Service user example
Sharon * is a resident in a residential home . Sharon ’ s mobility had been deteriorating , having sustained a fractured neck of humerus a year earlier .
Rehabilitation and attempts to improve her mobility had been unsuccessful and she was requiring the use of a hoist to transfer . Although she was able to sit out in her room , she was requiring more support to maintain her sitting position and she had previously been a regular attender to the home ’ s activities , which she was now unable to do , as she could not sit safely in a standard wheelchair .
We were able to review her transfers and provide education and support to the trainer in the care home in assessing which sling was most appropriate for her , due to right sided weakness . We then looked into specialist seating , which would enable Sharon to sit out , but also be able to be transported to the other parts of the care home .
For Sharon to be able to sit with others for meals and attend activities such as bingo was important to her . The smile on her face and her wave to the other residents when she entered the living room for the first time in several weeks was the best part .
* Name has been changed .
It is a new pilot in North Sedgemoor PCN , and in four other PCNs across Somerset , which we are trialling in our team to help stratify the care home residents .
Brave uses ‘ big data ’ and practice data to predict the likelihood of an unplanned emergency admission in the next year , generating a ‘ Brave Score ’. At present , the application updates itself every other week , bringing near real-time risk stratification data .
As a team we can review residents whose score is on the ‘ rise ’, focusing on proactive and anticipatory care to prevent admission and enabling conversations about wellbeing , rather than just medical care .
It can also correctly identify a wide range of health complexities , which can give clinicians an understanding of how complex the individual ’ s need might be and support caseload delegation .
As we are proactive and not acute , we are trying to focus on anticipatory care and select residents who have been given a ‘ mid-range ’ score . These residents are normally living with and
‘ managing ’ several long-term health conditions . We focus on living well with these conditions and providing an enhanced review of their medical and wellbeing needs .
As occupational therapists we are being dynamic in our approach , with constant changes to our process and how we do this . From our perspective it is interesting , as we are still trying to work out ‘ how ’ and ‘ what ’ is the best way for occupational therapy referrals . Time will tell .
We have worked jointly on cases , as well as starting to select residents and share the caseload . Again , this is another area we are constantly developing , with no fixed process yet .
Additionally , we are taking part in another pilot , where we complete a Comprehensive Assessment Framework at the end of intervention . This is completed online by all members of the team . Two care homes are also taking part , with the plan to roll out to other care homes .
This is based on the Comprehensive Geriatric Assessment ( Osterweil et al 2000 ). This gives an enhanced ‘ picture ’ of the individual , collated by a multidisciplinary team with what is meaningful to them , to support care and treatment .
This is becoming accessible by a system known as SIDeR – Somerset Integrated Digital e-Record ( Somerset CCG 2022 ). It is a shared care record , giving the user an overview of a person ’ s health and social care information in one record .
Support from other agencies and peer learning
We have recently begun a ‘ peer support ’ group once a month with our fellow primary care network occupational therapists , which has been hugely helpful in supporting each other with the common themes we are coming across .
We have attended the senior occupational therapy leads meeting , which has great scope for the PCN occupational therapists to join with and demonstrate impact , as well as supporting wider work in Somerset .
In our own multidisciplinary team , we are starting to work more collaboratively . We are providing medical colleagues with training on basic manual handling assessments , for when they are reviewing residents who do not require occupational therapy input , to give them the confidence to complete the moving and handling section of the Comprehensive Assessment Framework .
Likewise , they are supporting us to develop our skills in discussing advanced care planning and treatment escalation plans .
From a training perspective , there are so many opportunities . We think this is the first job where
22 OTnews June 2022