Working together

Case Study Two: Working Together Proactive Care
A case study showing how integrated care is working across Eastern Cheshire.
Presented at the Caring Together Stakeholder event 20 July 2015 at Poynton Civic Centre
www.caringtogether.info

1. Louise Rycroft Care-Coordinator

2. Priorslegh Medical Centre McIlvride Medical Practice The Schoolhouse Surgery, Disley Bollington Medical Centre 33,000 patients Our elderly population is 50% higher than the National average

3. “Vulnerable patients who may need extra support ” Patient Criteria

4. To support and coordinate care for patients with complex medical conditions who are discharged from hospital. Making contact with outside agencies on behalf of the patient should it be required. T o improving the quality and efficiency of the current discharge processes. To make better uses of resources in Primary Care and the community . To develop better partnerships working across the peer group and across agencies . To alleviate any worries or concerns a vulnerable patient may have once home aiding their recovery. Our Aims

5. Discharges from GP surgery Clinicians who have visited patients and feel extra support is needed for the patient or their family/carer Friends and family of patients expressing concern The care coordinator will then make contact with the patient within 3 days. Referral Process

6. Care Coordination Input GP Visit Referral to Community Matron District Nurse Visit Ambulance Booking Find out appointment details Referral to Macmillan Nurses Organise Respite Help organising carers Providing telephone numbers Referral to Social Services Help with medication Carer’s Support Signposting to voluntary services

7. The wider team… Intermediate Care Patient Journey T eam GP Surgeries Macmillan Nurses District Nurses Community Physio/OT Community Matrons Care Agencies Voluntary Organisations Social Services – Stockport, Macclesfield, Wilmslow, Derbyshire and Hospital Team

8. Case Studies

9. Mr S is a carer for his wife who has Alzheimer's Disease. He is managing her care by himself and is happy to continue to do this. He was concerned about what to do/who to contact in an emergency. We have provided him with a list of local agencies who he can contact should he need to. We make contact once a week .

10. Mr H lives alone and has memory problems. He has no family locally – his Power of Attorney is his niece who lives in Wales. He has been referred to the Memory Clinic for a formal diagnosis. We liaised between the Memory Clinic and his niece to organise this appointment. We have also arranged transport for him to attend an x-ray appointment. We called him regularly throughout the morning to remind him who his driver will be, when he will be picked up and the reason for the appointment.

11. Video Co-ordinated Care case Study – Mr Young https://www.youtube.com/watch?v=6gF9_SKGm4M

12. Feedback I’m so lucky to have this in my area That’s a brilliant idea and could be really helpful. Thank you! This is so reassuring I think you are both stars ! You are a god send and I am more than impressed with the service This is so helpful it will be great for me and my husband You’ve been ever so helpful, thank you It’s very nice that someone is thinking of me Everything has been sorted thank you so much for your help. What a fantastic service