Sharing of information avoids Gladys being admitted into hospital
Avoiding hospital admissions is one of the key objectives of Complex Care Teams and this case clearly demonstrates that the multi disciplinary care the patient received has indeed avoided the patient having to be admitted to hospital.
Gladys has Parkinson’s, lives on her own and has a history of falls but despite this she has tried her best to remain independent. Unfortunately Gladys suffered a stroke. Initially the GP wanted to admit her to hospital but Gladys did not want that and understanding her wishes the GP called the Rapid Response Team.
The Rapid Response Team took the details from the GP and started an Electronic Single Assessment Process (ESAP) episode. They visited Gladys and both a contact and Health Needs Assessment was carried out and entered on the ESAP system. A plan of care was formulated on ESAP and shared with social care teams who use the same system. Intermediate care and support workers were organised to support Gladys in her own home. The Rapid Response Team also shared information via ESAP with the out of hours nursing service who visited later that evening. Over the next two days Gladys was supported in her home by a number of health and social care professionals.
On the third day the Rapid Response Team visited Gladys and reassessed the situation, using ESAP to record any changes. These changes are immediately visible to those professionals involved in the Gladys care – everybody has the same information.
The review concluded that Gladys had ongoing health and social care needs and so she was referred onto the Complex Care Team using ESAP. Gladys’ case was presented and discussed at the Core Group meeting and it was decided who was the most appropriate person to take the lead. The CCT Community Matron and CCT Community Care Worker arrange to make a further assessment so they can decide on Gladys ongoing care needs. The Community Care Worker sets up a care package to support Gladys at home with everyday activities. The Community Matron continues to visit regularly to monitor Gladys health needs and acts as a pivotal link between all the health and social care professionals involved including the GP.
Gladys is still at home and the potential hospital admission was avoided which she herself was anxious to avoid. From the health and social care perspective the ability to communicate and share information easily saved both time and effort – not having to duplicate forms and ensured that at all times staff involved in Gladys care had the same up to date information. From Gladys point of view she did not to keep repeating the same information to different people.
The multidisciplinary approach to care has meant that Gladys has not ended up in hospital and has been able to live at home - one of the key functions of the CCT approach.
