Download - A Patient Journey
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A Patient Journey
Marianne Plater
Community Geriatrician
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●Referred by physio due to Fall ●Domiciliary Assessment:
●History ●Examination●Belief Structure●Family● Investigations●OPC follow up
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●Confirmed diagnosis: Cerebella Stroke
●Secondary Prevention considered
●Osteoporosis risk factors addressed
●Rehab = plateau
●Refused SS help
●Support from daughter
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●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
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●Admitted SGH 1 year later ●Pneumonia
●Confusion
●Prolonged Hospital Stay●Marked deterioration in function
●Marked deterioration in cognition
●Discharged home
• QDS POC
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● 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
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●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
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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
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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
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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