Working as a Team from Home: AVS–IDE–physio, Who Does What?

title: Working as a team at home: coordination of AVS, IDE, physiotherapist and caregivers

description: Comprehensive guide to understanding and optimizing multidisciplinary teamwork at home. Roles of the AVS, IDE, physiotherapist, occupational therapist: who does what, how to coordinate, effectively communicate, and provide consistent support.

keywords: teamwork at home, AVS home help, IDE home nurse, physiotherapist home, coordination of caregivers, multidisciplinary team, information transmission, home help

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home help, teamwork, coordination, AVS, IDE, physiotherapist, occupational therapist, transmission, multidisciplinary, health professionals

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Reading time: 22 minutes

“The nurse arrives while I am washing Mr. Dubois, we are stepping on each other’s toes.” “The physiotherapist changed the exercises, but no one informed me.” “Who should monitor the medication intake? Me or the IDE?” “The family tells me one thing, the nurse another, I don’t know who to listen to anymore.”

Maintaining an elderly or dependent person at home often requires the intervention of several professionals: social life assistant (AVS), state-certified nurse (IDE), physiotherapist, occupational therapist, attending physician. Each has their role, skills, and scope of intervention. But in practice, the boundaries can seem blurred, information gets lost, and coordination becomes a puzzle.

However, a well-coordinated team makes all the difference: better quality of care, enhanced safety, fewer errors, and above all, consistent support that reassures the person and their family.

This guide explains precisely who does what at home, how to effectively coordinate interventions, transmit essential information, and work as a team even from a distance.

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Table of contents

1. The different caregivers at home

2. Who does what: distribution of roles

3. Coordinating interventions

4. Transmission and communication tools

5. Managing complex situations

6. Building a real team at home

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The different caregivers at home {#intervenants}

Social life assistant (AVS) or home help

Main role: Assistance in essential daily living activities.

Tasks:

• Assistance with personal hygiene (excluding nursing tasks)
• Dressing, undressing
• Meal preparation and assistance
• Assistance with mobility within the home
• Housekeeping, shopping
• Social support, stimulation, connection
• Monitoring general condition and alerting if changes occur

Training: State Diploma of Educational and Social Assistant (DEAES) or professional title of Family Life Assistant (ADVF).

Cannot:

• Administer medications (except in exceptional cases with authorization)
• Perform nursing care (dressing, injections)
• Diagnose, medically evaluate

State-certified nurse (IDE)

Main role: Nursing care on medical prescription.

Tasks:

• Administration of medications (injections, infusions)
• Dressing, wound care
• Monitoring chronic conditions (diabetes, heart failure)
• Samples (blood tests, urine cultures)
• Monitoring vital signs (blood pressure, pulse, temperature)
• Therapeutic education for the patient and family
• Coordination of care pathways

Training: State Diploma of Nurse (Bac+3).

Interventions: On medical prescription only (except for monitoring and education tasks).

Physiotherapist

Main role: Rehabilitation, maintenance, and improvement of mobility.

Tasks:

• Rehabilitation after surgery, fracture, stroke
• Joint mobilization exercises, muscle strengthening
• Fall prevention (balance, proprioception)
• Lymphatic drainage, respiratory physiotherapy
• Advice on home adaptations for mobility

Training: State Diploma of Physiotherapist (Bac+5).

Interventions: On medical prescription, generally for a limited duration.

Occupational therapist

Main role: Adapting the environment and activities to preserve autonomy.

Tasks:

• Assessment of autonomy in daily living activities
• Recommendations for technical aids (grab bars, toilet risers, walkers)
• Home adaptations (removing obstacles, securing)
• Rehabilitation of daily gestures (grasping, dressing)
• Cognitive and motor stimulation

Training: State Diploma of Occupational Therapist (Bac+3).

Interventions: Often one-time (assessment + recommendations), sometimes regular follow-up.

Attending physician

Main role: Prescription, diagnosis, medical coordination.

Tasks:

• Diagnosis, prescription of treatments
• Regular medical follow-up
• Prescription of paramedical interventions (IDE, physiotherapist, occupational therapist)
• Coordination with specialists
• Writing certificates (GIR, APA, disability)

Coordinates the medical team, but is not always present daily at home.

Other possible interveners

Speech therapist: Swallowing disorders, aphasia, rehabilitation after Stroke.

Psychologist: Psychological support, grief support, illness support.

Dietitian: Nutritional advice, dietary adaptation (diabetes, malnutrition).

Social worker: Assistance with administrative procedures, rights, financial aid.

Meal delivery, teleassistance: Complementary services for safety and comfort.

