Mrs P, aged 93, had suffered a stroke, resulting in limited mobility and risk of falls. She was a high user of primary care services, mainly due to frequent urinary tract infections (UTIs). The community matron, taking on the case manager role, worked with the GP surgery to arrange for prescriptions for antibiotics to be held by the pharmacy without the need for a GP visit. This resulted in a reduction in the use of primary care services, as well as a better outcome for Mrs P due to the ability to start antibiotics as soon as a UTI was suspected.
Mr K has severe chronic obstructive pulmonary disease (COPD), and was new to case management after an admission for an exacerbation of COPD. He had previously been very independent but with the presence of community matron he had access to a trusted health professional. When his condition deteriorated this was detected by the community matron at an early stage. He was able to start his emergency treatment and was monitored daily through telephone calls or home visits until his symptoms improved. This prevented him being admitted to Torbay Hospital.
See more of our work on co-ordinated care
- Read the full case study on South Devon and Torbay
- Watch our video to find out more about South Devon and Torbay's approach to care co-ordination
- View our organogram showing South Devon and Torbay's care planning/co-ordination process
- Find out more about the project: Co-ordinated care for people with complex chronic conditions