Case Study One
Client Aim-'To stay out of Care Home'
Medication Management
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Speak to GP re medication.
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Visit pharmacy to talk about medication regime.
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Inform all parties regarding the new medication regime.
Safeguarding
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Chase Wellbeing service referral for stair rail (client was on knees going upstairs).
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Speak to the manager of Wellbeing and diffuse possible safeguarding issues.
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Refuse a discharge as unsafe.
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Visit and advocate for hospital in stay periods..
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On-going assessment of fluctuating capacity.
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Consistent involvement of client where able to make decisions.
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Try to find emergency care at 7.30pm.
Care Coordination
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Minimum weekly face-to-face visits by the Care Coordinator.
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Consistent liaison with main care providers.
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Consistent liaison with all family members.
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Work alongside District Nurses.
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Work alongside CPN.
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Work alongside Physiotherapists.
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Coordinate all providers for home discharge.
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Voice conference with all providers booked.
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Review held at any house with all providers.
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Meet with family.
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Support providers on being paid.
Home Safety and Maintenance
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Remove clutter on stairway.
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Fix faulty fire alarm.
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Replace faulty lifeline alarm.
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Remove wires around living room floor area.
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Meet plumber for quote on leak. Meet again for access and work. Arrange plumber to be paid.
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Bought slippers instead of shoes as too small to wear.
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Reorganise missed NHS. appointments (diabetic eye screening/podiatry).
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Organise transport to new appointments.
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Check unopened or filed mail.
Administrative Tasks
Legal and Financial Support
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Link solicitor with family LPA.
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Benefit check.
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Apply for and gain council tax exemption (saving £1200 a year).
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Speak with debt collection agency and end the harassment. Debt waived.
Emotional and Social Support
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Offer support in rekindling broken relationship with son.
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Organise Communion at home.
3 months example...
12 face to face visits, 38 phone calls and 54 emails, delivered across daytime, evening and weekends.