title: Working in a team at home: coordination AVS, IDE, physio and interveners
description: Complete guide to understanding and optimizing multidisciplinary team work at home. Roles of the AVS, IDE, physio, occupational therapist: who does what, how to coordinate, transmit effectively and offer coherent support.
keywords: team work home, AVS home help, IDE home nurse, home physiotherapist, coordination interveners, multidisciplinary team, information transmission, home help
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home help, team work, 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 get in each other's way." "The physio changed the exercises, but no one informed me." "Who should monitor medication intake? Me or the IDE?" "The family tells me one thing, the nurse tells me another, I don't know who to listen to anymore."
Keeping an elderly or dependent person at home often requires the intervention of several professionals: social life support assistant (AVS), state-qualified nurse (IDE), physiotherapist, occupational therapist, attending physician. Each has their role, skills, intervention scope. But on the ground, boundaries can seem blurry, information gets lost, and coordination becomes a puzzle.
However, a well-coordinated team makes all the difference: better quality care, enhanced safety, fewer errors, and above all, a 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 remotely.
Table of Contents
1. The different home interveners
2. Who does what: role distribution
4. Transmission and communication tools
The different home interveners {#intervenants}
Social Life Support Assistant (AVS) or home helper
Main role: Help with essential acts of daily life.
Missions:
- Help with bathing (excluding nursing acts)
- Dressing, undressing
- Preparation and help with meals
- Assistance with mobility in the home
- Housekeeping, shopping
- Social support, stimulation, connection
- Monitoring general condition and alerting if changes
- Administer medications (except with authorization)
- Perform nursing care (dressings, injections)
- Diagnose, medically evaluate
- Administration of medications (injections, infusions)
- Dressings, wound care
- Monitoring chronic pathologies (diabetes, heart failure)
- Sampling (blood tests, urinalysis)
- Monitoring vital signs (blood pressure, pulse, temperature)
- Therapeutic education of the patient and family
- Coordination of the care pathway
- Rehabilitation post-surgery, fracture, stroke
- Articular mobilization exercises, muscle strengthening
- Fall prevention (balance, proprioception)
- Lymphatic drainage, respiratory physiotherapy
- Home adaptation advice for mobility
- Assessment of autonomy in daily life activities
- Recommendations for technical aids (support bars, WC riser, walker)
- Home adaptation (obstacle removal, security)
- Re-education of daily gestures (grasping, dressing)
- Cognitive and motor stimulation
- Diagnosis, prescription of treatments
- Regular medical follow-up
- Prescribing paramedical interventions (IDE, physio, occupational therapist)
- Coordination with specialists
- Issuance of certificates (GIR, APA, disability)
Training: State Diploma of Educational and Social Accompaniment (DEAES) or Professional Title of Family Life Assistant (ADVF).
Cannot:
State-qualified nurse (IDE)
Main role: Nursing care on medical prescription.
Missions:
Training: State Diploma of Nurse (Bachelor's degree).
Interventions: On medical prescription only (except surveillance and education acts).
Physiotherapist
Main role: Rehabilitation, maintenance and improvement of mobility.
Missions:
Training: Professional Title of Masseur-Physiotherapist (Master's degree).
Interventions: On medical prescription, usually for a fixed duration.
Occupational Therapist
Main role: Adapting the environment and activities to preserve autonomy.
Missions:
Training: State Diploma of Occupational Therapist (Bachelor's degree).
Interventions: Often occasional (evaluation + recommendations), sometimes regular follow-up.
Attending Physician
Main role: Prescription, diagnosis, medical coordination.
Missions:
Coordinates the medical team, but not always present daily at home.
Other possible interveners
Speech therapist: Swallowing disorders, aphasia, rehabilitation post-stroke.
Psychologist: Psychological support, bereavement, illness counseling.
Dietitian: Nutritional advice, diet adaptation (diabetes, malnutrition).
Social worker: Assistance with administrative procedures, rights, financial aids.
Meal delivery, teleassistance: Complementary safety and comfort services.
Who does what: role distribution {#repartition-roles}
Bathing: who intervenes?
