to dress. No one on a trans-disciplinary team shuns their collaborative responsibility or protects their disciplinary turf. Furthermore, no discipline discharges a person from care while other team members are addressing other clinical problems that would, in other team models, be those other team members’ exclusive responsibility. Psychology works on falls; social work works on skin integrity, physical therapy works on depression, etc. The essential feature of how transdisciplinary teams function derives from the fact that every provider has responsibility for every hurdle to the progress of persons with brain injury. A couple of simple examples can illuminate the model of shared responsibility. For example, consider skin breakdown, a traditional area of nursing responsibility. Suppose a person is at risk for decubiti. The nurses set up a program to turn the person every two hours. However, the social worker enters the room and notes the person seems to be wiggling in bed. The social worker inquires about the person’s pain level and discomfort. When the person reports being uncomfortable the social worker gets the nurse to exam the person’s skin ahead of schedule. The nurse and social worker return to the room and discover increasing redness and care is provided. The social worker knowing the full treatment plan accepted responsibility for helping with skin care and the nurse responded to the social worker’s concern and did not insist that nursing was monitoring the situation adequately with the planned schedule. Or, suppose a psychologist reports that a person is making good emotional progress in the sessions in the psychologist’s office and depression is improving. However, the physical therapist reports that the person is frequently crying during treatment and simultaneously making depressive statements. Working as team, the physical therapist proposes a co-treatment session with the psychologist attending physical therapy care. In fact, during physical therapy/psychology co-treatment

the person is observed to be crying and venting frustration about the injury because of the emotional bond established due to the physical touching that occurs during physical therapy; the act of touching creates intimacy and emotional disclosure. The person’s coping is less emotionally advanced than observed during oral office discussions with the psychologist. The psychologist in this case welcomed the observations of the physical therapist regarding the emotional status of the person and the physical therapist felt comfortable on this trans-disciplinary team for taking responsibility to follow up in regard to the emotional coping of the person. There must be excellent communication between team members to accomplish the level of integration that trans-disciplinary teams require (see Fig. 6). Unlike multi-disciplinary and inter-disciplinary teams where communication primarily occurs between team members and the physician, trans-disciplinary teams encourage communication between all disciplines. Since persons with brain injury are integral team members, they are also viewed as essential to team functioning, communication, and decision making. Trans-disciplinary teams, accustomed to lowered boundaries between team members, can find it easier than other teams to integrate persons with brain injury into the team. Such a collaborative approach enhances engagement, motivation, and long-term selfmanagement (Smithson & Kennedy, 2012). How this happens structurally may vary across programs and may depend upon the cognitive and behavioral level of the persons being served. Some programs may insure communication and participation through individual meetings that are structured around the person’s abilities. This is true particularly for hospital based services or in programs that see people with severe cognitive deficits or behavioral intolerance precluding sufficient cognitive processing for attendance in full rounds. They may also hold brief daily walking rounds – coming to the person’s room – in which communication is shorter or simpler so that the person can participate. In other settings, especially outside institutional sites, in which the person presents with less behavioral dyscontrol or more extensive cognitive skills, full meetings will include persons being served. The inclusion of the person with brain injury is a vital aspect of trans-disciplinary teams. In Figs. 2 and 4 the circle, representing the person, is divided up by professionals with little say from the person. The person in these models does not determine the expertise of the professionals and what services they choose to give.

