What role does multidisciplinary teamwork play in the rehabilitation of patients with complex needs?

Multidisciplinary teamwork plays a central role in the rehabilitation of patients with complex needs by ensuring coordinated, comprehensive, and patient-centred care. A multidisciplinary team (MDT) typically includes doctors, nurses, therapists, mental health practitioners, pharmacists, dietitians, social workers, and other specialists relevant to the patient's conditions, working collaboratively to assess, plan, and deliver rehabilitation interventions ².

The MDT shares information and agrees on a rehabilitation plan and goals, involving the patient and their family or carers to provide joined-up support tailored to the individual's needs ¹. A named rehabilitation coordinator or key worker is assigned early to oversee the patient’s care pathway, coordinate between specialties, and act as a central point of contact for the patient and family ¹.

Regular multidisciplinary assessments and discussions, such as daily trauma meetings or ward rounds, ensure continuous review and updating of the rehabilitation plan, facilitating smooth transitions between hospital, inpatient rehabilitation, and community services ¹,². The MDT also supports discharge planning, reassessing needs before discharge and involving family members and carers to promote a smooth transition to outpatient or community rehabilitation ¹.

Effective communication and information sharing within the MDT and across care settings are essential to maintain continuity of care, manage complex rehabilitation needs, and address physical, psychological, social, and vocational aspects of recovery ¹,².