FEATURE INTEGRATION
The service has become incredibly personalised –
staff take on a wider range of roles, meaning they are
able to provide a fuller service for each person they
work with.
Kylie, for example, might go into the local hospital
to help support a patient she knows well, or to bring
them either to Mardy Park’s rehabilitation facility or to
head home under a Discharge to Assess model.
She can then set up a reablement or care
package without necessarily needing to involve a
social worker. If she needs support from a colleague,
she can pull them in without needing a formal
referral. It means a system where occupational
therapists set up long-term care packages, social
workers can take people commodes, and
physiotherapists can liaise
with families around
someone’s care needs,
all of which adds up to
a more straightforward
service for patients.
‘If it’s someone
we know, then even
though I’m usually in the
community, I can go into
the hospital to see them,’
she says. ‘Take a patient
of mine who has dementia:
I know him well, I know the
equipment he uses, what he likes to
be called and what he likes to eat, how he
wants a
jumper, but everyone
needs a different size and
wants a different pattern
...what matters is working
towards what each
person wants to achieve
‘‘Everyone
and how they are going
to achieve it.
likes his hair done and what it takes for him to be a
bit happier.’
The service in Mardy Park is also very accessible
by anyone, with a helpline staffed in working hours to
take calls from friends, family and neighbours about
offering support to someone in the community.
Says Kylie: ‘This model allows us to answer calls
and give accurate advice for our area but also speak
to the person directly about their needs and feelings
and find a solution that may not need a referral or
visit.
‘The focus is on putting experts at the front of
the business who can provide the right advice,
ascertain if an immediate response is required or
give advice that means the individual or family can
resolve themselves. It stops the generic referrals from
professionals and reduces the screening time for
these referrals.’
Changing for the future
The service has continued to evolve over the years.
Recent changes include the team being forwarded
calls from the ambulance service, where the integrated
service is better placed to support the person.
A member of staff can then visit that person at
home and use equipment such as ELK raisers and
raiser chairs to help them, or to change their care
package, to ensure that person won’t need an
ambulance visit, referral and potential admittance to
hospital.
Occupational therapists also now sit on housing
panels to ensure that appropriate stock is available
for people with disabilities. They have a strong
relationship with the adaptations grants service and
meet often with surveyors and contractors to provide
adaptations to enable the person to live well at home
independently, or reduce their care and support
needs.
The service also now has
access to 16 profile beds from
the Integrated Care Fund to
support people where they
can’t access health-funded
ones, as part of a Gwentwide
scheme. Says Kylie:
‘I have been working with
one man who got out of
bed and fell to the floor up
to 10 times a night. Rather
than having four hoisted calls
a day, he now has one call in
the morning and a stand aid. It’s a
big difference to the family’s life, as well as
resources having the profiling bed.’
And the biggest shift is a plan to move to placebased
working, dividing Monmouthshire into 12 areas
and having teams wrapped around those locations
that integrate with care services more.
But while the systems in Monmouthshire have
helped the service achieve success, Eve is keen to
stress that it’s the culture and principles that have
been put in place that have made the real difference.
‘Everyone wants a jumper, but everyone needs
a different size and wants a different pattern,’ says
Eve. ‘Even in Monmouthshire, we have very different
community needs – the north is very rural and
farming-based, while the south is on the M4 corridor
and has a more younger and transient population.
You can’t have the same model as it’s not the
same community. But what matters is working
towards what each person wants to achieve and how
they are going to achieve it.’
Andrew Mickel, OTnews journalist, email: andrew.
[email protected]
40 OTnews August 2020