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Case notes

Practitioners: Dave Doyle, service manager, intermediate care and Sheila Healey, social worker.

Field: Community older persons team.

Location: Knowsley.

Client: Millie Morgan is 88 and has lived alone in a fourth floor flat for many years. Her son Lewis visits daily and occasionally takes her out shopping.

Case history: Millie, unknown to social services, was admitted to hospital in January 2002 for a routine gall bladder operation. Unfortunately, not only did her operation go badly wrong leaving her with a horrific wound, but she also contracted methicillin resistant staphylococcus aureus (MRSA)- an organism that can cause infections such as boils or pneumonia. She needed intensive nursing care. At this time her outlook also changed. Bedridden for four months, she became depressed and could not see an end to her situation. Millie's consultant felt there she would not be able to return home safely as social services could only manage four calls a day and Millie needed 24-hour care. She would also be too marooned in her flat. The consultant considered the only viable option to be a nursing home placement.

Dilemma: Millie's depression about not being able to be her former self led to further deterioration in her physical condition.

Risk factor: By providing a chance to regain her former independence Millie might fail and thus never recover the energy or belief that she could change.

Outcome: Millie is back home, independent and flourishing.

As we age, our physical deterioration often triggers a similar mental reaction. Not being able to do the things you could before or irritating forgetfulness can cause depression, which at its most severe may cause you to feel like giving up the will to live. This potential life-threatening situation befell 88-year-old Millie Morgan.

Millie was told her planned gall bladder operation was routine and she would be back home within two weeks. Unfortunately, things went wrong leaving Millie with a huge open wound. She was still in hospital more than three months later.

Her injury not only affected her mobility and proved physically painful but also made her depressed. "She was very frightened and anxious about this 'gaping hole' as she described it," says social worker with the community older persons team, Sheila Healey, who was allocated Millie's case. "She believed that she was going to die."

Millie had been assertive, independent and sharp-minded. But the physical battering that she had taken mentally knocked the stuffing out of her. The prospect of care frightened her. "She didn't know anybody who had been placed in a care home. When I first met her she used the word 'workhouse'. She feared that we would be putting her away and chucking away the key," says Healey.

A nurse on the ward, however, believed that Millie had potential for rehabilitation and got in touch with a local scheme whose occupational therapist assessed Millie as suitable.

"The only concern we had at that time was that the scheme was day rehab. We arranged Millie's short-term discharge to a nursing home until the physiotherapist felt she was strong enough to attend the rehab scheme as a day patient," says Healey.

"We got her out of hospital - and that gave her hope," she continues. "She took a long time to come to terms with the fact that she had to be helped. She needed reassurance that, yes, she was in a nursing home but it was only for a short time. Her confidence grew. It was almost miraculous."

Three weeks on from her discharge she was able - with help - to get on social services transport. "She'd come into the day centre smiling and shouting 'hello' to people. This was a lady I could barely hear talking when I went into the hospital to assess her," says Healey.

While at the day centre Millie discovered a flair for crafts. "She managed to produce many different vases, photo frames, gnomes and cuddly toys. It was something she never thought of doing living alone. But the biggest thing for me was noticing how sociable this lady was. People loved her: the carers, the other patients, even staff who weren't part of the rehab got to know her. She was a star. And she was even presented with a golden star when she left - because she gave people hope: she would regale other users with her tale - 'I had a terrible time and look what happened to me, but I'm here now to tell the tale,'" says Healey.

The rehab continued from the nursing home for over two months until it was felt she could be supported in her flat. Millie was going home. "Our rehab service usually lasts up to six weeks and we do try and stick to it, but in practice we will go beyond those limits if we think it's appropriate for the individual concerned. And Millie was a case in point. She needed longer - it was as much about confidence-building as the therapy," says Dave Doyle, service manager, intermediate care.

Millie had a lot of medication. "And that's where our pharmacist, Jill Edwards, who's part of our team, stepped in," says Healey. "She checked that the medication was right and arranged for a simple dosette box to be installed. Jill was very patient with Millie, taking the time to show her how to use it. She tried it first in rehab and Millie was quite proud of her little box - the other users all wanted one as well!"

"For me, there's another issue around quality of life," adds Doyle. "What we aim to do is not just rehabilitate people and help them to survive in the community, but to give them a quality of life in their own homes as well. One of things we tried to do was work with Millie to open up all those abilities and skills that even she might not have recognised that she had."

Arguments for risk 

• There were a number of concerns to be ironed out. Not least, would Millie want to return home? But a visit home to re-familiarise herself answered that question. Crucially, Millie herself was clear: she wanted to go home. 
• She had a lot of medication - she also had hyperthyroid and arthritis - and was on several courses of antibiotics. The intervention of the pharmacist was crucial in making this risk managed safely.  
• Her isolation was another concern. "We were mindful of the fact that she was four floors above the rest of the community. While she was able to manage the lift we felt that she was quite at risk during the day. But we overcame that by installing one of our helpline alarms. Again it boosted her confidence," says Healey. 
• Millie would continue to attend the main part of the day centre bringing her companionship and opportunities to develop her involvement in crafts.   

Arguments against risk 

• A return home for Millie after being away for so long could backfire. Discovering that she cannot do the things she used to could destroy her confidence. Any fall could damage her wound further. 
• There were a number of practical concerns. Millie would not accept a morning call for help with personal care - as soon as she was able to bend she insisted that she would do that - no matter what difficulty or pain. Being a proud woman, if it became impossible for her to cope she might not say anything and her personal hygiene would deteriorate - along with the loss of confidence this would generate.  
• Millie lived on the fourth floor. While she was able to manage the lift she was at risk during the day. 
• Millie was not self-medicating at the home as it was all given out by trained staff. So there were dangers in her returning home to take care of her own medication.    

Independent comment

Thank goodness that the power of doctors to discharge patients instantly has been reined in, writes Jef Smith. Great vigilance is still required, however, to ensure that pressure for the rapid turnover of acute hospital beds does not bring about the convenient disposal of older people with complex needs into nursing homes from whence there is no return. Thank goodness, too, for visionary nurses, determined social workers, patient therapists and - most of all - courageous old people.  

Millie had plenty to be depressed about. Treatment which should have been routine had badly misfired and she was in considerable pain. Powerful people threatened her status and independence. Depression changes people's ability to cope and communicate, but usually not permanently. Fortunately, several of the workers who knew Millie saw that her essential strength constituted potential for recovery.  

Reassuring, non-threatening counselling helped Millie accept the temporary residential placement. The rules about the length of time allowed for rehabilitation were bent. The perils of a fourth floor flat and complex medication were dealt with, not by a disruptive move but with simple, low-tech equipment. 

Thoroughly rehabilitated, Millie is an inspiration to everyone - fellow service users, carers, and professionals alike - and the work of the staff in this story provides a model of how intermediate care can change lives.  

Jef Smith is a writer, trainer and consultant in care for older people.