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This is different in Fig. 5 where the circles no longer represent the person, but issues to be addressed by everyone, including the person, professionals, family, friends, employers, and other key stakeholders. Also, a second set of circles could be constructed representing strengths and resources of the person, professionals, and others that will be drawn upon at various stages of neurorehabilitation. Parenthetically, it is important to note that the literature is sometimes imprecise about terminology, particularly between inter-disciplinary and trans-disciplinary labels. Additionally, some literature written when inter-disciplinary teams were the most advanced team model in common practice actually described elements of trans-disciplinary teams, but still labeled them inter-disciplinary teams. Therefore, it behooves professionals to consider literature’s actual descriptions of team function, not the labels used by the authors. 2.4.2. Importance for neurobehavioral intervention Trans-disciplinary teams are particularly important when providing neurobehavioral treatment because of the complexity of the issues neurobehavioral conditions engender. In contrast to other areas of health care, neurobehavioral presentations tend to be diagnostically complex and etiologically multi-determined. Performing in concert is the key to teamwork (Bergquist & Malec, 2002). Neurobehavioral conditions are often not curable resulting in chronic health conditions and require ongoing treatment. Moreover, chronic conditions are increasing and are expensive to address (Cheak-Zamora, Reid-Arndt, Hagglund, & Frank, 2012). In addition, neurobehavioral conditions can entail psychological, social, vocational, recreational, financial, and familial effects that spread out from the injury or disease and their treatment or management. Disability is a common outcome of neurobehavioral problems. For example, persons after traumatic brain injury commonly experience issues with independent living, return to work, recreational pursuits, social life, transportation, etc. in addition to cognitive, behavioral, emotional, and activity of daily living functions (Tate, 2012). Moreover, the cognitive impairment of many persons experiencing neurobehavioral conditions makes them less likely to be aware of discordant services and less able to independently manage provider shortcomings in teamwork. Persons with chronic conditions and their family members often carry the burden of coordinating care, but frequently fail to do so over the long term (Cheak-Zamora, Reid-Arndt, Hagglund,

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& Frank, 2012). Hence, integrated teamwork is more essential for neurobehavioral issues than for simpler health conditions that are less intricate diagnostically, cleaner to treat, shorter in duration, without psychosocial or other fallout, lacking subsequent permanent disability, and devoid of cognitive impairment. 2.4.3. Core staff Core staff are inherent in any team model (Butt & Caplan, 2010). Consistent staff leads to treatment continuity, team-building, and less confusion among the people being served. (Commission on Accreditation of Rehabilitation Facilities, 2013). This is particularly important in trans-disciplinary teams where staff are significantly more integrated than on other teams. If a member of a trans-disciplinary team works as if on a multi-disciplinary or inter-disciplinary team, that professional will become more isolated, produce sub-optimal results and likely decrease the overall effectiveness of the team. As with any team sport (e.g., basketball), coordination is crucial and the team achieves success through a game plan (treatment plan) where every team member plays a coordinated role on every play (every targeted clinical issue). Players may have a greater or lesser role on every play and must be ready to increase, decrease, or change their role depending on circumstances, but they are not permitted to take off plays (“that problem is not my responsibility”), even when they originally have a minimal role. Individual players may outshine their teammates in certain skills, but teams win championships when everyone passes, shoots, rebounds, and defends. Similarly, trans-disciplinary teams achieve the best outcomes when roles are shared. Hence, as in sports, the introduction of a new teammate who does not understand the trans-disciplinary team model can hinder the team. Unprepared staff cannot independently float into a trans-disciplinary team without decreasing its effectiveness. The use of “float” staff or “pool” staff who are not trained in the trans-disciplinary model are also destructive to outcomes and can actually harm those receiving care. In contrast, the already isolated team members on multi-disciplinary teams can function much better with uninitiated teammates; substitutions are much less detrimental and probably can even be “tolerated” on a multi-disciplinary team because such teammates only affect one clinical area. Inter-disciplinary teams fall in the middle with na¨ıve teammates having a broader effect than on multi-disciplinary teams, but not so intolerably as on trans-disciplinary teams.

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2.4.4. Rounds attendance Trans-disciplinary rounds do not have each discipline reporting on discipline specific progress or hurdles in a round robin manner while other attendees remain silent taking notes. Rather, a particular discipline may initiate conversation on a given issue but then all disciplines contribute observations and all devise interventions across all disciplines (Karol, 2003). A true conversation takes place about the person and the clinical concern. (If the person does not have the ability to participate due to the severity of the cognitive impairment or the nature of behavioral dyscontrol in routine rounds, separate meetings ought to occur regularly with the person with brain injury and the family. In addition, briefer walking rounds that are shorter or less complex can be held with the person.) Regardless of the schedule and type of meeting or communication they should occur in a trans-disciplinary fashion with open communication and decision making. Team rounds in various settings, including acute settings, fulfill multiple functions (Stevenson, 2014; Warren, 2014). Trans-disciplinary rehabilitation rounds have two formal functions: reporting on progress and treatment planning/problem solving. However, a third implicit function is to create a cohesive team (Karol, 2003). Therefore, trans-disciplinary teams require full team attendance at all rounds. In some settings there might be an attempt to have representatives from “therapy” as a whole attend to communicate for nonattending teammates. This might permit fulfillment of the reporting function of the rounds – familiar to team members of multi-disciplinary and inter-disciplinary teams, but it is a poor substitute for actual team member attendance since other team members may have questions which the reporter cannot answer. Finally, in some settings the neuropsychologist functions in a consulting role to the team providing a written report; however, the neuropsychologist should be an integral team member attending the team meetings (Novack, Sherer, & Penna, 2010). Partial information forces the team to make decisions with incomplete insight. This can result in poorer care and longer lengths of stay when incompletely based decisions have to be revised at the next rounds. Additionally, the team lacks the insights and contribution in real time of all involved stakeholders who might offer ideas on how to address a particular problem. In effect, the team lacks the synergistic brain power of all of its team members. Finally, there is value in being present in the meeting as team members confront thorny clinical issues, or alternatively, celebrate successes.

