Case studies

“My Care Connection Team is helping me to stay in my own home”

82 year old Mary lives alone, and has complex needs. She has chronic obstructive pulmonary disease (COPD) and had been struggling to manage her health. Due to poor eyesight, Mary kept accidentally burning herself on the cooker, and recently, had two admissions to hospital. She had started to feel unwell again, when her GP referred her to one of our Care Connection Teams (CCT).

Betty, a Guided Care Matron with one of our Care Connection Teams visited Mary in her home. Betty did various things to help Mary in the short and long term.

Mary was out of breath and had symptoms of an infection, so Betty immediately prescribed Mary antibiotics and steroids to help improve her condition. Her diabetes was unstable, so Betty adjusted her medication. Betty referred Mary to the Single Point of Access – Respiratory Outreach Team, who followed up with providing Mary with physiotherapy and further advice.

Betty also referred Mary to H4All, to help her with social isolation and looking into options for care packages. Mary’s doing a lot better now. Betty gave her a care plan so now she knows how to recognise when her condition is getting worse, and who to contact when she needs help.

Betty visits Mary regularly at home to check in on her and make sure everything is alright. This helps to keep Mary out of hospital and in better health.

“We work very close with the GPs and lots of other services from Talking Therapies, to physiotherapy, speech and language, you name it. We help prevent hospital admissions in patients over 65 years old. We educate and teach patients self-management techniques to help them manage their conditions and keep their independence. We do a lot of liaison, connecting our patients to any specialist care or support they need and helping to coordinate their care. Their families contact us a lot when they don’t know what to do with their medication. It’s a complex job but very rewarding,” says Betty.