Michael (aged 38 years) had unstable diabetes, lives with his Uncle but plans to move to Skegness. Previously in full time employment Michael is now not working and receives incapacity benefit. With a history of alcohol abuse, Michael has an unsuitable diet and no structure to his day. He has to take his insulin four times a day but is uncooperative. He was being regularly admitted to hospital (once every 7 to 10 days) and shows attention seeking behaviour.
There has been a real team approach with intervention from the District Nurses, Diabetic Nurse and Community Matron who has a close liaison with the GP. His medication has been reduced to twice a day and it was found that his unstable diabetes was due to him not taking his medication properly.
A long term condition management plan has been put into place and has been given to MIU at Honiton Hospital and Devon Docs and in addition a message alert has been sent to SWAST informing them that the management plan is in place. Michael has been referred to Enabling for focus and structure to his day and the voluntary sector are looking into voluntary work that he could become involved in.
Michael has not gone into A&E and has made no calls to the emergency ambulance for 12 weeks. He has agreed to and signed his management plan which lists who can be contacted and at what time. Whilst on holiday to Skegness he kept well and as a precaution a message alert was sent to Skegness with details of his management plan. Michael is on board with Pathway to Work via the Job Centre and hopes to find work soon.
It is the multi disciplinary approach to Michael’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 Michael would be being admitted unnecessarily, to be able to avoid this happening is one of the key functions of the CCT approach.