These processes lead to cohesiveness and trust among team members and this does not happen by proxy. The team meeting is not just a cognitive exercise, but an emotional one that requires everyone’s presence to experience. Typically, financial reasons underpin the use of a representative system as it is cheaper to have less people away from billable time and, unfortunately, this is a persistent issue. More than 40 years ago Wright (1972) recognized that agency and professional needs could influence how services are coordinated. However, such considerations fail to account for the financial implications of care that is less well coordinated or takes longer to complete, to say nothing about the ethical considerations of inadequate case dialogue among providers. With the implementation of capitated reimbursement, at least in hospital settings, extended stays due to an insufficiency of treatment synchronization incur unreimbursed costs and longer stays do not increase revenue. In light of the current zeitgeist of care coordination it seems counter-intuitive to skimp on treatment planning. 2.4.5. Physical plant Physical proximity breeds familiarity that is essential for trans-disciplinary work. Team members ought to have office and work space close to each other. Office (or cubical) assignments are best made by team membership rather than via discipline specific departments. Otherwise it becomes too comfortable to associate only within one’s own discipline. Physical closeness can overcome this tendency and generate trans-disciplinary comfort. This is important for cross fertilization on a continual basis that is advantageous for trans-disciplinary work. Plus, there is little risk that disciplinary members will fail to consult within their discipline, as needed, even with less intimate offices, in contrast with the greater risk that they will not converse across disciplines unless the office assignments encourage it. This type of proximity also aids teams by improving opportunities for informal consultation (Wertheimer et al., 2008). These “curb-side consults” more readily permit treatment adjustments across disciplines in real time. Finally, the milieu should be psychologically facilitative of emotional supportiveness (Vash & Crewe, 2004). Treatment areas should also be similarly intertwined as opposed to carved out by disciplinary turf. For example, a therapy gym might have a therapeutic kitchen as well as parallel bars. Of course, some private treatment rooms are obviously required. Still, conjoined space leads to sharing of care goals and shared interventions.

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2.4.6. Leadership Implementation of a trans-disciplinary team requires leadership. The program leaders must understand the model and be committed to its implementation. Plus, leadership should be prepared to address scope of practice, role release, and peer pressure concerns. Leadership must also attend to the variables of team and organizational culture when initiating a transdisciplinary model. This makes staff selection crucial. 2.4.6.1. Scope of practice and role release. Therapists may express concern about scope of practice which usually refers to staying within one’s expertise. To be clear, trans-disciplinary team work does not require work outside one’s expertise, but provides a framework for staff to use skill sets that they might otherwise be inhibited from applying. The scope of practice of speech-language pathology can highlight how one trans-disciplinary team member can function broadly. The American Speech-LanguageHearing Association (2003) stated in “Evaluating and Treating Communication and Cognitive Disorders: Approaches to Referral and Collaboration for SpeechLanguage Pathology and Clinical Neuropsychology:” Speech–language pathologists also provide input on such areas [emotional states], and assist with formulating a hypothesis regarding a patient’s status, treatment needs, or possible outcomes. Furthermore, it is within the scope of practice for speech-language pathologists to evaluate, diagnose, treat, and counsel patients, family members, educators, employers and other rehabilitation professionals in adaptive strategies for managing cognitive-communication disorders. Speech-language pathologists also must integrate behavior modification treatment techniques as appropriate for the management of associated problems, such as agitation and selfabusive and combative behaviors. (p. 7) While the document goes on to note that “direct intervention for affective and anxiety disorders” (p. 7) is in the realm of psychologists, as related to scope of practice, the preceding quote certainly would appear to give credence to the idea that speech-language pathologists remain engaged in treatment across a wide array of intervention issues. Similarly, physical therapists might be called upon to address motivation. Winkler (2001) notes that motivation is one of the most common problems physical therapists must address in traumatic brain injury rehabilitation. On a trans-disciplinary team motivational

