Multidisciplinary care team for adults with disabilities in Delhi NCR
Our Multidisciplinary Care Model
What is a multidisciplinary care model?
A multidisciplinary care model brings together healthcare professionals, caregivers, therapists and families to develop and implement a coordinated care plan for each resident. At Saksham by Kriti, this approach helps ensure that medical care, rehabilitation, daily living support and family communication work together to support adults with disabilities living in residential, day care and respite care settings across Gurugram and Delhi NCR.
At Saksham by Kriti, our care philosophy is built on dignity, safety and long-term stability. Our multidisciplinary care model is how we put that philosophy into practice every day for adults with Down syndrome, cerebral palsy, severe learning disabilities and multiple disabilities.
We are a doctor-led, long-term residential care home in Gurgaon supporting families across Delhi NCR. Our model brings together our in-house healthcare team and, where appropriate, external rehabilitation professionals around a single, shared care plan for each resident. This is not a hospital or a basic nursing setup; it is a structured, team-based approach designed for adults who need 24/7 support over the long term.
Why a Multidisciplinary Care Model Matters
Families often coordinate between multiple doctors, therapists and caregivers. A multidisciplinary care model helps improve communication, reduce fragmented care and ensure that everyone involved works toward shared goals while supporting the resident’s long-term wellbeing.
We have also learned that effective long-term care depends not only on clinical expertise but on clear communication between residents, families, caregivers, and healthcare professionals. A coordinated team approach helps ensure that care remains consistent even as a resident’s needs change over time.
Who is involved in care
Depending on an individual’s needs and care plan, support may involve collaboration between our in-house healthcare team and, where appropriate, external rehabilitation professionals. This coordinated approach helps ensure residents receive well-rounded care while maintaining continuity between different healthcare providers.
- Supervising doctor / physician (for overall medical oversight and care reviews)
- Physiotherapist (for mobility, flexibility, positioning and strength)
- Trained caregivers (for 24/7 personal care, daily routine and behaviour support)
- Care coordinator / manager (to organise schedules, family communication and care plan updates)
Depending on a resident’s individual needs, we may also collaborate with psychologists, occupational therapists, speech-language therapists, and other treating specialists recommended by the family or healthcare team.
How our care model works
Step-by-step: from assessment to ongoing care
Initial Assessment
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Doctor Review
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Physiotherapy Assessment
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Daily Care Planning
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Family Discussion
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Personalised Care Plan
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Implementation
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Regular Reviews
Assessment and care planning
When a new resident joins us, we begin with a structured assessment:
- Medical history, current diagnoses and medications
- Functional abilities: mobility, self-care, communication, eating and swallowing
- Behavioural patterns: triggers, signs of discomfort, calming strategies
- Family input: what works at home, what does not, and what matters most to them
This information is used to create a personalised care plan that covers daily routine, therapy goals, medical needs and behaviour support. The plan is shared with the family and reviewed regularly.
Daily care and therapy
Our caregivers implement the day-to-day plan: helping with bathing, dressing, meals, mobility and activities. Physiotherapy is integrated into the resident’s ongoing care plan, while additional specialist therapies may be coordinated according to individual clinical needs and family preferences.
- Therapists design programmes that caregivers can use every day
- Staff are trained on safe handling, positioning and communication techniques
- Progress is reviewed and goals are adjusted as needed
For example, a physiotherapist may design a daily stretching and positioning routine that caregivers follow between formal therapy sessions. Where recommended, external therapists may provide additional input that is then incorporated into the shared care plan.
Medical oversight and reviews
At Saksham by Kriti, medical oversight is integrated into everyday life through our physician-led care model. Residents are supported by 24/7 nursing staff and trained attendants, with doctors available around the clock to guide medical decisions and respond to changing health needs.
Our approach includes:
- 24/7 doctor availability and nursing support
- Daily health monitoring by the nursing team
- Medication management and support through our in-house pharmacy
- Guidance on nutrition, sleep, mobility, and skin care
- In-house physiotherapy to support mobility, strength, and physical wellbeing
- Support during illness or medical changes
- Regular care reviews involving the healthcare team and family members
- Coordination with external specialists whenever additional expertise is required
This Doctor-led approach helps ensure that medical care, rehabilitation, and daily support are coordinated as part of long-term residential care for adults with disabilities.
How this model supports our services
Our multidisciplinary care model underpins all our core services for adults with disabilities in Gurgaon and Delhi NCR:
Residential care for adults with disabilities
Severe learning disability care
Whether a family chooses full-time residential care, short-term respite or daytime support, the same team-based approach applies: shared assessments, shared care plans and shared responsibility for outcomes.
