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Bay Health and Care Partners supporting people with their rehabilitation following COVID-19

23rd September 2020

People across Morecambe Bay who have been treated in hospital or in the community for coronavirus (COVID-19) have been supported in their recovery by a post-COVID rehabilitation pathway. The new way of working, which was introduced in April, offers this group of patients a full holistic assessment of their physical, psychological and social needs after being in hospital. Treatment is offered where possible or they are referred to another service which can best treat their needs.  

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The pathway is supported by the community and hospital physiotherapy and respiratory teams at University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT), frailty leads and Occupational Therapy staff from the Integrated Care Communities (ICCs), Cumbria County Council, Lancashire County Council, Morecambe Bay Clinical Commissioning Group (MBCCG), Primary Care Networks (PCNs), local GPs, Morecambe Bay Respiratory Network, Age UK, The Cumbria Neurological Alliance and Lancashire and South Cumbria NHS Foundation Trust.  

The first area of the new way of working has supported over 200 patients who have been treated in hospital and suffered moderate to severe respiratory complications. Long-term rehabilitation is being provided to 40 of these patients. By August clinical staff had carried out the following with patients who had been treated in hospital for coronavirus:   

  • over 400 clinical consultations (telephone/virtual/face-to-face where COVID secure)  
  • 53 initial home visits  
  • 168 follow up calls  
  • 84 follow up home visits.  

Sue Boulton, of Holme, near Carnforth, spent nearly a month in intensive care at the Royal Lancaster Infirmary back in April. She was left with complications including breathlessness and fatigue. She is undergoing rehabilitation at home with support from the respiratory team.

Sue said: “When I first came home, I couldn’t walk my dog or even the length of the living room without getting out of breath. I can now walk a bit further thanks to the exercises and support the team has given me.  

“Everything the staff said they would put in place was there when I got home including the oxygen I needed. I can’t thank the team enough for everything they have done.”  

The second area of this new way of working addresses the ongoing rehabilitation and recovery needs of people who had COVID-19 which was managed in the community and people with long-term conditions who have deteriorated in physical ability and independence.  

Ali Brenton, Specialist Respiratory Occupational Therapist for the Community Respiratory Team, UHMBT, said: “The aim of the COVID rehab pathway was to recognise not only those suffering from the infection itself but also the whole of the community who are suffering from the impact of the pandemic, shielding and lockdown. It has had a profound effect on everyone, not least those coping with chronic disease.  

“The impact of the pandemic has reduced normal fitness levels, tipping many further into frailty. It has also increased anxiety and low mood, living in a world dominated by threat and increased isolation and loneliness and access to support networks.  

“It has been a fabulous opportunity to develop a network of support for COVID patients, aiming to integrate both Community Therapy and Community Respiratory representation into the Community Multidisciplinary Team meetings run by the ICCs, thus increasing access to all the third sector groups and organisations that link with the ICCs.  It has facilitated easier referrals and raised awareness of access to current community resources to meet the complex patient needs created by the pandemic.” 

The third area of this work sees the Integrated Care Communities (ICCs) and Primary Care Networks (PCNs) across the Bay working hard to normalise the COVID situation by focusing on people’s individual needs. The teams are promoting the Population Health approach (improving the physical and mental health outcomes and wellbeing of people, whilst reducing health inequalities within and across a defined population) which means that teams signpost people to appropriate physical and social wellbeing services to help build their confidence again. The work of the ICCs and PCNs has included supporting people with:  

  • up to 300 online interactions at rehabilitation/exercise classes in Millom  
  • thousands of home welfare checks via telephone calls across the Bay  
  • supporting outdoor exercise facilities such as Pilates in the Park in Barrow   
  • offering chair-based exercises via Zoom with support from Age UK, local fitness instructors and local gyms  
  • issuing a community support bulletin which includes information about foodbanks, Third Sector and faith organisations along with wider community support.  

Feedback from the public on the work of the ICCs has included:  

“My sister has just used your list of local suppliers who are happy to support the community during these challenging times.”  

“Keep sending your list - it just saved a patient who has rung up in tears about being isolated and having issues. She made me want to cry but at least I could give her some contact numbers.”  

Karen Donaldson, Clinical Lead and Specialist Respiratory Physiotherapist, UHMBT, said: “When COVID hit we were faced with a new group of patients that hadn’t existed before. In the space of four weeks, we created a brand-new service from scratch and the support from our executive team, clinical staff, I3 team and partners have enabled us to do this – their support has been phenomenal.  

“This group of patients have been very poorly and most have been in intensive care. It is really rewarding to see that they are improving thanks to the work that we have been doing.”   

Lancaster GP Dr Pat Haslam, Respiratory Lead for Morecambe Bay Clinical Commissioning Group and is Clinical Lead for the Morecambe Bay Respiratory Network, said: “In my own practice, patients who have been through this COVID rehabilitation pathway have found it really beneficial and have commented that the team has been so helpful and supportive. Symptoms such as breathlessness and fatigue, amongst many others, have improved greatly.  

“As a respiratory network, we wanted a therapy-led rehabilitation pathway which is responsive to the patient’s individual needs. This is what this fabulous team have delivered and they are able to offer it across the whole of Morecambe Bay. It is great to see the Bay Health and Care Partners working together which continues to be a real strength for us across Morecambe Bay.” 

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