A Patient Journey

Marianne Plater

Community Geriatrician

●Referred by physio due to Fall ●Domiciliary Assessment:

●History ●Examination●Belief Structure●Family● Investigations●OPC follow up

●Confirmed diagnosis: Cerebella Stroke

●Secondary Prevention considered

●Osteoporosis risk factors addressed

●Rehab = plateau

●Refused SS help

●Support from daughter

●GP discussed at a surgery meeting

● (2 years later)● Concerns re increasing falls and frailty● Patient refusing SS ref

●Outcome: ref to Community matron● Gained trust with patient and family● Introduced POC personal hygiene ● Nutritional needs addressed

●Admitted SGH 1 year later ●Pneumonia

●Confusion

●Prolonged Hospital Stay●Marked deterioration in function

●Marked deterioration in cognition

●Discharged home

• QDS POC

● Ref by social worker● Due to on going deterioration

● Carers struggling to manage needs

● Moving and handling issues

● Ongoing falls

● Medication review

● Outcome● Multi-infarct Dementia

● Unavoidable falls due to

• Cerebro Vascular disease• Longstanding immobility• Risk taking behaviour

● DW Health and Social care team re prognosis / anticipatory CP

●Issues:●Capacity assessment re care needs

●Best Interest Meeting

●EOL management plan

●D/V assessment●Bed bound

●Bilateral pneumonia

●Both daughters present

●Mx plan die at home

End of Life

●MDT discussion ● GP on holiday patient not known to locum● Com Matron● OT● SW● Wider team

●Pressure relieving equipment●POC / CHC funding●Moving and Handling●Night needs●OOH / ambulance form

What went well●Fast and flexible

approach from a previously ‘routine’ service

● Integrated working with SS

●Families thank you letter = ‘seamless service’

What went wrong

●GP slow to offer syringe driver for symptom control

●Ambulance staff wanted to admit patient

Conclusion

●Cultural change in referral process●Working with people who are disengaged

with health or social care• Attitudes / beliefs• Dementia

●Monitoring / early warning of deterioration●Prognosis / identify dying phase●Involving the right people in decision making