Getting You Better. Together.

Physical Medicine & Rehabilitation Takes a Multidisciplinary Team

When Dan*, a thirty-four-year-old father with a cervical spinal cord injury, baked and frosted a cake for his son’s first birthday, the simple yet profound act represented a triumph of achievement—and of teamwork.

Everyone in healthcare talks about “teams” these days. But at Burke Rehabilitation Hospital, the breadth, range and closeness of our teams is really remarkable—and makes triumphs like Dan’s possible. It includes but goes beyond the team of therapists working hands-on in the gym, beyond the social workers connecting patients with community resources and supports so they can go home safely. And it goes beyond the medical team, the doctors and nurses, who keep a close eye on your health, pain, medications and risks.

What makes our care so special and our outcomes so successful is all these experts working together, with the patient at the center, communicating constantly, including in formal weekly team meetings organized around each patient, in informal small huddles where therapists and the social worker, for example, might discuss barriers and solutions to a patient’s discharge or where PT, OT and the resident doctor might revisit a patient’s pain management.

“We are a tight-knit team wholly focused on the patient,” says Elizabeth Dominick, PT, DPT, a clinical specialist in neurologic physical therapy and the Program Director of the Burke Rehabilitation Spinal Cord Injury/Neuro Program. “We communicate constantly, and all work together towards the same thing, our patients’ individual goals.”

For Dan, the goal was to participate in the milestone birthday while he was in inpatient rehabilitation. He had limited use of his hands and couldn’t grasp, but he worked on adaptations with Burke specialists in physical therapy, occupational therapy and therapeutic recreation, with additional support and input at every stage from the rest of the team, including nurses, doctors and social workers. “His accomplishment—baking and frosting the cake—took a lot of thought and planning from the whole team, and really showed how far he had come,” says Dominick. “We were all so happy for him, and that’s how it is here: we treat our patients like family.”

Putting the patient at the center

The key to being a successful team player is listening to patients. Only by listening can we find out where they are and where they want to go, see barriers to getting there, and put together a plan—and a team–to help them accomplish their goals. “All my patients just want to be heard,” says Elizabeth Kopram, MSN, RN, nurse manager on the orthopedic rehabilitation team.

Upon meeting patients when they first get to Burke, she holds their hand, sits at their eye level, even if they are in bed or a chair, and says, “We are a team.” Patient, family, the care team—all working together to help the patient get better and get home. Then she says, “Tell me what you are able to do, and I’ll do the rest. We are all here for you.”

She recently saw one of her patients, now at the end of her stay, walking the hallway with a walker, and exclaimed how well she was doing. Together, they remembered when the patient first came in, how Kopram held her hand and listened to her fears that she wouldn’t be able to walk, get her strength back, regain her independence. Now, the patient thanked Kopram and the team, and said, “I am so happy with where I am.”

‘We constantly compare notes’

Inpatients at Burke Rehabilitation Hospital receive up to three hours of physical, occupational, and, if needed, speech therapy under the care of a team that also includes physicians, rehabilitation nurses, social workers, psychologists, care managers, dieticians, and other clinical and support staff. Each patient is surrounded by their own select team, which coordinates closely in and out of the gym, from shift to shift and day to day, meeting regularly as a group to make sure the patient’s needs, goals and progress are attended to all times.

“We constantly compare notes, formally and informally,” says Juliette Kleinman, LCSW, ACSW, Director of Social Work Care Management. “Each team member from each discipline is a necessary ingredient, and we all work together to create the recipe for a safe discharge.”

For Jorge*, recovering from a stroke, it took a team working together to notice, elevate and solve a challenge he faced upon discharge—he could not read directions on his new medications. The occupational therapist first noticed he couldn’t read his pill bottles and immediately consulted with the team, beginning with the doctor, who reviewed his new medications. The social worker then placed the order with the pharmacy well before discharge, so the resident doctor could organize pill boxes and work with Jorge to set up a system he could follow. Nursing and social work ensured that the discharge continued safely.

“The entire team came together, thought outside the box, and came up with an intervention that reduced a very risky situation for this patient,” says social worker Katie Harris, LMSW. “Because of our teaching, he can recognize his meds and understand how to take them.”

The central role family plays

The Burke team considers the family a vital member of the team and (with the patient’s permission) connects early and often with family members and any other caregivers at home, such as personal aides. We offer caregiver support, educate and train family members on the rehab journey and any specialized care needed after discharge, such as feeding tube or wound care, and invite them into every step of the rehab journey. “That’s another excellent example of teamwork, making sure the patient and the family are prepared for a safe discharge,” notes Kleinman.

Just as the family is an important part of the care team, the care team often comes to feel like an extended family, says Dominick. “We are right there with people, we root for them and cheer their first steps.”

Her office is right outside the gym, and she will always come out when she hears a celebration. “That’s the best part,” she says. “When I hear yelling and cheering, I run out and I love to join the celebration as patients reach new milestones. Everyone wants everyone to do the best they can, and we certainly work together to make it happen.”

*Name changed