Cluster team helps patients remain independent and well at home

A cluster team supports people to regain their independence and helps keep them well at home and out of hospital.

Cwmtawe Local Cluster Collaborative’s (LCC) occupational therapy team works with patients to aid their independence, as well as participation in daily activities.

Occupational therapists support people to overcome challenges they may face when completing everyday tasks and activities that matter to them.

They look at all aspects of the person’s life and work with them to find practical solutions to help them maintain, regain or improve their independence and quality of life.

Pictured: Occupational therapy technician Rowan Pengelly and occupational therapist Aimee Collier-Rees.

The role was introduced in Cwmtawe LCC in 2019, with occupational therapist (OT) having Katy Silcox led the way.

Now, Aimee Collier-Rees has taken on the role within the cluster – which covers the Clydach, Morriston and Llansamlet areas of Swansea.

“The service supports a wide range of patients with functional needs,” Aimee said.

“I see people with mental health conditions, long-term conditions, physical issues and more to try and help them remain as independent as possible within their home.

“Some of the solutions can involve changes to the person’s environment or using different techniques and new equipment.

“We want to make sure people are accessing the services and support they need, which is where we link in with the cluster’s multidisciplinary team.”

The service is available to patients aged 18 and over who are registered at a Cwmtawe LCC GP practice (Cwmtawe Medical Group, Llansamlet Surgery and Strawberry Place Surgery), with practice staff able to make referrals.

Patients can also self-refer by asking for a referral in their GP practice.

Katy Silcox, clinical lead OT for the health board’s clusters and virtual wards, said: “It has been an integral service which was produced based on the needs of the cluster population.

“It is a holistic, proactive and preventative service which looks at supporting and empowering people to manage their health and wellbeing.

“Having OTs embedded in GP practices enables individuals to receive support earlier in their health journey.

“OTs are ideally placed in primary care as we work across physical and mental health to understand each person and work on what is meaningful to them.”

Pictured: Aimee with clinical lead OT Katy Silcox.

It also forms part of the award-winning Cwmtawe Mental Health and Wellbeing Hub, based at Strawberry Place Surgery, which gives patients access to wellbeing practitioners, a social prescribing service, all-age counselling service and more.

As part of the hub, the team meet fortnightly to confidentially discuss how to plan and manage patient care, and also to streamline referrals to the different members of the team.

The cluster has previously received multiple prestigious NHS Wales Awards in recognition of the wellbeing support on offer to its patients.

“I attend the mental health virtual ward which has been very positive because it is made up of the multidisciplinary team within the Mental Health and Wellbeing Hub,” Aimee said.

“We can work with the team to produce a plan, have discussions and use expert skills or experience to work out which service can best support that patient.

“It is really helpful to sit with the team and chat about different options that may help the patients. For instance, the counsellor may be supporting someone who could also benefit from OT intervention.”

While Aimee’s role is funded by the health board, the service has also introduced a cluster-funded OT technician too.

Rowan Pengelly supports both the OT and patients through ongoing interventions, which helps to increase the number of patients that can be seen.

Katy added: “Rowan plays a vital role in the delivery of the Cwmtawe OT service and really enhances what we can provide to patients, through completing assessments and delivering support.

“This can include emotional wellbeing activities such as relaxation, meditation and pacing strategies, as well as confidence-building sessions.

“Her role helps to provide shorter-term support which can really benefit people who may then not need further ongoing intervention.

“Our main aim is to improve the health and wellbeing of our patients, while also reducing the demand on those working in primary care.”

Mike Garner, Cwmtawe LCC lead, said: “I am extremely proud of the occupational therapy service supporting our local community.

“The service plays a key role in helping patients remain independent, well, and supported at home, while reducing pressure on acute services.

“By working holistically across physical and mental health and as part of our multidisciplinary team, the service ensures patients receive timely, joined-up care that focuses on what matters most to them.

“It is a great example of how community-based services can deliver real benefits for our population.”