A Step towards Transforming Care in the Community - TRANSCEND

The idea of a transdisciplinary practice started when a group of TTSH nurses visited Scotland during a District Health clinical attachment. An occupational therapist in his role as an advanced practitioner provided the team with an insight that the first touch point in the community may not always have to be a nurse. This concept kept the nurses thinking and when they returned home, over a casual lunch session with the allied health colleagues, one of the nurses seeded the idea of how transdisciplinary teams can transform the way care has been provided in the community.

The idea evolved and brought a group of like-minded allied health professionals (Dietician, Medical Social Worker, Occupational Therapist, Pharmacist, Physiotherapist, Podiatrist, Psychologist and Speech Therapist) to develop a four-day programme - Transdisciplinary programme for Community Health Professionals (TRANSCEND).

The programme focused on equipping community healthcare professionals with a broad range of essential skill set that could support health professionals to deliver care beyond one’s own professional training. The aim is to empower each health professional to provide a more person-centred approach to support the needs of residents in the community.

The pilot run involved a group of 13 learners from the TTSH Community Health Team (CHT) in early October 2020 using a blended online learning approach due to COVID-19 restrictions. The online guided self-learning modules include the following topics, supported by three facilitators guiding the group learning sessions till January 2021.

1. Overview of community health and person-centred approach
2. Identifying and managing common psychosocial symptoms
3. Promoting physical activity and safe mobility
4. Maintaining participation and safety at home and in the community
5. Nutrition screening and healthy eating advice
6. Medication safety and compliance in the community
7. Dysphagia awareness and safe swallowing
8. Basic diabetic footcare in the community
9. Nursing therapeutics essentials for community health professionals

Feedback from learners in the pilot run showed that a stronger focus of person-centred care, broader knowledge of the different professional domains and deeper appreciation of working as a team. They hoped for more face-to-face learning sessions to practise and obtain feedback on their practical skills.

We envision that Transcend could be the first step towards the development of transdisciplinary team care in the community. This streamlined care could potentially benefit residents in the community over receiving episodic care from many individual healthcare professionals. This require each community healthcare professional to shift from multi-disciplinary to trans-disciplinary team where there is continuous co-learning of knowledge and skills amongst the team members.

Moving forward we hope that Transcend would evolve to play a bigger role to support community health professionals in embracing a shared vision and transdisciplinary model of care, that could potentially shape Central Health’s priorities in active living and disease prevention.