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Who does what: distribution of roles {#repartition-roles}

Personal care: who intervenes?

Complete bed bath (bedridden person):

• Nurse if monitoring acts necessary (wounds, probes, stomas)
• Care assistant if simple personal care, without treatment

Wash at the sink or shower (partially autonomous person):

• Care assistant: Assistance, stimulation, safety
• Nurse if medical monitoring necessary (e.g.: diabetic patient with foot wounds)

Rule: If medical aspect (wounds, constant monitoring) = Nurse. If simple assistance = Care assistant.

Dressing

Care assistant: Help with dressing, choice of clothes, adaptation.

Occupational therapist: Advice to facilitate dressing (adapted clothing, techniques).

Physiotherapist: If rehabilitation of fine motor skills or shoulder/arm mobility necessary.

Meals

Meal preparation: Care assistant (shopping, cooking).

Assistance with eating: Care assistant (cutting, helping to eat).

Swallowing monitoring: Speech therapist (if swallowing disorders).

Diet adaptation: Dietitian (dietary prescriptions).

Placement of gastric probe, enteral feeding: Nurse (nursing act).

Medications

Administration of medications:

• Nurse: Injections, infusions, complex medications, monitoring.
• Care assistant: Can help with oral intake of medications prepared by Nurse or family (pill organizer) ONLY if written authorization and training. Cannot prepare or decide on medications.

Strict rule: Care assistant does NOT perform nursing acts. If in doubt, it is the Nurse.

Mobilization, transfers

Simple transfers (bed-chair, chair-toilet):

• Care assistant if patient is cooperative, no risk of falling, adapted equipment (patient lift).

Complex transfers (heavy, uncooperative, post-operative patient):

• Nurse or physiotherapist (assessment of capabilities, teaching proper techniques).

Rehabilitation walking, balance: Physiotherapist exclusively.

Pressure sore prevention

Daily monitoring: Care assistant (reports redness, changes).

Preventive care (light massages, creams): Care assistant.

Dressings, care for established pressure sores: Nurse (nursing act).

Regular position changes: Care assistant (every 2-3 hours).

Specific equipment (anti-pressure sore mattress): Nurse or doctor’s prescription, installation by Nurse or care team.

Falls

Prevention (home safety, balance exercises): Physiotherapist, occupational therapist, care assistant (vigilance).

After a fall:

• Care assistant: Alerts, basic first aid, reassures, does NOT attempt to lift alone if at risk.
• Nurse: Medical assessment, monitoring, care if needed.
• Emergency services/Firefighters: If serious injury, inability to move.

Medical follow-up

Daily monitoring (general condition, mood, appetite): Care assistant (reports information).

Medical monitoring (vital signs, treatments): Nurse.

Diagnosis, prescription: Treating physician.

Cognitive and social stimulation

Daily stimulation (discussion, games, activities): Care assistant (essential role).

Targeted cognitive stimulation: Occupational therapist, speech therapist, psychologist.

SCARLETT Program: Care assistant can use the tablet with the patient (adapted games, gentle stimulation, social link).

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Coordinating interventions {#coordination}

Why coordination is crucial

Without coordination:

• Information lost (change in condition not reported)
• Duplicates or omissions (two people do the same thing, or no one does)
• Conflicts (contradictory instructions)
• Burnout of interveners (lack of clarity)
• Risks for the patient (medication errors, falls not prevented)

With coordination:

• Smooth information flow, everyone knows
• Complementary, coherent interventions
• Enhanced safety
• Better quality of life for the patient

Who coordinates?

Ideally: A designated coordinator.

Often:

• Nurse coordinator (if complex care, home care service)
• Treating physician (medical coordination)
• Family caregiver (links everyone)
• Case manager (MAIA devices, autonomy coordinators)

In practice: Shared coordination, everyone communicates.

Coordination Meetings

Initial Meeting (establishing the support plan):

Participants: All stakeholders + family + patient (if possible).

Objectives:

• Introduction of each participant (role, frequency of intervention)
• Overall assessment of the situation
• Definition of common objectives
• Task distribution
• Organization of transmissions

Regular Meetings (every 3-6 months or if changes occur):

Remotely (video call, phone) or in person (less common).

Objectives:

• Review of progress
• Adjustments to the support plan
• Problem resolution
• Enhanced coordination

Intervention Planning

Shared Planning: All stakeholders know each other’s schedules.

Tools:

• Shared calendar (Google Calendar, dedicated app)
• Paper schedule at home (displayed, visible to all)

Avoid overlaps: Nurse and caregiver at the same time = confusion, not optimal.

