Closer working relationship between professionals and the ability to communicate better are key objectives of Complex Care Teams and this case clearly demonstrates that with these objectives achieved the results are far more beneficial and empowering for the patient.
Maureen had a below knee amputation 30 years ago and has a prosthesis. She has a degree of senile dementia but the longer you speak to her, the more she engages and the clearer the content of her speech. Due to several recent falls and calls to the Out of Hours (OOH) GP service her details were passed onto the Avoidance Admissions Nurse.
Maureen lives alone and has no family, but she has a friend Jenny who is her power of attorney. Her front and back doors were left open day and night. Maureen had a care package with carers coming in twice a day but it was clear that they were coming in too late in the morning and that because of this she was trying to attach her prosthesis herself and due to her confusion would do so unsafely and fall. Maureen also had a urinary tract infection and was eating and drinking very little. Even when her prosthesis had been properly attached, her mobility was poor.
The CCT Community Care Worker was contacted and it was decided that a 24 hour live in care package was to be put in place. Before this the carers’ morning visit was changed so that they came earlier and Maureen was given antibiotics for the urinary tract infection. High calorie protein drinks were arranged and Maureen was weighed weekly. Maureen was persuaded to accept a key safe, so that her doors could be locked and yet the carers were able to get in. An alert was sent to the OOH GP Service and SWAST with the number of her key safe and information to enable them to try to keep her at home rather than admit her to hospital.
Unfortunately whilst the 24 live in care package was being put into place Maureen had a fall which left her very shaken up and bruised. The paramedic was aware of the alert and was able to ring Rapid Response who intervened immediately. Despite the intervention Maureen deteriorated. It was decided to seek respite in a local residential home until the 24 hour care package began. The CCT Community Care Worker arranged this and the CCT Voluntary Sector Representative organised for the patient’s dog to go to the Cinnamon Trust. Unfortunately, whilst in the home, the patient deteriorated and was unhappy. They frequently forgot to attach her prosthesis, thus compromising her mobility and for the first time Maureen became incontinent at night. As soon as the 24 hour care package began Maureen was discharged to her own home.
Due to Maureen’s level of dependency, she has both a day and night carer. Her situation has been monitored and overall she has progressed extremely well. She has gained weight and is regularly helped to mobilise and feels secure. Her incontinence has stopped, but it did reveal that she hardly slept at all overnight and became so confused that she was extremely aggressive towards the carer. Through liaison with the GP her antidepressant has been altered to a sedating version which has been extremely successful.
Maureen’s friend Jenny was involved throughout this process. Maureen is now living safely and happily at home and those involved in her care know how to access help whenever they need to. This is as a result of the various professionals involved having a close working relationship, with reliable channels of communication and a belief that the patient is more important than the bureaucracy.
View from Admission Avoidance Nurse
Axminster Complex Care Team
March 2009
