Care Coordination Patient Case 1

Health Residential Rehabilitation admission following hip replacement, out of area discharge Discharged home from Rosedale totally self -caring, both re- habilitation fit and medically fit, refused all social care in put Referred by GP following 32 contacts to the practice in the month of September Social Circumstances All previous social care in-put declined, Attends luncheon clubs daily, Volunteers locally in charity shop Initial Assessment Initial Assessment by Care Co-ordinator Presentation, suggested that the Lady was not able to maintain ADL independently, she was using gutter frame to mobilise and appeared unsafe Care Co-ordination Support Workers start to support while further information was gathered Mrs Y was assessed as having on-going mental health issues; Depression fluctuating moods and previous suicide attempts which had not been addressed, non- compliance with prescribed medication, self-administers self- purchased 2 On-going Intervention Discussed at complex MDT panel Referred to Community Mental Health Team, Psychiatric assessment and allocated CPN Referral to Older Adult Mental Health Team (Social Care) Referral to Pharmacist for medication review (following discharge from latest surgical intervention) Patient outcome Patient has had her mental health needs met System outcome The patient mad no calls to her GP in October reducing impact on GP reception staff On going plan Lady assigned a Community Psychiatric Nurse within the CMHT and a social worker from the Older Adult Mental Health Team. Patient will be discussed at the weekly CHMT meeting until stable Monitoring of patient calls to the GP via weekly drop in at the surgery. Mrs Y

Health Mrs G was independent at home, lived out of area in Worcestershire Admitted to hospital following a fall and diagnosed with UTI Now experiencing loss of confidence in ability to carry out any activities of daily living Medically fit and discharged to our area to stay with family, equipment in place but no onward care and support sourced Social Care Not in receipt of any support services Our Service Urgent Referral from GP, Family had made several calls to practice trying to source help as all family members worked and unable to support Mrs G in the daytime, visit carried out by Care Co-ordinator who assessed that there was re-ablement potential. Mrs G was very keen to regain confidence and independence. Referral to re-ablement, however in the interim Care Co-ordination Support Workers supported twice a day until re-ablement could commence service Patient outcome Reduce risk of admission to hospital as family unable to maintain support in the day Regain independence reducing the need for social care in put System outcome Reduced calls to GP services Reduced the need for Social Care Input On going plan Contact details of Care Co-ordination service provided should family need advice and information in 3 Mrs G

Health Mrs X has become very frail, taking the decisions not to eat and drink, she had reduced mobility and significant impact on informal carer as lady very demanding on him. Mr X (informal carer) now neglecting own health and experiencing decline in physical well being Increase in visits by Long Term Conditions Nurses Frequent GP home visit requests Social Care Mrs X In receipt of 2 visits daily visits from carers, however, resistive towards agencies and abusive behaviours to carers has meant that agencies withdrawing quickly with no notice. No input for Mr X Urgent review requested by Social Worker Our Service Urgent assessment with care Co-ordinator, joint visit with District Nurses, discussion with husband about short term support, he agreed to re -ablement for him to support with showering and ensure medication taken appropriately which he accepted. Interim care and support provided by Care Co-ordination Service Support Workers until re-ablement had capacity to intervene Patient Outcomes Mrs X was reviewed, support increased to enable her needs to be met. Relieved pressure on husband. Mr X supported to regain his own physical wellbeing. System Outcome Reduced calls required by District Nurses, reduced the risk of admission to hospital for both Mr and Mrs X Ongoing plan Further review of Mr X following period of re-ablement with Social Care and Care Co-ordination services. Referral to Age UK Co- ordinator to ensure that Mr and Mrs X are aware of community services that may also support 4 Mrs X

@CPRCCG 5