Occupational Therapy News OTnews February 2019_Joomag | Page 24

FEATURE LONG-TERM CONDITIONS
The Live
Well Leeds
project
Liz Spence, senior
occupational therapist at
Leeds Community Healthcare,
reports on a new two-year
model of care project, to help
improve health outcomes for
people in the Leeds with long-
term conditions
L
iz Spence, an occupational therapist from
Leeds Community Healthcare, joined
colleagues from nursing, physiotherapy and
medicine (a GP and a geriatrician) to work on a
two-year new model of care project, known as The Live
Well Leeds Project.
The purpose of the project was to identify key
components of care that had the potential to lead
to better health outcomes for people with long-term
conditions.
The project was commissioned by Leeds South
and East Clinical Commissioning Group and was
delivered across two primary care practices in the
Beeston and Cross Gates areas of Leeds. These
practices were chosen to reflect different population
characteristics; Beeston is known to have high levels
of deprivation and higher levels of disease comorbidity
at a young age, while Cross Gates is known to have
an older age population living with multiple disease
comorbidities.
Local involvement
Five hundred people from each practice were identified
using READ codes (NHS 2018) and the Electronic Frailty
Index (NHS England 2018) as living with four or more
long-term conditions (including either chronic obstructive
pulmonary disease or cardiovascular disease) and mild,
moderate or severe frailty.
People’s involvement in the project started with an
introductory telephone call, and while some people were
a little surprised at being contacted directly, around 200
people from each practice were happy to talk.
24 OTnews February 2019
Initially, the Live Well Leeds team had considered
carefully who would be the most appropriate professional
to make the first contact, based on a person’s medical
history. However, it soon became apparent that a
person’s medical history had little bearing on their current
situation and that whichever profession made first contact
was not actually important.
Conversations, goals and support
Once engaged in the project, people were visited at home
and encouraged to talk about their life so far, what was
happening for them now in relation to keeping well, and
finally, asking where they wanted to be in the future.
A summary of the discussion was recorded on a
simple template, together with outcomes from screening
questionnaires for falls, mood and memory. The EQ5D
(measure of generic health status), LTC6 (long-term
conditions questionnaire) and PAMS (Patient Activation
Measure) were completed as outcome measures at the
start and finish of interventions.
Following the initial conversation, focus was given to
goal setting and support networks.
The Live Well Leeds team identified family, friends and
community support and a visual representation of this
network was left with the participant. The use of health
coaching and motivational skills was used to support
the process of goal setting; many people found it difficult
to identify goals, but often found it easier to talk about
needs, wants and hopes for the future.
While each person had individual goals, there
were some common themes that emerged from the
conversations. For example, people wanted their