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Integrated Service for Older People

Our Integrated service provides early intervention by Health & Social Care professionals working in a co-productive and prudent way, as one service across different health & social care organisations in Monmouthshire. We work alongside service users, helping them to lead as independent a life as possible and providing proportional, timely interventions based on encouraging independence. We help to keep people independent for as long as possible by asking the “What Really Matters to You” question, listening to the responses and working creatively to find solutions and achieve people’s personal outcomes. Our aim is to enable individuals to reach their goals and their full potential. The Integrated service in Monmouthshire comprises of Community Occupational Therapists, Social Worker, Physiotherapists & Community Nurses working together as locality focussed teams. The Community Nursing services within Monmouthshire were restructured so that District Nursing, Chronic Conditions Nursing & Rapid Response Nursing services are managed as one Nursing Team and work as one Nursing “Family”, a model which is now being rolled out across all other boroughs and Community Nursing Teams within ABUHB. The Integrated team is supported by a new Integrated Assessment process (and documentation) that focuses on proportional assessments of people’s needs. Key to this is to find out what matters to the individual. This means not making assumptions based on what traditional District Nursing, Occupational Therapy, Social Worker & Physiotherapist’s assessments might think is important. This work is based on the WAG Older Persons & Prudent Healthcare guidance. All community services work together to reduce overlap and duplication of assessments between the different professionals, who are required to think beyond traditional remits and traditional care needs (and boundaries) to help people with the needs they identify as important to them. Our goal is to help people live independent and fulfilled lives, lessening their need for traditional health & social care services. What people have told us in response to the “What Matters” question has been surprising and at times humbling:
  • “I just want to be set free to live my life and not let cancer rule me and not wait in for District Nurses to visit” – a patient who we taught to self care for his PICC line.
  • “I want to be able to go to a tea dance not have to stay in because I have Parkinson’s disease and am at risk of falls” – a gentleman supported by the Chronic Conditions Nurse at Caldicot. She linked him with the local Community Coordinator (Monmouthshire Initiative) for Caldicot who linked him in with a local group in his area who then provided transport and company for the tea dance.
  • “I was listened to about what I am actually worried about which are the daily things not my imminent terminal prognosis”.
  • “I am amazed that I can have intravenous antibiotic treatment at home, the service is amazing and it’s brilliant that I didn’t need to stay in hospital”.
The greatest challenge is that this requires staff to change their culture and to think in entirely new ways. The ethos is based on Edgar Cahn’s view of co-production: to “enable citizens and professionals to share power and work together in equal partnership, to create opportunities for people to access support when they need it”. Hilda Hallett, for example, had bilateral circumferential leg ulcers of 10 years standing with lymphodema and multiple co-morbidities and agoraphobia. She received care through the Integrated Service. This included proactive planning to respect her wishes not to go into an acute hospital when unwell & acknowledging her low self esteem & agoraphobia. The outcome was two community hospital admissions where bedrest was provided to allow her leg ulcers to heal, which they did in an amazing 10 weeks. Community Nurses in-reached to provide the specialist lymphodema bandaging whilst she was in the local community hospital and contribute to her discharge plans. Her discharge home was facilitated with a reablement package of social care and she regained her independence despite living in cramped accommodation, further complicated by being a bariatric lady. Her social package of care ceased. She remains independent. Her leg ulcers have remained healed: her bandaging is undertaken weekly by the nursing team (previously 2 nurses at approximately 90mins per visit x 3 per week) and support garments provided by the Lymphodema Specialist Nurse based in the Acute Trust as an alternative to bandaging. Two years on she has enough self confidence to move to a ground floor purpose-built flat within the local area where she will have social contact with other residents. Continuing NHS healthcare has funded a recliner chair to facilitate her leg elevation to support her lymphodema management and maintain leg ulcers healed. Previously she would not have met the criteria for a social services funded rise and recline chair as she did not need this to get up to be mobile. Equipment to maintain her independence at home has been provided by the Community Occupational Therapist and we have “set her free”. Asked what was important to her, Hilda responded that it was the fact “that we never gave up on her”. Working in a co-productive and integrated way with people on what really matters to them is contributing to the future health and well being of the population. By working in a smart and prudent way to facilitate independence the Integrated Service hopes to reduce people’s future need for health & social care support. For more information, please contact Jackie Shacklady, Integrated Nursing Team Leader, Caldicot –

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