Complete bed bath (bedridden person):
Bathing at a sink or shower (partially autonomous person):
Rule: If medical aspect (wounds, vital signs monitoring) = IDE. If simple help = AVS.
Dressing
AVS: Help with dressing, clothing choice, adaptation.
Occupational Therapist: Advice to facilitate dressing (adapted clothes, techniques).
Physio: If fine motor skills or shoulder/arm mobility rehabilitation necessary.
Meals
Meal preparation: AVS (shopping, cooking).
Help with feeding: AVS (cutting, helping to eat).
Swallowing monitoring: Speech therapist (if swallowing disorders).
Diet adaptation: Dietitian (dietary prescriptions).
Gastric tube placement, enteral feeding: IDE (nursing act).
Medications
Administration of medications:
Strict rule: AVS does NOT perform nursing acts. If in doubt, it's the IDE.
Mobilization, transfers
Simple transfers (bed-chair, chair-toilet):
Complex transfers (heavy, non-cooperative, post-operative patient):
Walking, balance rehabilitation: Physio exclusively.
Pressure sore prevention
Daily monitoring: AVS (reports redness, changes).
Preventive care (gentle massages, creams): AVS.
Dressing, care for established sores: IDE (nursing act).
Regular position changes: AVS (every 2-3 hours).
Specific equipment (anti-pressure sore mattress): IDE or physician prescription, IDE or care team installation.
Falls
Prevention (home security, balance exercises): Physio, occupational therapist, AVS (vigilance).
After a fall:
Medical follow-up
Daily monitoring (general condition, mood, appetite): AVS (reports information).
Medical monitoring (vital signs, treatments): IDE.
Diagnosis, prescription: Attending Physician.
Cognitive and social stimulation
Daily stimulation (discussion, games, activities): AVS (essential role).
Targeted cognitive stimulation: Occupational therapist, speech therapist, psychologist.
EDITH Program: AVS can use the tablet with the patient (adapted games, gentle stimulation, social connection).
Coordinate interventions {#coordination}
Why coordination is crucial
Without coordination:
With coordination:
Who coordinates?
Ideally: A designated coordinator.
Often:
In practice: Shared coordination, everyone communicates.
Coordination meetings
Initial meeting (set up the care plan):
Participants: All interveners + family + patient (if possible).
Objectives:
Regular meetings (every 3-6 months or if change):
Remotely (video, phone) or in person (rarer).
Objectives:
Intervention planning
Shared planning: All interveners know each other's schedules.
Tools:
Avoid overlaps: IDE and AVS at the same time = confusion, not optimal.
Plan transmission time: 5-10 minutes margin between two interveners for exchange.
Daily communication
Liaison book (paper or digital): Central transmission tool.
See dedicated article: Transmission file: digital liaison book.
Direct messages (SMS, calls): In case of emergency or important information.
Dedicated application: Some platforms allow secure messaging between interveners.
Transmission and communication tools {#outils-transmission}
Paper liaison book
Classic support: Notebook at home, each intervener writes.
Advantages:
Disadvantages:
Content:
Digital liaison book
Mobile app or web platform: All interveners connect.
Advantages:
Disadvantages:
Existing solutions:
DYNSEO toolbox: Guides and tools for effective transmission implementation.
Shared patient file
Computerized medical file (if type SSIAD, HAD structure): Centralizes all medical information.
Secure access: Authorized professionals only (medical secrecy).
Content:
Advantages: Global view, optimal coordination, security.
Oral transmission meetings
Oral transmissions between two interveners (handover).
Example: Morning AVS transmits to afternoon AVS, IDE transmits to AVS.
Duration: 5-10 minutes.
Content: Essential information, priorities, alerts.
Limitations: Lost information if not noted, availability not always possible.
Communication with family
Family = essential partner: Knows the patient, their habits, preferences.
Regularly inform: Evolution, decisions, schedule changes.
Listen to feedback: Family often first reports changes (appetite, sleep, mood).
Respect medical secrecy: Medical information = patient or legal representative consent.
Handling complex situations {#situations-complexes}
Conflicting instructions
Situation: The doctor says one thing, the family another, the IDE a third.
