Hearing how their patient managed to get out of her house for the first time in nearly two years has highlighted how our Glasgow City Health and Social Care Partnership’s (HSCP) Community Rehabilitation Teams are helping patients to maximise their independence.

“I am overwhelmed at the compassion, dignity and respect given to me from your whole team,” the patient told Lynn Haughey, Team Leader of the North East Rehabilitation Team, one of three teams across the city. “I would like to say a massive thank you to all who were involved in supporting me right from the initial meeting, and had a total understanding of my needs.”

The rehabilitation team works closely with others across our HSCP, including Homecare Reablement Team, social work, district nursing and other community organisations. 

Relationships with acute hospital discharge and ‘front door’ services are another priority, with a commitment to see patients referred from Accident and Emergency and Scottish Ambulance service colleagues within 24 hours. The team also provides a same day response to GPs in relation to patients at risk of admission. All of this helps prevent unnecessary hospital admissions and any delay to people being discharged home. 

Lynn puts much of the team’s success down to its unique multi-disciplinary approach, with eight different health disciplines working together to support patients, as individuals with identified needs and goals, throughout their rehabilitation journey.

“We really do work together as a co-ordinated team,” says Lynn, “Each profession has a different skill set and by working together, we can support the patient in a holistic way, not just focussing on the one specific issue but addressing all aspect of rehabilitation, focussing on what is most important/required at the time. We look to the future, giving information, advice, exercises and support to help our patients, build strength and prevent decline. That way, we can build up resilience and support our patient to become and stay more independent, at home and in the community.”

The teams consist of nurses, physiotherapists, occupational therapists, podiatrist, speech and language specialist, dieticians, community psychiatric nurse, pharmacist, support workers and administrative officers. Their referrals can come from hospitals to facilitate timely discharge and from community where therapeutic input is provided to patients with long term conditions such as Huntington’s, Parkinson’s and Motor Neurone Disease (MND) and frail elderly.

“The one thing we all have in common when we’re working with a patient, no matter how they’ve been referred to us, or what their condition is, is that we set rehabilitation goals. These may be for someone who’s frail or recovering from a hip fracture to overcome their fear and get back out into the community to prevent becoming isolated. A physiotherapist and support worker can help by practicing scenarios like pavement kerbs and walking in more crowded areas, or it may be their goal is to regain independence, strength and weight gain after a period of being unwell.”

For some patients, support might not be needed right now, but Lynn’s team can check in regularly and set rehabilitation goals at the right time, “MND patients are referred to us at diagnosis, but some people may still be working and might not need support at the moment, but we keep in touch every six months, just to make sure they’re getting the support they need as their condition changes, and to answer any questions, or give information.”

For other groups, such as people living in residential care homes, the goal can be to prevent falls by building resilience, increasing physical movement and education. Recent innovations in the homes include a walking aid clinic at Riverside to help people maintain mobility. Monthly drop-in clinics with the physiotherapist and the physiotherapy support worker has already reduced the number of falls, and a seated exercise class is being looked at for residents. We promote independence by encouraging people to do and use what they can, so they don’t lose it, all based around the Care About Physical Activities (CAPA) principles.

This holistic approach, focussing on people’s strengths as well as their areas of need, has resulted in a great outcome for the patient who wrote to Lynn, citing team members’ compassion, understanding, practical advice and support.

“I was looking for and needed advice given plain and easy to understand and follow. Nurses who came out when my skin started to break were out within 48 hours, and got a barrier cream organised and brought a cushion for my back to prevent further damage. Absolutely fantastic team! 

I was treated as an individual throughout. I suffered for 16 months not knowing your team existed and I can only say I’m privileged to have met some of them who have given me the ability to get outside again after nearly two years.”