News

Practice Panel Older people team - Leeds primary care trust and social services department.

Case Study :

The name of the service user  has been changed.

Situation: Enid Sullivan is 87 years old and lives alone in an upstairs maisonette she has lived in for 46 years. She bought the home together with her husband Jeff - the only family she had - who died in 1996. She has a volunteer to help with shopping and trips out but refuses help from social services: partly because she thinks they want to put her in a home. A worker carried out an initial assessment and told her that stairs were "inappropriate".

Problem: Despite the stairs Enid is determined to soldier on and stay in the only home her and Jeff - whom she profoundly misses - knew together. Indeed the house is as it was when Jeff died. Enid has no central heating and relies on a small gas fire - but forgets to put it on - and wraps herself in the blanket that was on their bed when Jeff died from a heart attack during his sleep. Since then she has often been in hospital with pneumonia, chest infections and having both her hips and knees replaced or operated on. Recently, worn out from the climb to her door she suddenly felt dizzy and collapsed. After a few hours she managed to get to her phone and call 999. She was taken to A&E, where she is now well known. The hospital discharge team does not think a referral home without support is feasible, but Enid will hear of nothing else.

Panel Responses

Joanna Gare

Once Enid had dialled 999 for an ambulance, the crew would attend and assess Enid's condition. If Enid lived in Leeds and an acute hospital admission was not necessary, with her consent the ambulance crew would refer to the community rapid response team.

A senior nurse from the team would respond within a maximum of two hours to Enid's home. The nurse would make a thorough assessment and take a medical, social and physical history. Enid can take control of her predicament and work closely with the rapid response nurse to agree any further action; Enid's reluctance to receive help in the past may stem from a fear of losing control and choice over her care.

The rapid response nurse would liaise closely with Enid's own GP and review possible causes of her collapse. In this case it might mean a review of her medication and her long standing chest condition.

A domiciliary assessment by the consultant for elderly medicine linked to the rapid response team may be required thus avoiding Enid having to go into hospital, and investigations into the reasons for poor memory loss could be started.

Rapid assessment by the occupational therapist and physiotherapist would help Enid to identify any help required to improve her mobility problems and management of daily activities.

The team could offer 24-hour support tailored to Enid's needs as appropriate for up to 72 hours. Building up a rapport and trust will help to reassure Enid that there are services in her own community to support her and help her to remain independent, without the need of an acute hospital admission.

The team will work very closely with social services, and with Enid's consent the environmental problems can be addressed: that is, heating, fitting the stair rail and any other aids and adaptations tailored to her needs.

Once Enid's condition is stable a referral to the community matron will ensure that proactive and preventive assistance is in place to enable Enid to be more involved in her care management.

Kathryn Evans

Enid would probably be brought to the attention of the advanced specialist practitioner (ASP) - the equivalent to a community matron.  Their role is to work with patients like Enid who are what the government now describe as "very high intensity users" by virtue of her hospital attendance.

The ASP, who is attached to the GP practice, would then review Enid's medical records held at the surgery and discuss Enid with the family doctor before arranging to see Enid.  She would be thoroughly assessed when she is "well" and not in a crisis.

The role of the ASP would be to work with Enid to develop a plan of care which should be based on Enid's own goals.  This may be, as the case study shows, "to stay in her own home".  The ASP would then work proactively with Enid towards achieving this goal.

The ASP would explore the possibility of either central heating being fitted to reduce risk of hypothermia or fire - or possibly alternative accommodation if this means Enid staying in the community.  Further risks would be negotiated with Enid: for example, she may be offered a care alarm to call for help if she falls again.

The ASP would assess Enid's blood pressure and review her medication and her compliance with taking them, making sure she knew and understood the reasons for taking them, and how.

It may be that a neighbourhood network or other voluntary group may run exercise classes which Enid could attend to strengthen her muscles, improve balance, reduce risk of falls, improve her ability to walk up her stairs, as well as reducing social isolation.

It would als be very important to explore with Enid how she felt about the death of her husband - and in doing so it might be necessary to draw upon the resources of a counsellor.

One of the important aspects of the ASP's involvement would be about educating Enid about her illnesses such as chest infections and pneumonia, explaining early warning signs and what to do and who to call when they occur.  The ASP would also act as a key person in integrating all aspects of care for Enid drawing on voluntary, health and social care services as necessary.

User View:

In an ideal world Enid would benefit from a place at a sheltered accommodation complex, with access to 24-hour warden support or Lifeline alarm facilities but this is a much more complex and heart-rending situation, which requires skilful handling, write members of Knowsley Older People's Voice and other service users.

In light of the stalemate in which Enid could not return home without support but is refusing help, it may be possible to offer her an intermediate care bed for rehabilitation. This would allow time for a care plan to be devised with Enid before her discharge.

A "worker" has advised that the stairs are too much for Enid but we would question this  assessment. An occupational therapist should find out if Enid can cope adequately at home. This could take place while Enid is still in hospital or an intermediate care facility. She could then have the necessary adaptations provided to help Enid remain independently in her own home.

During this time a grant could be applied for, with help from the local council's energy efficiency officer, to secure improvements to her home including central heating and a gas safety check to ensure that the accommodation is warm and safe.

Because of Enid's perception of social services we would see a volunteer as being the key to gaining trust and helping to explain to Enid that she has choices available. They could suggest that Enid puts her name forward for sheltered accommodation, as there could be a long waiting list.

It could be explained that there is no  commitment to accept the accommodation, even  if it is offered to her. In the meantime, she could  visit various types of accommodation to  see what is available in the area. 

Bearing in mind that she is reluctant to accept input from social services, Enid may accept involvement from other agencies such as Age Concern, Red Cross, Pensioners Advocacy Services and local church and community groups.

Enid does not seem to have recovered from the loss of her husband and may be suffering from depression. She might benefit from access to a bereavement counsellor to help her begin to regain her confidence and independence.

By members of Knowsley Older People's Voice - an older people's forum based in Knowsley, Merseyside - with help from service users at St Mary's Day Centre in Halewood and the Ageing Well group from Kirkby.