Allow transmission time: 5-10 minutes buffer between two stakeholders to exchange information.

Daily Communication

Communication Notebook (paper or digital): Central transmission tool.

See dedicated article: Transmission file: digital communication notebook.

Direct messages (SMS, calls): In case of emergency or important information.

Dedicated app: Some platforms allow secure messaging between stakeholders.

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Transmission and Communication Tools {#outils-transmission}

Paper Communication Notebook

Classic support: Notebook at home, each stakeholder writes.

Advantages:

• Simple, accessible
• No need for technology
• Visible to all (including family)

Disadvantages:

• Risk of loss, degradation
• Not always read (forgetting, lack of time)
• Difficult to centralize, archive

Content:

• Date, time, name of the stakeholder
• Observations (general condition, mood, behavior)
• Care provided, assistance given
• Notable events (fall, refusal of care, medical visit)
• Transmission for the next stakeholders (e.g., “Caution, pain in right knee”)

Digital Communication Notebook

Mobile app or web platform: All stakeholders connect.

Advantages:

• Accessible remotely (even without being at home)
• Real-time notifications
• Centralization of information
• Secure archiving
• Traceability (who wrote what, when)
• Possibility of photos (wounds, home adaptations)

Disadvantages:

• Requires smartphone/tablet, internet connection
• Training required
• Cost (depending on the solution)
• Variable acceptance (some prefer paper)

Existing solutions:

• Home care coordination apps (Medeo, Lifen, Whoog)
• Custom solutions (some SSIAD structures)

DYNSEO Toolbox: Guides and tools for implementing effective transmission.

Shared Patient File

Electronic medical record (if structure type SSIAD, HAD): Centralizes all medical information.

Secure access: Authorized professionals only (medical confidentiality).

Content:

• Medical history
• Current treatments
• Hospital reports
• Prescriptions
• Test results

Advantages: Global view, optimal coordination, security.

Oral Transmission Meetings

Oral transmissions between two stakeholders (handover).

Example: Morning caregiver transmits to afternoon caregiver, nurse transmits to caregiver.

Duration: 5-10 minutes.

Content: Essential information, priorities, alerts.

Limits: Information lost if not noted, availability not always possible.

Communication with Family

Family = essential partner: Knows the patient, their habits, their preferences.

Inform regularly: Progress, decisions, schedule changes.

Listen to feedback: Family often signals changes first (appetite, sleep, mood).

Respect medical confidentiality: Medical information = consent from the patient or legal representative.

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Managing Complex Situations {#situations-complexes}

Conflicts of Instructions

Situation: The doctor says one thing, the family another, the nurse a third.

Solution:

• Clarify roles: Who decides what (doctor for medical, family for daily preferences).
• Coordination meeting: Bring everyone to the table.
• Written reference: Written support plan, validated by all, displayed at home.

Rule: In case of contradictory medical instructions, always refer to the attending physician (absolute priority).

Information Not Transmitted

Situation: A caregiver does not read the communication book, or forgets to write.

Solutions:

• Reminder of Importance: Transmission = patient safety.
• Training: Some do not know what to write, need support.
• Appropriate Tool: If paper book is not read, switch to digital with notifications.
• Quality Control: Responsible person (coordinator, service manager) checks regularly.

Overload of Caregivers

Situation: Too many different caregivers = confusion for the patient, diluted information.

Solutions:

• Limit the Number of Caregivers: Small, regular team (same people).
• Stable Schedule: Same caregiver on Monday, same nurse in the morning, etc.
• Systematic Introduction: Each new caregiver introduces themselves, explains their role.

Patient Refusing Care

Situation: Refuses the nurse, accepts the caregiver, or vice versa.

Solutions:

• Change Caregiver: Sometimes, it’s a matter of feeling, personality.
• Explain the Role: Patient does not always understand why multiple people.
• Involve the Family: Reassures, explains.
• Respect the Refusal: If patient is lucid, has the right to refuse (except in case of danger).

Emergency Intervention

Situation: Caregiver arrives, patient on the floor, unconscious, or respiratory distress.

Protocol:

1. Assess the Situation: Immediate danger? (e.g., gas leak, fire)

2. Secure: Move away from danger if necessary.

3. Call for Help: 15 (SAMU) or 18 (Firefighters) depending on urgency.

4. Do Not Move if fracture or trauma is suspected.

5. Reassure: Speak calmly, stay present.

6. Notify Family, Nurse, Service Manager: As soon as possible.

7. Record in Communication Book: Circumstances, time, actions taken.

First Aid Training: Essential for all home caregivers.

