- “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”.
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: