The importance of MDT working – a case study. Alison Watson and Zoe Stocker Adult Social Care

A journey through Adult Social Care - Pat  7/2/2014 : Referral to the Disability Services Team (DST)  26/2/14: Allocated to OT  4/3/14: Initial visit and functional assessment carried out

Pen picture - Pat  Social situation  Presenting symptoms and barriers to independence

Functional assessment 4/3/14 Issues identified:  Standing to prepare food in the kitchen  Transfers in/out of bed, toilet and bath

OT recommendations:  Perching stool  Dycem  Toilet frames  Bed stick  Powered bath lift

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Result! 3 properties and several months later.. following OT viewings… Most of the criteria were met:  Bungalow  2 bedrooms  Outside access adaptable (but not brilliant)  Internal circulating space for wheelchair  Adaptable bathroom

House move Delayed due to unforeseen circumstances. Offer for bungalow accepted on 20/10/14. Disabled Facilities Grant recommendation submitted on that day. Finally moved on 12/12/14

Visit 16/12/14  Findings…..  Pat agreed to a referral to the social work team

Meeting Pat.  19/12/14. Allocated case.  Introductory visit. Explain services available. Leave self assessment paperwork.  Information on financial assessment.

Care Act 2014  Managing and maintaining nutrition.  Maintaining personal hygiene.  Managing toilet needs.  Being appropriately clothed.  Being able to make use of their home safely.  Maintaining a habitable home environment.  Developing and maintaining family or personal relationships.

Care Act 2014  Accessing and engaging in work, training, education or volunteering  Making use of necessary facilities or services in the local community including public transport and recreational facilities or services.  Carrying out responsibilities the adult has for a child.

Meeting Helen and Malcolm  Return with Support plan.  Approval of support plan.  Request services.  Finding a provider.

Introduction of carers.  09/01/15. Introduced Allied Home Care carers to Pat.  District Nurses.  ‘PEG-gate’  ‘Bed-gate’.

Review of Care needs.  A constant process which is informed by MDT.  Joint visits to avoid Pat having to repeat herself.  Copying in other professionals to .  23/06/15.Increase in care provision.  07/10/15. CHC funding. Transfer to Joint care management.

 Pat and family  MND specialist nurse  O.T.  Physiotherapist  MND wheelchair therapist.  District nurses  Speech and language therapist  Respiratory team  Social worker People who are part of the journey…

 G.P.  Dietician and Fresenius nurse  Tissue viability nurse  Palliative care team, Wheatfields Hospice  MND consultant  MND association  Home care providers.  Continence services  CHC assessor. Plus..

The final word..  Over to Pat…….

Pat’s farewell gesture to everyone!