BETTER TOGETHER They say it takes a village to raise a child. We discover how keeping people well and out of hospital is all the better through teamwork.
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aula McNulty is an experienced occupational therapist. But sometimes her patients will have more than therapy needs.
When this happens Paula can draw on the expertise of any one of a group of professionals. She coordinates the Integrated Care Team (ICT), a group that includes GPs, physiotherapists, social workers, mental health, allied health professionals, matrons, district nurses, voluntary services, pharmacists and administrators.
They’re ready to step in and provide whatever is necessary. They’re all ready to step in and provide whatever’s necessary for the person to recover or stay well – not just their health but often their life. The team will come together to look at factors that may be contributing to that person’s distress or poor health, based on goals set by the person themselves. They’ll then call on the best source of help.
Paula McNulty.
Paula chairs the Aintree, Croxteth and Norris Green team. She says every case is different.
“It could be health related, but equally someone may need help with finances or to be reconnected with their community. We could step in to help an elderly carer who has their own health issues. “Parents who are unsure of the development stages for their baby may benefit from a health visitor giving them little nuggets of knowledge, to reduce anxiety and help them be the mum and dad they want to be. They can advise them on other services that can support them, such as children’s centres.”
A single piece of information could make a big difference to someone’s life. “As a team we have years of experience and rich resources and knowledge to tap. It’s good to know that one of us might have that single piece of information that could make a big difference to someone’s life.”
A CHANCE AT LIFE Paula recalls a 50 year old lady with Asperger’s Syndrome, epilepsy and difficult to control diabetes (the diabetes could lead her to present with erratic behaviour which caused great distress to her family). “When we met her she was very distressed and frustrated. During a recent hospital stay she had been prescribed medications which stabilised her mood. But we all wanted more for this lady who had missed out on so many life opportunities.” The team linked in with a specialist diabetes nurse at the Royal Liverpool Hospital and a specialist epilepsy nurse at the Walton Centre. Liverpool City Council’s telehealth service provided an epilepsy sensor mat for her bed at home, so the team could keep a record of seizure episodes. The Trust’s Asperger service advised on the best way to communicate with the patient about staying well, and a learning disability nurse accompanied her social worker on visits to offer support and insight into her particular needs relating to her medical problems.
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The team worked with her family, signposting them to an autism passport which can help other agencies understand her needs when family can’t be around her.
They’ve recently linked with the student support team at a local college. The lady is going to the Trust’s Life Rooms and using the Household into Work scheme to access programmes to prepare her for full study. Says Paula: “She’s now in a position to fulfil her ambition of studying. Her family is delighted too. With the benefit of the wisdom and knowledge of everyone involved this lady is finally having the life she deserves.”
CALL ON ME: The team can call on: specialists such as alcohol and drug support workers, Talk Liverpool talking therapists, Personality Disorder Hub practitioners, Citizen’s Advice Liverpool, Liverpool Diabetes Partnership, registered nurses, general practitioner, advanced nurse practitioner, health practitioner assistants, physiotherapists, occupational therapists, therapy instructor, social worker, pharmacist, pharmacy technician, hostesses, and podiatry and community care assessor.