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issues are not handed off to the rehabilitation psychologist, but are owned by all disciplines. Complementary to one discipline conceptualizing a wider scope of practice is the willingness of another discipline to accept “role release.” Role release refers to a willingness to permit other disciplines to perform therapeutic activities normally in the domain of another discipline. As one discipline becomes comfortable working more broadly, a parallel one must accept the first discipline on its “turf’ and vis-a-versa. A discipline must not just practice expanded scope of practice onto others’ turf, but it must simultaneously encourage role release of its own turf to other disciplines. Physical therapy can serve as an example. McEwen, Arnold, Jones, Shelden, & Rapport (2000), published by the American Physical Therapy Association, wrote: “Role release is a defining characteristic of transdisciplinary teamwork. Role release involves delegating tasks and teaching methods usually performed by one discipline to team members of other disciplines” (p. 67). Furthermore, the American Physical Therapy Association (2010), writing about team based service delivery in pediatric care, said: “In this team approach [referring to trans-disciplinary teams], physical therapists share aspects of their discipline and learn aspects of other team members’ disciplines. This sharing of information and professional competencies is called ‘role release’ ” (p. 2). It is apparent that physical therapy appreciates the value of both letting other disciplines into its traditional area of expertise as well as being committed to assisting in treatment concerns beyond its own traditional borders. One could even go further and acknowledge that disciplines are also lowering their traditional barriers in goal formulation as well as treatment. The World Confederation for Physical Therapy (2011) wrote: “Members of inter-disciplinary teams also need to interact with each other and with patients/clients/family and caregivers to determine needs and formulate goals for physical therapy intervention/treatment” (p. 4). Although failing to recognize the distinction between inter-disciplinary and trans-disciplinary terminology, the World Federation of Physical Therapy does articulate the importance of a trans-disciplinary perspective as applied to goal setting by physical therapy. In fact, for all disciplines the trans-disciplinary model should apply to treatment initiation, goal setting, treatment delivery, and discharge decisions. Of course, even within a trans-disciplinary team, the team members recognize that not every discipline is expert in others’ core competency areas. However, this

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does not preclude team members from helping to treat others’ clinical intervention targets, looking to the relevant discipline team members to provide necessary levels of support and expertise. A physical therapist may not be as knowledgeable as a psychologist on behavioral or emotional issues, a recreational therapist may not be as conversant with balance problems as a physical therapist, and a nurse may not be as informed about communication disorders as a speech-language pathologist. However, treating emotional and behavioral matters does not occur just during psychotherapy, balance training is not occurring just during physical therapy, and treatment for communication difficulties does not happen only during speech therapy. Upon reflection this makes sense as dysfunctional behaviors, balance problems, and communication disorders more likely continually present organically throughout the day rather than just during artificially scheduled treatment times. All disciplines must be prepared to facilitate the care of all problems including behaviors, balance, communication, etc. However, role release and other aspects of transdisciplinary teams do not occur in one step (King et al., 2009). Team members must develop understanding of each other’s theories, information, practices, how each makes their observations and decisions, and what techniques and methods each uses. There are levels of role release including general information – sharing of information, informational skills – sharing of decision making, and performance competencies –sharing of interventions (Lyon & Lyon, 1980). The most advanced trans-disciplinary teams share all functions. 2.4.6.2. Staff selection. Staff selection is key in starting trans-disciplinary teams. Professionals fail in this model when they are unable to problem solve on unfamiliar grounds, are insecure about their knowledge and skills, or are rigidly set in their professional ways. Open discussion about the model and its implications needs to begin between prospective team members when they are volunteering for the team and when leaders are selecting team members. A shared vision about roles and goals enhances team function (Smithson & Kennedy, 2012). The trans-disciplinary team model cannot be successfully imposed by an outside authority (i.e., administrator) on professionals who do not understand the model nor want to be on such a team. Hence, it is crucial to use professionals who are volunteering to work in this model. Even with self-aware and knowledgeable volunteers, some team members may find that the reality is more challenging to their desired pro-

