Community hub case studies

15th February 2018

The following case studies illustrate the positive impact that the community hubs are having on people’s lives. Patients’ names have been anonymised to protect their confidentiality.


Team Bollington, Disley and Poynton (BDP)

Whole-system approach to older people’s services: Study 1

Mr T has advanced dementia and is having treatment to manage his symptoms. He lives in Poynton with his wife, who is struggling to meet his needs.

Mr T attended A&E and was seen by the BDP community matron, who works part-time in the frailty service. The plan was for Mr T to be supported at home but no intermediate care, rapid response or reablement was available. The default position would be to admit Mr T to hospital.

Due to improved working relationships from co-location of services in Poynton, the community matron contacted a social worker in BDP and arranged an urgent joint visit the next day.

The social worker and community matron visited Mr T at home, completed a holistic assessment and arranged for a care package. A patient passport was completed with Mr and Mrs T, and North West Ambulance Service was notified to avoid any transfers to hospital for the same issues over the weekend.

The care package started the following week.

Outcome: Co-location enabled services to share contact details, enabling Mr T to be supported at home and avoid a hospital admission.

Whole-system approach to older people’s services: Study 2

Mrs H, aged 99, lives alone and is fiercely independent. Mrs H’s health is deteriorating, with memory loss and reduced vision and mobility.

From sleeping in her chair, Mrs H developed oedematous (swollen tissue) and infected legs which were dressed by the district nurses a few times a week.

Mrs H started to neglect her personal care, develop continence problems and began leaving her oven on, creating a fire risk in her kitchen.

Her case was discussed at a multi-disciplinary team meeting at which it was agreed for the social worker to visit for a review.

The social worker arranged for financial support from the Department for Work and Pensions, referral to the continence service, a fire home safety check, installation of assistive technology, and carers’ support for Mrs H’s nephews.

Mrs H was reluctant to have people in her home and to accept help. However, a joint approach by the social worker, district nurse and community matron persuaded Mrs H to accept support.

The reablement service assessed Mrs H’s level of independence and encouraged her to self-care.

Outcome: Regular visits, improved diet, medication management, a safer home environment and elevation of her legs all contributed to Mrs H continuing to live safely at home.

Team Knutsford

Care home support

Mrs J, aged 89, became a permanent care home resident. She has severe heart failure, serious breathing problems and short-term memory loss. She was admitted to hospital twice during her first month in the home because of breathlessness.

Her GP referred her to the community matron for ongoing management. Her future care needs and advanced care plan were discussed with Mrs J and her family.

Mrs J said she did not want medics to attempt resuscitation if she became critically ill and didn’t want recurrent hospital admissions, preferring to be cared for at home whenever possible.

The matron educated the carers to enable them to feel more confident in supporting Mrs J during episodes of shortness of breath and to prevent them from feeling panicked into phoning for an ambulance.

The care plan was changed to ensure that carers contacted the community matron if concerned.

Outcome: The whole team worked well together to support Mrs J, who had no further hospital admissions and died peacefully in her room at the care home.

Integrated care

Sixty eight-year-old Mr P lives with his wife in a rented property in a remote rural location. He has a history of alcohol abuse and has started falling.

He fell down the stairs and was admitted to hospital with a fractured skull, spinal fractures and a bleed on the brain. He was transferred to Stockport for rehabilitation and made subject to deprivation of liberty arrangements as he lacked capacity to make decisions on his care.

Following alcohol restrictions and necessary care and support, the deprivation of liberty was lifted and Mr P discharged himself.

Mr P was incontinent, refused to wash or change his clothes, was out drinking and had a poor diet. Mrs P continued to care for him as she had for many years.

The GP asked for Mr P to be discussed at the Knutsford multi-disciplinary team (MDT) meeting. A number of actions were agreed including a referral to the continence service, and a carer’s assessment and support were arranged for Mrs P, together with lifestyle help.

Further discussion at the MDT led to a joint visit by a GP and social worker, a holistic assessment carried out by a social worker and community matron, and a mental health referral.

Outcome: The MDT approach and regular discussions ensured all relevant services worked together to find solutions and continue to monitor Mr P’s complex situation.

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