Stuart cares for his wife Louise who has ME and diabetes and has been bed bound for 10 years. Stuart has leg ulcers which need changing weekly and it was when he started not turning up for his appointments that the District Nurse became concerned. At a recent appointment it was clear that he was not coping. The nurse was concerned about his general wellbeing, weight loss and burn marks on his knees. Stuart declined help from Social Services but did agree to talk to the CCT social worker.
After a joint home visit it was clear that Stuart was not coping and that the difficulties were not just about the care of his wife but were also his own as his wife explained how his behaviour and personality had changed. When Stuart answered the door on his hands and knees it became clear how he had got the burn marks and quite how poor his mobility was. The nurse found large quantities of medication scattered all over the house which had not been taken. His wife also disclosed that he had brandished a knife at her, pulled her hair and smashed the place up.
The care of Stuart and Louise was discussed at the CCT Core Group and an action plan put together. Stuart is now under the care of a psychologist, and the CCT social worker is monitoring the home situation closely. Extra help is going in to the home now to assist them, and as such, he is now managing to get some rest and his wife is being well cared for. Medication is delivered in a ‘nomad tray’ for both him and his wife to avoid confusion and for safety reasons. Stuart is now very calm, as he no longer feels alone and he has help coming in the form of domiciliary care and community nurses attending daily. Stuart will continue to be discussed at Core Group until the time comes to discharge him safely.
Before CCTs this case would have meant referrals to different teams which would have been difficult to co-ordinate and time consuming, and often wasted a lot of GP’s time. Now the approach is that all professionals are in the same team and that their care is aligned around the needs of the local population. The team feel that they are all batting for the same side, which is more efficient and results in better, faster access to health and social care services. Staff, too, find working in this way less frustrating and more rewarding.
Without the multidisciplinary approach to care, Stuart and Louise have not slipped through the net, and neither of them has ended up in hospital - one of the key functions of the CCT approach.
