12-week rehabilitation pathway at The Dean

Admission: The first 24-72 Hours

Access to appropriate expertise early on in the rehabilitation process can significantly impact how a patient achieves personal goals and positive outcomes, so as soon as a new patient arrives at The Dean they begin to meet with each member of their MDT. These meetings form the basis of a second assessment report which each of the clinicians contribute to. This report is completed in collaboration with the patient, working together to set treatment goals and ensure holistic rehabilitation.

Michelle adds: "Our therapists are really passionate about enabling people to progress in their rehabilitation and achieve their own personal goals, so they know how important it is to meet with the patient as early as possible in the rehab process. 

“This second MDT report is crucial for the success of the rehabilitation, because it helps us to set goals in collaboration with the patient, and it also looks at what mental capacity assessments might be necessary. We look at the person holistically to meet not just the physical needs but the emotional and psychological ones as well."

Days 7 – 14: Goal planning and outcome meeting

The Monday following admission is when the MDT meets to allocate the therapy hours following the assessment, as well as complete their Functional Independence Measure (FIM), Functional Assessment Measure (FAM) and Therapy Outcome Measures (TOMs). In gathering this information, the team can assess the potential impact of therapeutic interventions and share that as part of the goal-setting meeting with the patient.

Michelle explains: "When a person comes in, their main desire might be to walk out of The Dean, but the physio knows that progress can only happen so fast, and walking might not be achievable in the time frame.

"So, in the meeting, we can discuss with the patient what is achievable in terms of mobility, for example, by using a wheelchair or Zimmer frame. This is also an opportunity for us to address needs the person might not have considered they need to work on, like getting dressed, washing, eating and other activities, and we can start building goals around those."

Regular MDT meetings: Adapting therapy to progress

The Dean team have implemented a weekly meeting so they can assess the progress made by different therapies and re-allocate hours if necessary. The MDT meeting allows therapy to be flexible and responsive to changing needs. While working with patients with a range of conditions, they have discovered how vital it is to make changes to the pathway to improve outcomes.

Michelle says: "We'll look at the care plan and see if we need to step back on one therapy profession and have another step in, because we've made progress in a certain area. It's also an ideal opportunity to look at things like personal care and see where therapy goals can be enforced by nursing staff.

"For example, a therapy team may be working with a person on cleaning their teeth, and they've got to the stage where they can stand at the basin and brush without support. The nurses and carers may be able to take over that instead of it happening during therapy time, freeing that time up for other things. 

"Through the MDT meetings and regularly reviewing progress together, we've also realised that it's crucial for us to do a home visit in week 3 so that we can begin planning for the discharge after week 12. This allows us a suitable amount of time to get the home ready with equipment and adaptations so the patient can be properly supported when they are discharged.

“I have emphasised the importance of the therapy team's involvement in the pathway, but it should be mentioned that the success of this pathway hinges on the wider MDT as a whole. Our nursing colleagues play an vital role in the general care and well-being of our residents, and collaboration between the wider team is imperative for the meeting of goals.”

Week 4: Post admissions meeting and progress report

At four weeks, the MDT will arrange a meeting that involves the patient, their funders, and the MDT, including neurologist Professor Derrick Wade, Consultant of Neurorehabilitation, who spends two days per month with us. This meeting gives everybody a chance to look at progress, review any challenges, review the home visit assessment and discuss any other considerations.

Michelle explains: "It's our chance to discuss how the initial four weeks have gone, what difficulties they've been facing, if there are challenges we need to foresee and the occupational therapists assessment of the home visit. It could be that a patient needs a specialist wheelchair, but the wait for that can be two to three months, so we need to order the exact chair the patient needs at this point.

"We're also considering how they'll be supported when back at home and if there is wheelchair access to their toilet and bedroom. Are they on a single-floor residence (like a bungalow) or a house? If there will be issues for them returning home, we can speak to funders at week 4 to look at what adaptations or renovations might be necessary. 

“Following a home visit we would make the necessary referrals and recommendations to the community teams to ensure that, where possible, the home environment is adapted, where appropriate.

"Although funders may not extend funding beyond 12 weeks, they would need to know of any obstacles or challenges there may be with regards to the home environment if not suitable for discharge, as this may entail engaging other external agencies. Therefore we moved the home visit forward to week 3 to allow more time for any recommendations to be implemented if needed.”

Group support: The new initiative to help patients cope with change

Rehabilitation can often be an anxious time for patients, particularly around returning home and the new challenges that might bring. In order to better support patients, The Dean has implemented a new initiative - a weekly group to come together to talk through these issues, share their feelings and voice their concerns. 

Michelle says: "We started picking up on how anxious people were about going home and the challenges they would face when they do. There can be a lot of confusion, fear and grief when you go through an experience like this. The grief in question is the way you grieve losing your identity or losing your role in the family.

"For example, you may have been the breadwinner but now you are dependent on your family to care for you. There is something very powerful about sitting in a group and hearing that your fear is the same fear that another person is feeling. The feedback we've had from people who've attended these groups has been incredible. 

"There was one gentleman who had been a successful pharmacist and a very high-functioning individual. He felt like he'd lost everything – his pharmacy, his ability to walk, his place in the family. But in the groups, we started looking at what he could control and what he could do at home.

"He started thinking about how he'd always wanted to learn how to cook, and how to use social media so he could have something to talk to his children about. These may seem like small things, but you should have seen his face and expressions as these opportunities dawned on him, it was really powerful. There are so many things you can't control, but you can look at things you can and move forward."