fessional image and comfort zone than they thought. Turnover on the team early on should be expected as team members sort out their experiences and role concerns. However, professionals on trans-disciplinary teams are typically very committed to it once the team bonds together and solidifies its working relationships. 2.4.6.3. Peer pressure. Peer pressure can be a surprising consideration, though this may not become apparent immediately. There can be disapproval about role appropriateness from colleagues within a discipline who only work on multi-disciplinary or inter-disciplinary teams when they observe the diversity of treatment issues a trans-disciplinary colleague is addressing. At such times, trans-disciplinary team support, as well as leadership reassurance, can ameliorate the pressure. Physical plant design that places trans-disciplinary colleagues together can help as well. The warnings signs of peer pressure are usually a desire to focus on only a narrow set of symptoms or to express a desire to discharge a person from care after accomplishing specific objectives, but before other trans-disciplinary colleagues have accomplished other goals. In addition, a narrowly focused team member may express little interest in helping to problem solve for treatment hurdles outside their traditional scope of service. Such team members must be reminded of the value of their collaborative contributions and ownership of all problems. Otherwise, team members who are regressing will show gradual withdrawal from team participation. Leadership must nurture trans-disciplinary thinking and therapy since there is a tendency to regress to the security of inter-disciplinary thinking, if not the even more absolute sanctuary of multi-disciplinary teams. It still remains easier to think of only one’s own discipline and treatment issues rather than everyone else’s treatment issues. This is perhaps a reflection of training programs which fail to emphasize teamwork even for inter-disciplinary collaboration (Sander & Constantinidou, 2008). Again, program leadership would do well to discuss the implementation of trans-disciplinary teams with each individual team member before actual implementation and obtain specific interest in working in this fashion. In fact, a written commitment to the model that includes the model description and principles can be beneficial. It becomes a touchstone during difficult cases when team members want to disengage. This is often seen when treating neurobehavioral problems when team members are either stuck in how to proceed or are at physical risk of harm during their involve-

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ment. Leadership needs to be prepared to re-direct team members who want to discontinue intervention involvement. Otherwise, the team will disintegrate in the face of challenging cases. On the other hand, team members who actively endorse trans-disciplinary work can receive great professional satisfaction. They find that they are not confined by restrictive silos about the components of care they are or are not permitted to discuss and treat. The trans-disciplinary model is liberating for innovative, confident providers who are motivated to learn. 2.4.6.4. Culture change. Leadership must be prepared to address existing team or organizational culture when implementing a trans-disciplinary team model. Facilities can differ on a number of variables such as facility culture (Is the facility family like? Is it entrepreneurial? Is it bureaucratic? Is it productivity oriented?), relationships (Are physicians supportive? How formal are relationships? How task oriented is the team? How adaptable is the team?), and current team function (How does the team integrate opinions? How does the team communicate? How effective is the team? Is there collaboration with teammates and with administrators?) (Strasser et al., 2002). Awareness by leadership of baseline functioning on such factors is vital before trying to initiate changes in team function. Trans-disciplinary teamwork requires trust because team members are crossing traditional disciplinary boundaries. Defensiveness can arise related to the perceptions team members have about how their professional judgment is viewed by teammates and about encroachment on professional territory (Strasser, Falconer, & Martino-Saltzmann, 1994). Hence, it behooves leadership to set the tone early about the value of transdisciplinary work and to articulate a commitment to the model. Leaders must also ensure that training is available for prospective team members on how to work collaboratively (Law, 2013). To a large extent, the formation of trans-disciplinary teams focuses on therapists’ roles (e.g., occupational therapy, physical therapy, speech-language pathology, psychology, recreational therapy, and chaplaincy). However, in clinical neurorehabilitation settings nursing staff must also be integrated into the trans-disciplinary team. (Kneafsey & Long, 2002). Rehabilitation nursing staff tend to have an indispensable, though not exclusive role in establishing the therapeutic environment, implementing generalization of therapeutic skills, providing feedback on performance and learning, etc. In this regard

