And that has meant the teams have been in a strong
multidisciplinary position to minimise how many people are going
into any one person’s house during the COVID-19 pandemic.
One lady has a district nurse going in to support with tissue
viability and skin integrity issues; the same nurse is then able to
check with how she is getting on with her reablement package,
saving an additional visit from an occupational therapist.
Boosting reablement
In particular, the integration agenda has helped advance
reablement in the Highlands. Having integrated teams has helped
ensure there are single points of access in which work can be
appropriately allocated to the right lead professional.
To further advance reablement in the region, the Indicator
of Relative Need tool was introduced to help monitor people’s
progress, and to highlight potentially outsized care provision that
may need attention. In total, the team has been able to reduce
unnecessary care packages and delay admissions to long-term
care beds.
Gillian Murray, the allied health professions team lead for East
Ross – which is not working under the new neighbourhood
model, but uses a similar approach – says: ‘It’s not just about
the resource, but about creating something that is more tailored
for people and helping them to get more and more independent.
Improving people’s quality of life is one of the main goals.’
The overall results of integration and the neighbourhood model
have been positive. Carole is keen to drive the model further, she
plans on: creating better links with GPs; tying in more closely
with community resources and the voluntary sector to build more
resilience in communities; pushing further a reablement focus
into care homes; and having a second attempt at delivering a
discharge to assess model from the acute hospital.
‘It’s a journey and we’re still very much on it,’ she says: ‘I’m
confident that by being in the neighbourhood teams that we’re
in the right place to have the right information, make the right
judgements and make recommendations, and most importantly to
keep rehabilitation and reablement right at the centre of everything
we do.
‘There have been many challenges, but great results as well.
The occupational therapists are now held in very high regard by
their teams; they really are seen as a valuable resource.’