On home Ground

Physios in care homes can transform lives, but provision can vary, says Joanna Lyall

Time is of the essence for patients in care homes. For this frail patient group, delays in accessing care can be a wait that the person cannot afford and from which they cannot recover. Yet, with appropriate and timely physiotherapy, such scenarios can be avoided. Nursing and residential care homes offer wide scope for improving the lives of older people, many with long-term conditions. And there seems to be growing recognition of the role physiotherapy can play in maintaining residents' mobility, preventing falls and training staff. Access to physiotherapy is not always direct, though, with types of provision varying from home to home. A survey of 274 private nursing homes in England, Scotland and Wales in 2001 found only 10 per cent of residents received physiotherapy. Three quarters of homes relied on referral to physiotherapy via a GP, while 25 per cent had a visiting physio who attended one to four sessions a week in the home. Increasingly, though, care homes are employing therapists on a private basis to provide on-site physiotherapy. It's a trend that perhaps is in part driven by care homes' desire to be competitive in a market that is set to grow as the population ages. Advertising you have a resident physiotherapist can provide that necessary competitive edge. Improving care is also a factor, says Stephen Wood, who recently started working privately part-time for a nursing home. 'They very much want to maintain all of their patients. They are very proactive and it's about not waiting until mobility decreases,' says Mr Wood, who is journal editor for Agile, the clinical interest group for physiotherapists working with older people. PHYSIOS ON SITE Pat O'Brien is the first physiotherapist to be employed by Cornwall Care, a group of 18 homes, which is establishing rehab teams within their care homes. She is a firm believer that physiotherapists working on site in care homes can make a huge difference  to the quality of care, and hence, the quality of life  of residents. 'Given that the residents are elderly, and suffer from multiple pathologies often compounded by dementia, having a physio based within the home allows interventions to be totally flexible around the needs of the resident,' she says. Being based in-house means physios have the time and opportunity to get to know residents well, enabling them to intervene at the first sign of a decline in mobility or significant change in functional ability. With dementia patients, says Ms O' Brien, this can be invaluable. 'Once a movement pattern or skill has been allowed to be lost for only a short while, retrieving it from memory can be almost impossible.' Whatever the style of physiotherapy provision, the challenges of working in care homes remain. Physios  stress the need to develop good working relationships with care home staff, some of whom may not have English as their first language. Many carers may be working with a physiotherapist for the first time,  and physios can be invaluable in providing advice  and information on handling, rehab and mobility. A lack of equipment or space can also be a challenge, with physios expected to work in small spaces or residents' rooms with limited equipment. Physios may find themselves advising on floor coverings, footwear and armchairs, and making sure support packages are in place if residents are going back to their own homes after rehab. There is also scope for innovation such as the introduction of exercise groups, music therapy and t'ai chi. With both challenges and opportunities, physiotherapy in care homes can be a rewarding career. And with homes increasingly employing physios privately, the potential to offer physiotherapy to a sometimes overlooked client group is enormous. FL FURTHER INFO Barodawala S et al. 'A survey of physiotherapy and occupational therapy provision in UK nursing homes', Clinical Rehabilitation (2001), 15:607 Flexibility is the key 'I have never been so happy professionally, or able to work at such depth as I'm doing now,' says Nicky Atherton, a senior mental health physiotherapist in the 12-bed dementia wing of Charnwood House, a residential unit in Coventry. 'You need to be very flexible to work in a care home, and ready to advise on a huge range of topics, from flooring, to chairs and lifting and how to put on a splint. But it's wonderful to work so closely with other staff. You really have a chance to influence things,' she says.  She works two and a half days a week at the home Ms Atherton, who is employed by Coventry and Warwickshire partnership trust, works with a consultant psychologist and advanced occupational therapist to provide an intermediate care service. The majority of patients are in their 80s or 90s and the rehab aim is to return to independent living, generally in sheltered housing. Many come from hospital, following a fall or hip replacement, with the average stay eight to ten weeks. When residents first come into the home, Ms Atherton does a full physical assessment and reviews their medication. Then she works on building up their movement skills.  'I think if homes could see the benefits physiotherapy brings they could give their residents more help,' she says. Working with dementia Gemma Cottrill is senior physiotherapist in a specialist dementia outreach team in Nottingham, launched in May in 2007.  The team provides support to 18 residential and nursing homes, served by 12 GP practices. Working with an occupational therapist, two nurses and a support worker, Ms Cottrill has a caseload of seven patients in three homes, all with dementia. She visits each resident once a week for 30 minutes. All are referred by GPs. 'Mobilisation after a hip operation can take much longer for someone with dementia so we will be working with some clients for a year,' she says. 'We do assessments, set up exercise diaries and advise on equipment. We also advise on pain control and make sure the patient is taking their medication correctly.' Training care staff in homes plays a large part of the role. Teaching sessions cover what is dementia, preventing falls and promoting mobility. 'Working with homes is quite different from being in hospital and you have to be very flexible,' says Ms Cottrill. 'We're often working with carers whose first language isn't English and you need to adapt your communication style. 'The feedback from our training sessions has been very positive and I like the teaching mixed in with the caseload.'  Improving care Ruth Carter works in a nursing home support team consisting of two physios and three nurses based at Brighton and Sussex University hospital trust. It was launched in 2003 with the aim of improving care for people with long-term conditions, reducing emergency hospital admissions, and preventing delayed discharges.    The team supports 27 nursing homes, including elderly mentally infirm units, in Brighton and Hove. Members assess new residents, provide one-to-one treatments, and advise staff. 'It's wonderful to be able to spend one-to-one time with residents and get to know them,' says Ms Carter. 'I think the team is unique and it's stimulating to be working in a new way. I see fewer patients than I would in hospital because of the travelling, but there's a chance to build up long-term relationships.     'Part of the role, as I see it, is to find out what people want to do, rather than thinking what we can get them to do… I think there's enormous scope to improve continuity of care for older people and I like that. I enjoy building up relationships with the homes and would like to see a special forum for physios working in homes.' Junior opportunities Nicola Glimmerveen (below)  graduated this summer and was hoping to find a job in the NHS when she saw an advertisement for an activity coordinator in Dormy House, a private home in Sunningdale, Berkshire, offering residential, nursing and dementia care. She applied and was subsequently offered three days a week working as a physiotherapist.  She works in her activities role the other two. 'I am working on my own as a physio here, and that's a bit daunting, but it's a wonderful experience. I feel I am making a difference to the residents, by helping to keep them mobile and independent. 'There's no special equipment, so you have to improvise.  But the home is well furnished and there are rails along the corridors.'
Joanna Lyall

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