Solution:
Rule: In case of contradictory medical instructions, always refer to the attending physician (absolute priority).
Untransmitted information
Situation: An intervener does not read the liaison book, or forgets to write.
Solutions:
Overload of interveners
Situation: Too many different interveners = confusion for the patient, diluted information.
Solutions:
Patient refusing care
Situation: Refuses IDE, accepts AVS, or vice versa.
Solutions:
Emergency intervention
Situation: AVS arrives, patient on the floor, unconscious, or in 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 suspicion of fracture, trauma.
5. Reassure: Speak calmly, stay present.
6. Inform family, IDE, service manager: As soon as possible.
7. Note in liaison book: Circumstances, time, actions taken.
First aid training: Essential for all home interveners.
Building a real home team {#construire-equipe}
The pillars of an effective team
1. Mutual Respect
Each intervener has their expertise, their essential role.
AVS is not "just" a housekeeper: They know the daily patient, habits, subtle changes. Their perspective is valuable.
IDE is not "just" for shots: Global medical vision, care coordination.
Physio is not "just" for moving: Expertise in readaptation, prevention.
Value each other: "The AVS noticed that Mrs. eats 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 change, disturbed sleep).
No judgment: Mistakes happen, the important thing is to correct, learn.
3. Common Goals
All work for the same goal: Well-being, safety, patient autonomy.
Shared care plan: Everyone knows the global goals (e.g.: "Maintain walking autonomy, prevent falls, preserve social connection").
4. Trust
Trust each other's expertise: IDE trusts AVS for alert, AVS trusts IDE for care.
Delegate: Do not want to do everything yourself, accept that others have complementary skills.
5. Flexibility
Adapt: Situation evolves, patient changes, adjustments needed.
Be reactive: If problem, talk quickly, find solution together.
Recognition and value
Frequent burnout in home help (mental, emotional, physical burden).
Support each other:
DYNSEO training for professionals: Learn to stimulate, create connections, benevolent support techniques.
Conflict management
Inevitable conflicts: Different personalities, stress, fatigue, divergent vision.
Solutions:
Talk directly: Problem with a colleague? Discuss calmly, face-to-face.
Mediator: If conflict persists, involve service manager, coordinator.
Refocus on the patient: "What's best for Mrs. Martin?" Bring back to the essentials.
Testimonials
Marie, AVS
"At first, I didn't know how to work with the nurse. She would arrive, do her dressings, 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, IDE
"I intervene at Mrs. Dubois for complex dressings. The AVS is there every day. At first, I didn't ask her anything. Then one day, she said to me: 'I notice she eats less, she seems sad.' I dug deeper: start of depression. We set everything up. Without the AVS, I would've seen nothing. Now, I always ask for her opinion. She knows the patient better than I do."
Sophie, Physiotherapist
"I come three times a week for rehabilitation after hip fracture. The AVS walks Mrs. Martin on other days, with the exercises I've shown. Result: recovery twice as fast. Teamwork is that. I'm not there every day, but the AVS takes over. Together, we do miracles."
Conclusion: A united team for better support
Working as a team at home is a daily challenge. Different interveners, dispersed locations, no common office, no daily meetings. And yet, it's possible. With clear roles, effective transmission 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, no overstepping, no forgetting)
2. ✅ Communicate systematically (liaison book, oral transmissions, meetings)
3. ✅ Respect each other (each profession has its expertise)
4. ✅ Share goals (work for the patient, together)
5. ✅ Continuously adapt (situation evolves, adjustments needed)
6. ✅ Support each other (value, recognition, mutual aid)
You are not alone. Our home help toolbox accompanies you with practical guides, transmission tools, synthetic sheets. DYNSEO training: Techniques to stimulate and create connections. EDITH Program: Gentle cognitive stimulation, usable by all interveners.
DYNSEO resources for home help professionals:
Working as a team at home means accepting that each one contributes their stone to the building. The AVS knows the small daily habits, the IDE monitors the medical aspects, the physio returns mobility, the family brings affection. Together, we form a safety net, a united team around the same patient. And that is the real wealth of home support: this plurality, this complementarity, this solidarity.