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rehabilitation nursing is a recognized specialty that partners across disciplines (Association of Rehabilitation Nurses, 2014; Goonan, Kahn, & Straus, 2013). Transdisciplinary work requires integration across traditional therapies and nursing including incorporation of boundary changes. It is also crucial to understand physicians’ perspectives on team models. Trans-disciplinary physicians have a different relationship with team members than on multi-disciplinary or even inter-disciplinary teams. Role release applies to physicians as well. On multi-disciplinary teams, every decision is run past physicians (refer to Fig. 3); on trans-disciplinary teams physicians are an essential, integral part of the team (refer to Fig. 6), but over time the team and physicians establish trust as to what decisions require physicians’ input and what freedom exists to operate independently. Conflicts can arise if there is not agreement about physician-team relationships, communication, decision making authority, legal responsibility, etc. (Savage, Parson, Zollman, & Kirschner, 2009). 2.4.6.5. Implementation. Leading a team from other models to a trans-disciplinary one requires attention to the unique issues in each setting (Gordon et al., in press). Training in the model is essential because educational settings may not have provided instruction in the model; traditional training may have emphasized that students stay within boundary silos and not infringe on other disciplines “turf.” Gordon, Corcoran, BartleyDaniele, Sklenar, Sutton, & Cartwright (in press) suggest that professional re-education could include problem-solving, simulation, case vignettes, and video of successful and unsuccessful team strategies. An example of leading a program to a transdisciplinary model may provide waypoints to consider. First, confidential interviews with existing program staff provided insights into their perspectives about the barriers that hindered achieving great outcomes. Interviews incorporated solicitation of advice about what staff needed and what they would change programmatically. Interviews included staff from clinical disciplines (e.g., therapies, nursing, social work) and nonclinical staff (e.g., housekeeping, administration), the latter whom Vash and Crewe (2014) note may spend sustantial time with the persons being served. These interviews revealed staff silos with little collaboration across disciplines or even between staff with different roles within disciplines. Not surprisingly there also existed inadequate communication. Staff related being rebuffed when they attempted to comment on the decisions of another discipline.

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Based upon these interviews, leadership outlined a set of principles in the form of a written program commitment statement. This document promulgated the concept that all of the problems of the people being served with brain injury were the responsibility of everyone to help solve. Silos were to be avoided; everyone was to help everyone with every problem. Part of the staff’s responsibility was to help each other in the performance of their jobs. The document specifically stated that the program staff would function in a trans-disciplinary team. Leadership encouraged staff who were comfortable with these ideas to apply to continue to work in the program. Hence, everyone who was going to work on the trans-disciplinary team was a volunteer. Finally, leadership then individually interviewed those believing that they wanted to work in this model at which time the model was explored again and the interviewer provided the commitment document to sign; this was then countersigned by a supervisor. After staff were selected, leadership provided extensive in-service training to further review the model. These in-services highlighted how the model works with an emphasis on trans-disciplinary roles in comparison to multi-disciplinary or inter-disciplinary ones. Staff across disciplines attended these in-services together. Topics included role release and scope of practice. The presenter provided case examples of trans-disciplinary collaboration for examination and discussion. Following these educational sessions, leadership conducted individual discipline sessions to address lingering discipline specific issues such as billing and charting. The program’s round attendance was expanded to include a full complement of program staff from a baseline of a few representatives. The round’s structure was altered from having each discipline report on their area of expertise to a model of having a discussion of clinical issues and hurdles to transition to the community that all disciplines problem solved together. Rounds report summaries were changed from discipline specific topics to clinical issues for everyone to address. Finally, leadership initially attended rounds to redirect relapse away from multi-disciplinary or inter-disciplinary thinking until a culture shift to trans-disciplinary processes became embedded in the team function. Leadership also provided reinforcement whenever the team achieved success through transdisciplinary efforts and highlighted that such outcomes could not have been reached without trans-disciplinary work.

