Service Lead: Sharon Davies
Clinical Leads in Primary Care; Nicki Price, Claire Raymond, Jane Moran and Karen Holloway
Hywel Dda University Health Board
Traditionally people access Occupational Therapy (OT) services at points of crisis. We wanted to evaluate the impact of earlier intervention from Occupational Therapists in a Primary Care model, with a focus on prevention and self-management, since we are the only Allied Health Professionals (AHP) qualified in physical, psychological and mental health, and therefore understand the impact of these conditions on daily life.
General Practice is under significant pressure, serving a population with multiple and complex health and social care needs. Coronavirus Disease 2019 (COVID-19) places a further challenge to the health and care system, and highlights the value of flexible, adaptable AHPs in Primary Care.
Image: example of poster available in practices (contact info redacted).
“Having an OT as part of the core team is brilliant, something is lost in formal referrals but with you in the surgery you are more likely to pick up in cases, be involved in conversations about patients and be part of the initial conversations when we don’t know what to do.” Dr Dew GP, Winch Lane Surgery Haverfordwest
Our model involves embedding an Occupational Therapist within the GP Practice group. We believe that Occupational Therapy has a significant role to play in delivering a cohesive and integrated primary and community service by focusing on prevention, proactive care and self-management.
South Pembrokeshire Primary Care Cluster, in partnership with Hywel Dda University Health Board (HDdUHB), are one of the pioneers of the model of Occupational Therapy in Primary care. In addition it hosted the Occupational Therapy Vocational Clinic (OTVoc) National Research Project undertaken by HDdUHB Occupational Therapy Service and the Royal College of Occupational Therapy (RCOT).
Following evidence gathered from these projects, the aim was to evaluate:
Patient outcomes, alongside conducting value-based healthcare analysis;
Transformation of the Occupational Therapy Service to provide a health and well-being service that focuses on prevention and self-management;
Value and impact of the OT skill set in Primary Care as part of the Occupational Therapy Service continuum of provision;
How the above supports prudent healthcare, as we use collaborative conversations to find ‘what matters to people’, making sure that the right care is available at the right time, from the right source, at home or nearby;
Ability to respond to demographic.
We aimed to improve:
Understanding of skillset and offer of OT by providing a Clinical Lead Occupational Therapist as the interface of every surgery in Pembrokeshire;
Upstream Occupational Therapy provision.
COVID-19 Lockdown 2020 coincided with the beginning of our project, bringing additional challenges, including:
Necessity to prioritise support so that people remained safe at home and avoid unnecessary admissions - to achieve this we used a RAG rating, similar to those used across other services;
Red: Intervention will prevent admission; reduce immediate risk of manual handling injury and/or care support breakdown
Amber: Where assessment and intervention is not urgent, however requires regular contact to monitor and reduce risk of escalation
Green: Individual able to self-manage situation
Impact of remote working on communication, development of team work, and opportunities to promote understanding of the OT offer to Primary Care - in response we agreed a communication framework to enable collaboration on person centred holistic care, which includes technology-enabled multi-professional meetings, remote access to Primary Care records and an easy reference poster, which increases our availability and offers alternative solutions to proactively support well-being.
Providing accessible services across Pembrokeshire - we enhanced the interface between Primary Care and Community Therapy Teams, and created a centralised, single point of access for Primary and Community requests for assistance.
Image: Infographic showing that the average wait for referral decreased by 95%, and the longest wait decreased by 88% after the project start; that 74% of patients were assessed within 24 hours of their referral; and that of the 42% patients who were referred due to reduced function, 67% showed early improvement upon OT intervention.
COVID-19 became a catalyst for change at an accelerated rate. Our key outcomes were:
Occupational Therapy in Primary Care is well placed to play an essential role in identifying and delivering the Welsh Government framework “Rehabilitation: a framework for continuity and recovery 2020 to 2021” for groups impacted directly or indirectly by COVID.
Early intervention and ‘what matters to you conversations’ helps people to engage in occupations that are meaningful to them.
The OTVoc offer helps people to have improved confidence and ability to manage their own health condition(s) and daily life and consider returning/remaining in work, as evidenced in the report by Fiona Nouri et al.
“Benefits both patients and GPs, for patients who are repeat users of our surgery it has opened other avenues or support networks. Patients feel more confident/informed in managing their conditions and therefore as a result have attended the surgery less.” Dr Tobin Neyland & Johnston surgery
A closer, centralised working model of Primary and Community Care across Pembrokeshire has enabled consistency and improved response times. There is equity of service across North and South Clusters, 67,000 patients registered across the 8 North Cluster GP practices can now access Primary Care OT.
Feedback from patients and their relatives
“I felt listened to, it made a real difference” Patient
“I plan and pace my day better which means I achieve something every day” Patient
“Improved the quality of my dad's life during this period of his illness.” Relative
“The Occupational Therapist advice and support has made a significant impact on my confidence and ability to provide the care that my dad requires at home. I understand how to assist him to manage breathlessness- to arrive to the bathroom with sufficient energy to wash and shave.” Patient's daughter
Feedback from Primary Care Colleagues
“… My role as a GP is to treat patients holistically within the community. This can be hard sometimes when services are limited. Seeing our work in tandem, and the positive impact that this has had on both physical and mental health issues during the pandemic has given me a sense of satisfaction and relief. Since having a timely, efficient OT service to utilise for my patients, I have seen improvements in their progress and in their confidence. On a personal level, it is refreshing to have a team of professionals with such a ‘can do attitude,’ ready with ideas and approaches to help. Having that easy access for a query or a concern is very useful. It doesn’t feel like a ‘separate service’ this way, it is more collaborative, and that serves the community best.” Dr Amy Nelson Fishguard Health Centre
We will continue to promote the agenda for proactive and preventative involvement in General Practice across HDdUHB.
We will engage in whole system transformation to maintain and improve patient care within our local communities, as the added value that Occupational Therapists bring to General Practice is increasingly recognised.
We will promote the Occupational Therapy skill set to help people with health problems or disabilities return to and stay in employment, by increasing the access to AHP Health and work reports written by Occupational Therapist.
We will continue to evaluate early OT involvement, including within COVID-19 population groups, recognising positive outcomes and identifying areas that fall short of expectation.
Our Exemplar Experience
Bevan assisted in providing the framework for negotiating strategically, maintaining project focus and delivering improvement during a year of uncertainty.