Archive

Case notes   

Practitioner:   Paddy Goslyn, project manager, Caroline Barr, occupational therapist, and Margaret Snell, nurse co-ordinator, Reading primary care trust.  

Field: Older people's services. 

Location: Reading, Berkshire. 

Client: Olive Bestwick is 81 and lives alone following the death of her husband, Bernard, two years ago.  

Case history: Olive found her husband's dead body upstairs in their bedroom, and has not gone back upstairs since, choosing to sleep on her sofa downstairs. Her house was then burgled, which has made her terrified of leaving the house and anxious about everything around her. Olive also has a history of falling, which has resulted in many hospital admissions over the years. With no central heating, most of Olive's falls have occurred when she has bent down to switch her gas fire on or off. She has no family, friends or support network and is isolated and vulnerable. After another fall - combined with suffering from constipation and being generally unwell - she was re-admitted to hospital. 

Dilemma: Olive wanted to go home but none of the professionals involved felt this was an option, after assessments. 

Risk factor: Olive's cognitive impairment and mild dementia plus her anxiety made a return home too risky. 

Outcome: After a prolonged assessment, Olive was placed, with her agreement, in residential care. She is now calm, relaxed and enjoying the company of others.

It is generally recognised that acute hospitals are far from ideal environments to make decisions about long-term care. There needs to be a more relaxed place and more time to think through the options.

However, once out of hospital the general choice - if home or a care home are inappropriate - is intermediate care. But this usually has a six-week limit. And even when the timescales can be more flexible there are strict guidelines about eligibility - for example, people need to be medically stable and have obvious potential for rehabilitation.

But what about those people with a degree of cognitive impairment, or even mild dementia? Rehabilitation, it seems, is clearly not for them.

This apparent anomaly concerned staff at Reading primary care trust and Reading social services in Berkshire. Their innovative solution was to add an extra dimension to their assessment and intermediate care rehabilitation unit, which is based at a former residential care home in the city. Four of its 31 places are now used by the new assessment and intervention service (AIS).

"There were people whose hospital discharge pathways were unclear and might need more time," says project manager Paddy Goslyn. "So we set up a service to run alongside rehabilitative care - same ethos, same ways of working but with two differences: we will accept mild to moderate cognitive impairment and we're not going to time-frame it. It [rehabilitation] would take as long as it needed."

Olive Bestwick certainly fell into this category; indeed, a series of falls was indicative of her cognitive impairment. However, after another stay in hospital, staff were keen to move her on - and in stepped AIS.

"After the hospital social worker's assessment there was a lot of confusion about her pathway out," says Goslyn. "The occupational therapist and physiotherapist did a home visit and believed a return home to be out of the question. The hospital registrar felt that Olive needed extra-care sheltered housing. The psycho-geriatrician concluded that, given her cognitive impairment and mild vascular [blood vessel] dementia, she needed EMI [elderly mentally ill] residential care. The social worker felt that Olive would be OK in extra-care sheltered housing."

And among all this assessment activity sat an anxious Olive who was insisting that she wanted to go home.

"We talked to her about our new service and she wanted nothing to do with it at first," says Goslyn. "But she agreed to a day visit to see what it was like. And following that, she decided to come."

Occupational therapist Caroline Barr says: "When she came in she was quite mobile and independent. She could get on and off the bed and use the shower and toilet. But she had short-term memory problems so she needed constant prompting. We moved her to one of the rehabilitation flats for a couple of weeks just to see how she would get on. However, we decided she wasn't safe in that environment and moved her back to AIS."

Moving Olive into a group environment proved crucial. Barr says: "It was the contact with other people and the socialisation that changed her. Her nutrition improved. She started to say that she didn't want to be alone anymore."

The team worked closely with Olive's social worker and decided a residential placement would be best - but not EMI. "If she had been placed in an EMI unit she wouldn't have had the socialisation," says nurse co-ordinator Margaret Snell.

The A&I service was created to close inflexible service gaps. Intermediate care services manager Sandra Pickwick says: "Practitioners have come up against situations where there wasn't anything to meet certain needs. We know that an acute hospital is not the best place to make a long-term care decision, so we needed somewhere we could have a multi-disciplinary input to help individuals make their own decision where that was possible."

Snell agrees: "If you're in an acute hospital you're often in your night clothes and that de-skills you, and you've just got your bed space. Whereas here they are in a home-like situation and they can build on what they have already. This gives them time to have proper assessments and find their potential."

Arguments for risk 

• There is much talk about person-centred and holistic services. But how much action? Olive wanted to go home. Although she had bouts of forgetfulness and short-term memory problems, her desire to go home remained a constant. Her home was all she knew and, despite the bad memories and awkward layout, it was what she wanted. 
• She had a history of falls and had lived with it. Her refusal to go upstairs, while understandable, was affecting her quality of life. Perhaps the workers could have pursued the possibility of re-housing - which would maintain her sense of independence. 
• Olive was capable, although she needed prompting. The psycho-geriatrician in his assessment concluded that her cognitive impairment and dementia required no treatment or follow-up - only that the community psychiatric nurse be involved. 
• A suitable home care package could have provided appropriate monitoring and support, while - along with possible day services - affording daily contact.    

Arguments against risk 

• l It was apparent that, given her abilities, Olive could not cope at home. Her two-week spell in the home-like rehabilitative flats at the unit proved that. 
• l Olive did want to go home. But she was anxious about being in hospital - and even an uncomfortable existence at home must have seemed preferable. However, what was needed was time to be sure. 
• l Staff also needed time for Olive to appreciate the choice that was available aside from home or hospital. Once she realised there was no rush to do anything, her anxiety dropped. As Goslyn says: "Her social worker said to me that the one thing that calmed her down well was when she asked 'How long am I going there for?'. And the worker said 'As long as it takes'. He said you could actually feel her relaxing because nobody said 'You are going for two weeks' or 'You are going for four weeks'. So that was quite a strength."

Independent comment 

Almost everybody agrees that acute hospitals are highly dysfunctional establishments, writes Jef Smith. Most patients are elderly, probably vulnerable and confused by the trauma of admission, the stress of treatment or both.  

Many are also disoriented, perhaps seriously confused. For hospitals to define their role as simply treating such people as quickly as possible and moving them on, and to plan their environments and regimes around that perception, is unrealistic. At present all other agencies in the therapeutic network have to adapt to how hospitals operate. We need to look at how hospitals cause problems by insisting on such a constricted interpretation of their function. 

That perhaps is for the future. Here and now the team around Olive did a splendid job of compensating for the system's weaknesses. They recognised that she was unlikely to thrive at home and that her initial wish to return home represented her need to evade what she saw as even worse options. 

They saw that contact with others would help to improve her quality of life. They offered her the chance to live independently, in a way which enabled that plan to fail, perhaps predictably but without undermining Olive's confidence. Most important of all, they acknowledged that she was unlikely to take major life decisions speedily and made time for reflection a main consideration. Such assessment and intervention units should be universally available. 

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