What this means for families
For parents and siblings, our multidisciplinary model offers three key benefits:
- One clear plan: You do not have to coordinate between separate doctors, therapists and caregivers. The team works from one shared care plan.
- Consistency: The same approach is used by all staff, every day, so progress is more stable and setbacks are easier to spot.
- Confidence: You know that medical, therapy and daily care are all being considered together, not in isolation.
Families are encouraged to ask questions, share observations, and participate in regular care discussions so that important decisions are made collaboratively.
How this connects to our care philosophy
Our multidisciplinary care model is a direct expression of our care philosophy:
- Dignity: We treat each resident as an adult with unique needs, not a diagnosis.
- Safety and structure: A clear team and clear plan reduce risks and confusion.
- Realistic progress: We focus on small, meaningful gains across medical, functional and daily living domains.
- Family partnership: Families are part of the team, not outsiders looking in.
You can read more about our beliefs and approach on our Our Care Philosophy page.
For families considering residential care
If you are exploring residential care for your adult child, you may be wondering:
- “Will my son or daughter get proper medical attention?”
- “How do therapists and caregivers work together?”
- “Who do I talk to if I have a concern?”
Our model is designed to answer those questions clearly:
- Medical oversight is built in through our physician-led care model, not as an optional add-on.
- Physiotherapy is integrated into the ongoing care plan, while additional specialist therapies may be coordinated according to individual clinical needs and family preferences.
- You have a named care coordinator and access to the supervising doctor for updates and concerns.
To see how this model works in a full-time living setting, you can read more about our residential care for adults with disabilities in Delhi NCR.
Frequently asked questions
Multidisciplinary care means that healthcare professionals, caregivers and families work together around a shared care plan. At Saksham by Kriti, this includes our in-house team and, where appropriate, external therapists and specialists, all coordinated to support adults with disabilities in residential, day and respite care.
Families often coordinate between multiple doctors, therapists and caregivers. A multidisciplinary care model helps improve communication, reduce fragmented care and ensure that everyone involved works toward shared goals while supporting the resident’s long-term wellbeing.
Depending on needs, support may involve our supervising doctor, physiotherapist, trained caregivers and care coordinator, along with external occupational therapists, speech-language therapists, psychologists or other professionals recommended by the resident’s treating team or family.
Therapists design programmes and train caregivers on safe handling, positioning and communication techniques. Caregivers then use these strategies every day, with progress reviewed and goals adjusted over time.
Families are part of the team. We share information openly, involve you in care planning and reviews, and respect your experience of your adult child. You have a named care coordinator and access to the supervising doctor for updates and concerns.
Care plans are reviewed regularly, with frequency depending on the resident’s needs. Reviews may be triggered by changes in health, behaviour, mobility or family circumstances, and always involve discussion with the family.
Editorial review
This page has been prepared by the Saksham by Kriti Editorial Team to explain how our multidisciplinary care model supports long-term residential, day care, and respite care services for adults with disabilities.
The content reflects our organisational care processes and physician-led approach to coordinated long-term care.
Prepared by: Saksham by Kriti Editorial Team
Last Updated: August 2026
Explore Your Care Options
Choosing long-term care for an adult with disabilities is a significant decision, and every family’s situation is unique. If you would like to understand how our multidisciplinary team approach works in practice, our team is here to answer your questions and guide you through the available care options.
Whether you are exploring residential care, respite care, or day care services, we encourage families to discuss their concerns, understand the care process, and learn how personalised support plans are developed.
Call us to discuss your family’s needs or schedule a visit to Saksham by Kriti in Gurugram.
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Our Team
Dr. Sanjeev Tyagi | Medical Leadership at Saksham by Kriti
Medical Leadership at Saksham by Kriti Dr. Sanjeev Tyagi Dr. Sanjeev Tyagi is an anaesthesiologist, intensivist, and pain physician with more than 25 years of
Dr. Abhishek Kumar Bajpai
At Saksham by Kriti in Gurugram, he contributes to rehabilitation programmes for adults living with Cerebral Palsy, Down Syndrome, Severe Learning Disabilities, and other lifelong conditions that may affect movement, posture, balance, coordination, or physical function. Every rehabilitation plan is developed with the individual’s abilities, goals, and overall care requirements in mind, supporting meaningful progress while respecting personal dignity and independence.