People with long term neurological conditions (LTNC) often see ongoing physiotherapy as the only way to maintain health and independence. A community based neurological therapy team can offer much more.
A broad spectrum of conditions from MND and MS to brain injuries, LTNCs will affect individuals and their families in one way or another for the rest of their life. Symptoms may be primarily physical though there is often a complicated range of functional, cognitive and emotional changes. By using an integrated team approach, often within the person’s home and environment, community based teams offer rehabilitation and disability management to maximise independence, maintain life roles, manage risks and foster a sense of control over the condition. Teams will include a range of therapy disciplines for a holistic approach.
The NSF for Long Term Conditions (2005) highlighted that community rehabilitation is cost effective in re-integrating people into the community, preventing unnecessary hospital admissions, improving well-being, and lessening the burden of care.
With stretched resources, enabling patients to self-manage is key to issues of capacity and demand,such as attending a fatigue management course, or provision of a home exercise programme. Cross-team liaison with GPs, District Nursing, Social Service and other groups is crucial for provision of optimal care for LTNCs; e.g. medication and complex positioning programmes with GP, District Nurses and care team to manage spasticity at home.
The Royal Free Neurological Rehabilitation Centre (NRC) has a 15 bedded inpatient unit alongside the Community Neurological Conditions Management Team (CNCMT) and Vocational Rehabilitation Service, providing a service to Barnet (North London) and surrounding boroughs. The teams include neuro– specialist Physiotherapy, Occupational and Speech and Language Therapy, as well as MS Specialist Nursing, Neuropsychology, and Dietetics.
The CNCMT was established in 2010 following a review of community rehab services by the PCT commissioner. Growing year on year, the 22-strong team supports nearly 400 people with progressive LTNCs as well as those with newly acquired injuries, averaging 45 referrals/ month.
To manage local demand a range of care-pathways allows for a patient-centred approach, aiming to maximise independence and also adapt to the needs of the person and family over differing stages.
• Crisis management: May be required for those with highly complex needs to prevent admission to hospital.
• Rehabilitation: An intensive episode of community based rehabilitation to improve level of functioning
• Condition Management: An episode of intervention to improve disability management
• Resettlement: After a hospital stay or moving to a new home to establish a support programme. • Self management: Requiring a programme to support self- care
• End of Life/ Complex case management: Ongoing or flexible intervention for end of life care and /or integrated case management.
Points to remember when referring to community teams:
• Physiotherapy may be part of the solution but consider the range of MDT professionals to support better management
• Early intervention is key. Refer patients early after diagnosis so community teams can develop rapport, support self management, anticipate and respond to crises.
• Specialist nurses are a knowledgeable resource for symptom management, often following patients over time and have close links with community services.
• Help manage patient’s expectations – teams may prescribe self management programmes for patients, though rarely offer ‘maintenance’ therapy – i.e. ongoing regular therapy.
• Different therapeutic approaches and intensity of intervention will be needed dependent on the nature and stage of the condition, as well as psychosocial variables.
• Providing clear reasons for referral will speed up the process. Discuss with the patient what they need as well as want.