OTnews August 2020 | Page 39

INTEGRATION FEATURE
started with a blank piece of paper and thought, “what would
work for Mrs Jones and how do we develop that?”’
Eve had supportive bosses in the early development of the work,
and the workforce was gradually won over as the system was
rolled out and central to that has been empowering occupational
therapists to work in partnership with their patients. ‘Whether
that person is in hospital or at home, you are their occupational
therapist,’ says Eve. ‘It’s a partnership based on relationship with
the patient.’
In the early days of integration, Eve spoke with people in receipt
of services, went back through case notes and files, and was
shocked at how much energy went into supporting people without
achieving what that person needed.
The team now put ‘what matters’ conversations with their
patients at the heart of everything they do, using everyday language
to set goals that are meaningful for them.
That means that ‘independently making a cup of tea’ won’t be
found in any list of goals (‘I want to be able to toilet independently,
but it’s not what gets me out of bed in the morning,’ points out
Eve), but instead staff work towards goals that focus more on
activities to support people’s wellbeing, be it walking the dog or
making a meal for family members.
‘I looked at one case study, a young woman with Multiple
Sclerosis, who over three years had had something like 350
contacts across health and social care,’ she says. ‘At the end of
the day, all she wanted to do was to be confident to go out with her
friend and she wasn’t, because she was incontinent. But after all
that intervention she still couldn’t do what she wanted to.
‘We helped her in the end, but that’s why we need to have those
“what matters” conversations and bring it back to the person. We
need to be proper occupational therapists and always think about
what’s important to that person.
‘If you’re always bringing it back to what does a good day look
like for Mrs Jones, then you’re on the right track.’
The structure
The principles behind the work are delivered
through systems and structures that have
accreted over the last decade of integration.
Kylie works at the community hub situated
at Mardy Park in Abergavenny, which sees
a whole variety of staff and groups working
out of the one building. The multidisciplinary
team includes occupational therapists, district
nurses, social workers and physiotherapists,
as well as a dementia community care team
and a reablement care team.
Services are are also provided through
a rehab unit, day centre and memory
clinic, while there are also community
engagement workers looking at volunteering
and befriending opportunities, and a Growing
Spaces gardening group for learning disabilities
and mental health difficulties.
The hub offers agile working, including hot
desking, for its multidisciplinary staff (‘you get to
know all members of your team and can ask for
advice and share knowledge and skills’, says Kylie),
while a single electronic data recording system makes
it easier to share information between staff while reducing
duplication.
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