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Case study: ‘The team of health and social care professionals working together made Bert’s care run smoothly’

User AvatarPosted by Daniel Harper at 13/07/2018 15:35:18
Bert and Pat Simmonds

A new way health and social care professionals are working together helped Pat Simmonds, 72, to care for her husband Bert at home.

Bert, now 77, has a number of health conditions including diabetes, high blood pressure, nocturnal epilepsy and vascular dementia. His health meant Bert found it very difficult to visit his GP, Dr Becky Prince, at the Snodland Medical Practice and Pat would often have appointments on his behalf or Dr Prince would visit him at home. The couple regularly took three walks a day as Bert liked to get out of the house, however, on a couple of occasions he passed out while they were walking. Both Dr Prince and Pat became concerned that as Bert’s condition deteriorated, it would become more difficult for Pat to look after him.

In April 2017, Dr Prince referred Bert’s case to a newly-formed team of health and social care professionals established to support people with complex health needs. Led by Dr Prince, the team includes a dementia specialist; a community nurse; a complex care nurse, who specialises in treating conditions such as diabetes and heart failure, and social care workers. Together, the team find ways they can better care for patients like Bert at home and make life easier for them, their carers and family.

As Bert’s condition deteriorated, the couple became reliant on their son, who lived half a mile away, to come and help Bert get out of bed in the mornings. To help them manage, the team organised for specialist equipment, a hospital bed and hoist, to be delivered to the couple’s home and organised for carers to visit twice a day to help Pat care for Bert. The team’s dementia practitioner also arranged to visit the couple at home with a consultant psychogeriatrician, who specialises in mental health for older people, to review Bert’s medication.

Pat said:

“I’m so grateful for the support we got, it made Bert’s care run smoothly and I wouldn’t say anything could be improved.”

The team also gave Pat a special patients’ phone number to call in case Bert’s condition deteriorated or she was worried.

She said: “It’s really reassuring to know that your call will be answered straight away by someone who knows Bert’s situation.”

This new way of working together enabled the team to proactively plan Bert’s care and anticipate his needs. When it came to the point that Bert required full-time care, the dementia practitioner and consultant visited the couple at home and arranged a placement in a specialist unit for later that day. He is now living in a local care home, where Pat regularly visits him.

Pat said:

“I really feel I wouldn’t have managed as long as I did if it wasn’t for all the help I got from Dr Prince and the rest of the  team.”