Reducing calls and visits to hospital is one of the key objectives of Complex Care Teams (CCTs).
This case clearly demonstrates that the multi disciplinary care Jim received has achieved this objective. View from Community Matron,Sidmouth Complex Care Team (April 2009).
Jim (aged 89 years old) lives alone and receives care from various multidisciplinary agencies. He had a Cerebal Vascular Accident (CVA) 15 years ago which left him with left sided weakness. Several adaptations have been made to his home with various pieces of equipment including an electric wheelchair. The district nurse team have been involved as Jim has a urethral catheter which needs changing regularly. All personal care and general living needs are provided by a local care agency. Jim has also been diagnosed with Chronic Obstructive Pulminary Disease (COPD) and has had frequent problems resulting in emergency hospital admissions, followed by episodes in the community hospital.
Jim was referred to the CCT by his GP who discharged him from the community hospital. They were asked to monitor his condition and reduce his steroids. When a full health needs assessment was done several problems were highlighted. He had difficulties with his wheelchair and needed a profiling bed. His carers were having moving and handling difficulties when he was hoisted. Jim was calling out of hours with blocked catheters which the evening nurses were changing and often this information didn’t get back to the district nurse team so it was difficult to monitor. He said he often felt that he was going to develop a chest infection as he became short of breath and started to cough, but he didn’t like to bother the doctor as it might just get better on its own and the doctors are very busy!.
I was able to discuss this information with team members at the core group and work together to resolve the highlighted problems. In the past this would have meant several phone calls and a lot of frustration. Jim felt confident that we were all talking to each other and could coordinate all his care needs.
The OT addressed equipment issues with the care agency and gave advice around moving and handling. The community matron devised a management plan to address his COPD exacerbations, we know that if we can identify this early and prescribe steroids and antibiotics we can avoid a hospital admission. As an independent prescriber I was able to do this having discussed it earlier with the GP.
I also involved the care agency who would be instrumental in supporting Jim, as this is generally in the evening or at weekends. In the past they would have phoned for an out of hours Dr or called an ambulance. The usual outcome would be hospital as his condition had deteriorated to the point that he couldn’t remain at home. Regular visits to monitor his COPD also allow the monitoring of his catheter which has been problematic, with regular ongoing health promotion it will probably settle down.
Another worry for Jim was a letter he had received telling him that he could no longer afford the local agency he had been using due to a change in his direct payments. To remove his usual care agency would be extremely detrimental to his health and would put his ability to remain home at risk.
The OT contacted direct payments who informed her that he had been receiving a jointly funded package from DCC and CHC. His care package had been reviewed and the direct payment reduced, but due to some confusion around the process Jim had inadvertently over-spent his revised care allowance. A joint visit was arranged between the community matron and CCW. Together we were able to re-write Jim’s care plan taking into account all his ongoing needs, he was able to remain with his care agency without incurring further debt.
The CCT is based in the community hospital and there are strong links with the hospital discharge nurse who attends the weekly core group, the community matron has access to the GP vision system which allows daily contact and access to patient details. For the first time we have Social workers, CCWs, therapists, community nurses, GPs, CPNs, hospice nurses, community hospital staff and care agencies all working together for the best outcome for our cluster clients.
It is this multi disciplinary approach to Jim’s care that has led to the reduction in the number of calls and visits that he had made to A&E. Without this approach Jim would be still being admitted unnecessarily, avoiding this is one of the key functions of the CCT approach.