Concurrent with these staff and procedure changes, the physical plant underwent remodeling, in part, to help integrate team function. The occupational therapy, physical therapy, and speech language pathology offices and gym were relocated to be on the brain injury floor next to the brain injury nursing units. The recreational therapy office was placed on the nursing units and space was allocated for activities on the units. Social work offices were placed directly on the nursing units. The brain injury leadership office was located on the nursing units, as was psychology. In summary, transition to a trans-disciplinary model requires dedicated attention to the steps required for implementation. This is not a casual undertaking; leadership must provide resources and time to make it happen. These include: [1] a clear understanding of the pre-existing function and culture of the existing team; [2] a thorough appreciation of the model by leadership and a commitment to it; [3] provision by leadership of a vision of team function; [4] investment by staff in the trans-disciplinary model; [5] extensive staff training in the model; [6] revamping of procedures and forms to support the model; [6] alteration, as needed, in physical plant design; and [7] on-going guidance to accomplish enculturation in the model to prevent relapse. 2.4.7. Community The importance of a trans-disciplinary team in the natural community environment likely exceeds its importance in facility based programs or even in onestop integrated community programs. In community based care, the person receives help from a range of providers (in-home assistance, vocational providers, physicians, therapy clinics, transportation companies, chemical health community services, psychologists, etc.) just like everyone else (Ravesloot & Seekins, 2012). The lack of coordination of these services leads to fragmentation and is one of the major issues facing community based care after brain injury (Katz, Zasler, & Zafonte, 2013). A team that can cross disciplinary boundaries and have all providers be responsible for insuring attention to all problems is essential. Too often during a provider visit a concern will arise outside the typical expertise of that provider and therefore be ignored by the provider who assumes someone else will take responsibility. In contrast, for example, imagine that during a psychotherapy visit a person discloses discontinuation of a CPAP machine. The psychologist, not necessarily a sleep disorder expert, concerned about the impact of this on mood and cognition, facilitates contact with other providers, who then work together

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to solve the concerns of the person about the CPAP machine. In the process, the person’s mood and cognition improve after the reasons for non-use are addressed as a team. Rather than having the discontinuation of the CPAP fall through the cracks of the system, the psychologist worked with the team across agencies to address the reasons for the discontinuation. Five initiatives could help toward the achievement of coordinated care. First, more available case management by experts in brain injury could insure that clinical issues are addressed by providers across sites. Such care coordinators must be sufficiently familiar with brain injury so that they can recognize omissions in service delivery. Second, schools need to train providers to take responsibility for care coordination along with training clinical procedures. This needs to be viewed as a core skill for clinicians. For clinicians already in the field, training seminars in communication and care coordination could be offered (Karol, 2011). Third, board certification should include coordinated consultation as a required competency. For example, the American Board of Rehabilitation Psychology (2012) states that candidates for board certification must demonstrate “effective consultation with other professionals appropriate to the needs of the client in ways that will promote useful outcomes for the client . . . ” (p.10). Fourth, clinicians should be reimbursed for time spent in care coordination (e.g., phone calls), not just for direct treatment time. Fifth, persons with brain injury ought to be taught how to manage their providers to facilitate communication and care management (Karol, 2004). This could include how to best interface with provides to obtain the best care. “Trans-agency” integration of team members who work trans-disciplinarily is crucial. It is not uncommon to find financial considerations and competitive agency stances interfering with trans-disciplinary work. Transdisciplinary interactions in a trans-agency environment abut against agency pressures on professionals to spend time in billable pursuits. In addition, some organizations view information, forms, skill sets, etc. of their staff as corporate secrets or competitive advantages that they are reluctant to share, thereby inhibiting the openness that is a requirement for trans-disciplinary work across agencies. Parallel with role release the field could benefit from “agency-release.” 3. Conclusions The trans-disciplinary model is the gold standard for teams in neurorehabilitation. Such teams entail more

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integrated service delivery than do other teams. Problems do not fall through cracks between disciplines because everyone is responsible for all issues. Life skills are taught in a cohesive manner since disciplines coordinate efforts on clinical target hurdles. Plus, there is greater commitment to rehabilitation goals by staff who share in decision making and these professionals also bask in professional growth without silos. All these benefits of trans-disciplinary teams set the stage for better care. Trans-disciplinary teams represent considerable progress from single discipline, multi-disciplinary, or inter-disciplinary models. Trans-disciplinary teams represent a more persons-centered approach. However, to implement a trans-disciplinary model, teams must have excellent communication between all disciplines and shared decision making including persons with brain injury. Core staff who attend rounds are essential. The physical plant can facilitate the implementation of a trans-disciplinary team, though leadership on scope of practice and role-release is paramount. Otherwise, peer pressure and institutional or program cultural variables will doom the team. Hence, the importance of staff selection cannot be underscored enough. Finally, transdisciplinary teams are more essential in community based neurorehabilitation settings than facility based ones because of the greater threat of disjointed care.

Acknowledgments Appreciation is due Karen Brudvig for her assistance in research for this article.

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