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Building a Real Home Team {#building-team}

The Pillars of an Effective Team

1. Mutual Respect

Each caregiver has their expertise, their essential role.

Caregiver is not “just” a housekeeper: They know the patient daily, their habits, their subtle changes. Their perspective is valuable.

Nurse is not “just” for injections: Overall medical vision, coordination of care.

Physiotherapist is not “just” to make move: Expertise in rehabilitation, prevention.

Mutually Value Each Other: “The caregiver noticed that Mrs. is eating less, thank you for reporting it.”

2. Open Communication

Ask Questions: If in doubt about who does what, ask.

Share Observations: Even if they seem trivial (mood changes, disturbed sleep).

No Judgment: Mistakes happen, the important thing is to correct, to learn.

3. Common Goals

Everyone Works for the Same Goal: Well-being, safety, autonomy of the patient.

Shared Support Plan: Everyone knows the overall objectives (e.g., “Maintain walking autonomy, prevent falls, preserve social ties”).

4. Trust

Trust Each Other’s Expertise: The nurse trusts the caregiver to alert, the caregiver trusts the nurse for care.

Delegate: Do not want to do everything oneself, accept that others have complementary skills.

5. Flexibility

Adapt: Situation evolves, patient changes, adjustments are necessary.

Be Reactive: If there is a problem, discuss it quickly, find a solution together.

Recognition and Valuation

Burnout, frequent exhaustion in home care (mental, emotional, physical load).

Support Each Other:

• Thank, recognize each other’s work
• Share difficulties (do not stay alone in a difficult situation)
• Celebrate successes (patient who walks again, who smiles again)

DYNSEO Training for Professionals: Learn to stimulate, create connections, techniques for supportive accompaniment.

Conflict Management

Conflicts Inevitable: Different personalities, stress, fatigue, divergent views.

Solutions:

Talk Directly: Problem with a colleague? Discuss calmly, one-on-one.

Mediator: If conflict persists, involve service manager, coordinator.

Refocus on the Patient: “What is best for Mrs. Martin?” Bring it back to the essentials.

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Testimonials

Marie, Caregiver

“At first, I didn’t really know how to work with the nurse. She would come, do her dressings, and leave. We didn’t talk. Then I started noting my observations in the book: ‘Mr. Leroy slept poorly last night.’ The nurse reacted, informed the doctor. The treatment was adjusted. Now, we really work together. I feel heard, valued.”

Thomas, RN

“I intervene with Mrs. Dubois for complex dressings. The caregiver is there every day. At first, I didn’t ask her anything. Then one day, she said to me: ‘I think she eats less, she seems sad.’ I dug deeper: beginning of depression. We set everything up. Without the caregiver, I wouldn’t have seen anything. Now, I systematically ask for her opinion. She knows the patient better than I do.”

Sophie, physiotherapist

“I come three times a week for rehabilitation after a femoral neck fracture. The caregiver makes Mrs. Martin walk on the other days, with the exercises I showed. Result: progress twice as fast. That’s teamwork. I’m not there every day, but the caregiver takes over. Together, we perform miracles.”

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Conclusion: A united team for better support

Working as a team at home is a daily challenge. Different professionals, scattered locations, no shared office, no daily meetings. And yet, it’s possible. With clear roles, effective communication tools, mutual respect, and smooth communication, the multidisciplinary team becomes a strength for the patient and their family.

The keys to success:

1. ✅ Clarify roles (who does what, without encroaching, without forgetting)

2. ✅ Communicate systematically (communication book, oral transmissions, meetings)

3. ✅ Respect each other (each profession has its expertise)

4. ✅ Share objectives (work for the patient, together)

5. ✅ Continuously adapt (situation evolves, adjustments needed)

6. ✅ Support each other (appreciation, recognition, mutual aid)

You are not alone. Our home care toolbox supports you with practical guides, communication tools, and summary sheets. DYNSEO Training: Techniques to stimulate and create connections. SCARLETT Program: Gentle cognitive stimulation, usable by all professionals.

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DYNSEO resources for home care professionals:

• Home care toolbox: guides and practical tools
• Training: Stimulate and create connections with DYNSEO games
• SCARLETT Program: Adapted cognitive stimulation

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Working as a team at home means accepting that everyone contributes their part to the whole. The caregiver knows the little daily habits, the RN monitors the medical aspects, the physiotherapist restores mobility, the family provides affection. Together, we form a safety net, a united team around the same patient. And that is the true wealth of home support: this plurality, this complementarity, this solidarity.