We have put in place extra resources and staff to deliver integrated care for people with complex and long term health conditions who need extra support to keep well and out of hospital. Patients who are identified by their GP to receive this joined up care will have a visit from a community matron who will assess them and then put in place all the care they need. This can include health care, social care and support from local voluntary organisations.
We are also sharing information across the services that care for patients. This is important because it will allow everyone who is caring for each patient to have the right information quickly to make the right decision. Patients can opt out of having their information shared if they want to.
Patients will also be helped to take better care of their health and understand their conditions better.
You can read below some recent examples of patients who have benefitted from our new model of integrated care.
“SG” is a 59 year old male known to the community mental health team. He has had a series of emergency calls to NHS 111 and visits to the Princess Royal University Hospital Emergency Department. A visit to the patient showed that home hygiene is compromised, he is struggling to survive on benefits and his home was cold through lack of heating.
Advice was given on benefits and the need to maintain provisions such as buying non-perishable items. A food bank was contacted to provide assistance, credit was put on his energy meter and his Oyster care so that he could travel to planned medical appointments.
In the six weeks before the MDT got involved, SG had called 111 on 16 occasions and visited A&E 4 times. Six weeks after the intervention, there have been no emergency contacts.
“CS” is a 74 year old female currently receiving reablement after coming out of hospital. She lives alone in an upper floor flat. Her carer is a friend but she doesn’t live nearby.
She has a complex history of severe Chronic Obstructive Pulmonary Disease (known to Community Respiratory team), Ischemic Heart Disease and confusion. Oxygen was prescribed but later removed on safety grounds. In the last two years she has had an acute myocardial infarction and breast cancer. She will not accept support with personal care, is non-compliant with medication and refuses to attend a memory clinic.
The MDT arranged a memory assessment, establishment of power of attorney with next of kin, a social care package following reablement, review from Medicine Optimisation Service, and oxygen re-established following disconnection of unused gas cooker. Bromley Care Coordination is now providing support.
Medicine compliance is now greatly improved resulting in a reduction in calls to primary care. Measures are now in place to prevent hospital admission.
“PB” is a 91 year old female presenting with multiple issues including angina (ischaemic heart disease), increasing episodes of falling , cognitive impairment with reduced hearing and vision (registered severely sight impaired) and deteriorating memory.
She lives alone with carer support. Due to decreased mobility she sleeps downstairs. A zimmer frame has been provided but standing capacity is poor. Mobility is further compromised through knee pain due to osteoarthritis and callous on her heel from a longstanding pressure ulcer. Additional equipment includes a riser recliner chair with pressure relief and a commode. A carer attends 5 times/week and the family complete shopping tasks.
PB adheres to her medication regimen but does not understand why she is taking all her medication. PB requires assistance with chair / bed transfers and with personal care tasks washing and dressing and toileting. PB has a persistent dry cough.
Following the MDT, the District Nurse has reviewed pressure sores and completed ear syringing, she has been referred to the Falls Team and Memory Clinic, Community Physio is reviewing mobility and further aids with the Community Matron. Drugs reviewed by the Gerontologist and a rapid access medical review organised with Cardiology. The patient is now under the care of St Christopher’s and Age UK are providing support.
Feedback received from the patient’s daughter (and carer):
“I can't thank you enough for everything you have done for my family. It was such a relief for me personally to be able to hand over the management of mum's various problems to someone knowledgeable and competent, instead of travelling through unfamiliar territory on my own when much was at stake for us. With kind regards and gratitude.”