How our community rehab service is supporting people this winter

Giving people the confidence to remain at home without needing a stay in hospital is so important as we reach the winter months and pressure increases on the NHS.

Our community rehabilitation service does just that with its team of occupational therapists, physiotherapists, pharmacy technicians, rehab assistants and rehab assistant practitioners, who look after patients with long term conditions, helping people to remain as independent as possible either in their own home, or in a nursing or care home.

Vicky Bull, the service’s manager within the Mendip neighbourhood, covering the Frome, Shepton and Glastonbury area, explains: “Over the winter we encourage people to keep as active as possible, which is even more important during these colder months.

“We work closely with our colleagues at Musgrove Park Hospital, Yeovil District Hospital, our community hospitals and adult social care to identify patients who need our support, and we can also signpost them to other services, such as health connectors and the voluntary sector.

“It’s especially important at this time of year as the darker evenings mean there’s an increased risk of isolation, as well as possible issues with heating and general comfort at home.

“We’re very holistic in our approach, with everything we do person-centred and tailored to each individual patient.

“We always focus on what’s important to the patient, what they want to achieve, and how we can get them to that point, but of course we do need to check whether their goals are realistic.

“Getting to know the patient and finding out what makes them tick is important, so we can start them on that journey to getting the right support.

“We develop home exercise programmes and tailor them to patients’ needs, and our pharmacy technicians support with helping patients to get the best out of their medicine, checking compliance, educating patients and ensuring patients aren’t experiencing any side effects that can cause major issues, such as falls.”

The community rehabilitation service is split into teams that cover different areas of Somerset, so they tend to organise support that’s tailored to their population.

Vicky continues: “In Mendip we have a strong focus on falls prevention and frailty, with multidisciplinary falls clinics running twice a month.

“Then in West Somerset, we have a ‘Living Well with Parkinson’s’ group, where our colleagues support those patients early in their diagnosis, giving them the tools to remain as fit and healthy as they can.”

Liz Goodwill, a senior occupational therapist and lead for the South Somerset team, said it’s important to remember that our community rehabilitation service isn’t a crisis service, but is instead here to help keep people out of hospital.

“In many ways we’re the ‘fun team’ as we get patients out of their comfort zone, doing things they wouldn’t normally do, to get them up and mobile,” she says.

“In fact, for one of the patients we recently supported, our resident assistant took her into town to a coffee shop for the first time – something she hadn’t been able to do for years. It was a really meaningful activity for her and meant her confidence and ability to get about has grown so much.

“The COVID-19 pandemic and lockdowns set some of the people we support back quite a bit, as many lost their confidence in going out and about, so they became de-conditioned and even lost friends through it.

“It has been really tough getting some of those people physically and mentally back out doing those things, but that’s where we come in.”

It’s not just elderly and frail people who the team supports, but also those with long term conditions.

“We have a lot of young people on our caseload at the moment, particularly in South Somerset where we’re supporting a high number of patients with brain injuries,” Vicky continues.

“We look at every function of their normal life and help them to relearn skills and get back to work or their usual daily life activities.

“As we’re a community rehabilitation service, we can support patients with achieving their goals. We can also signpost people to community groups, such as gym classes and even Men’s Sheds.

“We’re very much into an enabling approach, so we try to push the patient to take ownership of their goals – we don’t do ‘for’, we do ‘with’.

“We receive referrals from district nurses, GPs, hospitals, and patients themselves – it may be that their mobility has deteriorated, or they could be struggling with their medication.

“It may not be urgent, but by our team getting involved we can prevent them from going on that slippery slope to a crisis and losing their independence.”

One of the patients recently supported by the team was referred in by his GP as he had reduced mobility and knee movement.

Since the pandemic he’d been struggling to take part in many of his usual hobbies, and was unable to climb the stairs so needed to sleep in an armchair in his lounge.

Our multidisciplinary team met to discuss his care and a physiotherapist went to visit him at home to look at setting up a microenvironment, but he was still keen to return upstairs.

His goals were to be able increase independence, take part in his regular hobbies again, spend time with family, and get back to sleeping upstairs.

With input in the patient’s own home, the team was able to establish appropriate short-term goals each week and provide him with an environment specific exercise programme to build up his lower body strength.

Over the course of the treatment, and from positive risk taking and encouragement, the patient achieved his goal of returning upstairs to sleep. His sleep significantly improved, and he was able to elevate his legs overnight, which helped to reduce his lower limb swelling and protect his pressure areas as he wasn’t sitting up all night.

As a result of the intervention, it improved his confidence and lower limb strength, and he has since been on coach trips with his wife and to the theatre with family, achieving his long term goal of spending time with his family.

A huge thank you to the incredible work by everyone in our community rehabilitation service!