Devised jointly by the local community, GPs and other frontline health professionals My Care, My Way is a new approach to healthcare, aimed at over 65s, and intended to help our older patients remain independent in their communities and have more control over their care
Teams, led by registered nurses and supported by health and social care assistants, are now embedded in local GP surgeries and aim to develop complete care plans with patients which identify their specific needs and then work to optimize their health and social wellbeing.
Our plans are holistic, which means they aim to cover all aspects of health and social wellbeing. Plans may set out health related goals around weight loss or stopping smoking, but we can also help patients achieve other goals, from finding appropriate social support to lending a hand filling out forms.
Part of our work also consists of linking patients to a range of services provided by organizations like Age UK and Open Age, operating in local communities across the borough. These include 1-to-1 services like befriending, mobility support and massage therapy, as well as group activities like dance, gym sessions and gardening. The one-to-one services and group activities which our My Care, My Way team can refer patients into include:
ONE to ONE Services:
- Creative Befrienders (matching people with dementia who have been artists or are interested in the arts with a volunteer artist by their expertise and interest to work on a one-to-one basis in their own homes)
- Light de-cluttering
- Dementia 1 to 1 Support (assisting patients with Dementia manage their conditoin through activities that help retain memory functoin and providing guidance on managing the condition more generally)
- Escorting (supporting patients with mobility problems get to appointments)
- Exercise at Home (provision of balance and strength exercises for patients unable to leave their homes)
- Information and Advice (advice, casework, advocacy and support around maximising income, housing conditions and health and wellbeing)
- Link-up into Open Age ( activites (helping people link into a range of classes and activities)
- Massage/Reflexology Therapy
- Safe at Home (safety checks and onward referrals)
- Walking Support (provision of a walking companion to aid recovery, level of fitness and confidence, e.g. after a fall or hosptial admission)
- African Dance (Gentle dance classes and exercise to music)
- Supported Gym Sessions (helping people maintain a healthy weight)
- Healthy Community Lunch at Venture Centre (providing a nutritional meal whilst engaging with others)
- Men's Only Activites at Open Age (encouraging men to become more involved in their local community and engage in new activities as part of improving their own health and wellbeing)
- Arts in the Community (for patients with demendtia with/without their carer - 6 week arts projects, e.g. music, theatre, opera, visual art working with local arts venues and resources)
- Gardening at St Charles Health and Wellbeing Centre - on raised beds, suitable for people with limited mobility or mental health issues
Since each patient is different, each care plan is tailor-made to individual needs. Plans can be drawn up through 1 hour consultations at either the St Charles Health and Wellbeing centre in Exmoor Street (click to find on a map), or the Violet Melchett Health Centre in Flood Walk (click to find on a map). These consultations will usually involve the patient, GP, case manager and other health professionals (e.g. social workers). Consultations can be arranged and more info found, by simply calling the practice. Alternatively, housebound patients can be visited at home.
My Care, My Way patients who would like to be reviewed again for further services can contact our Senior Case Manager and the team can arrange a home visit. Additionally, patients who have recently had hospital admissions will be reviewed again by the My Care, My Way team once they are back at home.
Case managers and our assistants exist to act as a single, known and trusted point of call for patients, helping them navigate the NHS and coordinate their care. We want to help older patients manage and understand their health conditions so they can remain independent, avoid repeated hospital admissions, and get proper care and support at home once they’ve been discharged. For more information on how My Care, My Way could help you or a member of your family, please contact reception.