The last editorial suggested that rehabilitation needed to involve the patient in learning, and depended upon a group of professionals to identify what actions might help the patient, and to undertake or arrange the necessary actions. In many cases there will be both a wide variety of actions needed from a reasonably large number of people and organisations, and the process is likely to be extended over weeks, months or occasionally years. This editorial shows that these features characterise the rehabilitation process as complex and therefore it needs to be managed by a trans-disciplinary team. Some of the characteristics of teamwork are discussed. This leads to a discussion of teams in rehabilitation, showing that there are currently many different types of teams organised around different areas of interest and that a patient might need access to several specialised teams. It is then argued that the complexity of team coordination is best resolved by formal rehabilitation planning meetings, held early in a patient's involvement with rehabilitation; this should increase effectiveness and efficiency. Finally the editorial argues that rehabilitation would be improved by having rehabilitation teams that mirror the existing medical specialities, ensuring that all patients thereby have easy and early access to rehabilitation planning.
Keywords: Biopsychosocial model; Goal setting; rehabilitation Process.
© The Author(s) 2015.