These accounts show the positive difference that Pembrokeshire's community resource teams have made for patients and their families.
Mrs K’s story
Mrs K is 91 and was living alone in her own home. Her grandson asked social services for support as he noticed a change in her behaviour. Social services referred her to the local community resource team (CRT). Mrs K has advanced dementia with very poor short-term memory. She is doubly incontinent, and inadequately attempts to clean herself. Unsupervised, she gives her food and drink to the dog, resulting in weight loss. Before the involvement of the CRT team, Mrs K had no services in place.
Post-referral, the CRT organised visits from the community psychiatric nurse, a psychogeriatrician, a support worker and a social worker, who subsequently put together a care package that ensures Mrs K is safe at home. This required delicate discussions, as Mrs K becomes very distressed when she hears about long-term care, and due to her advanced dementia she is unable to comprehend why this is needed. Her grandson, who began looking after her after his mother died a few weeks before the referral, moved in and supervises her during the night. The dietician monitors her weight, and carers support and encourage her at meal times. She receives four daily visits from carers at home, and attends a day care centre at a local nursing home once a week. After working with her over the past 12 months, the support worker has her consent to try longer-term interim care to provide respite for her grandson. Voluntary services help with grocery shopping, and a power of attorney document is held by a solicitor.
The care package organised and provided by the CRT supports Mrs K in her own home when the only other alternative would be admission to a nursing home for the elderly and mentally infirm. The current arrangement also reflects the wishes of the family and provides support for the grandson.
Mrs A’s story
Mrs A, aged 91, was referred to the community resource team by her family because she was experiencing difficulties living at home on her own. Mrs A was not previously known to social services.
It became clear that Mrs A had lost all confidence in her ability to manage at home and was spending 24 hours a day in bed. Mrs A said she was in chronic pain although medical investigations were inconclusive as to why. Mrs A’s family were very concerned and were asking Mrs A to give up her home and enter long-term residential care. Mrs A was asking for admission to hospital to be looked after there.
The CRT responded to the referral within 24 hours and discussed potential options with Mrs A as part of the assessment process. Mrs A acknowledged that she was very low in confidence about her ability to manage and felt that things had got on top of her. A decision was made to access short-term residential care in a local authority home to try and help Mrs A regain her abilities and confidence using trained rehabilitation carers.
Within four weeks at the home Mrs A returned to a physical and mental level where she felt able to return home with some home care support. The home care support was designed to work with Mrs A to regain her independence.
After six weeks’ of re-ablement in her home, Mrs A returned to a level of function that she had not been at for many years, and was completely independent. She no longer needed the support services and continues to live independently in her own home. Mrs A and her family have been very complimentary about the way that services responded to Mrs A’s needs thereby preventing admission to hospital and long-term care.
See more of our work on co-ordinated care
- Read the full case study on Pembrokeshire's community resource teams
- Watch our video to find out more about Pembrokeshire's approach to care co-ordination
- View our organogram showing Pembrokeshire's care planning/co-ordination process
- Find out more about the project: Co-ordinated care for people with complex chronic conditions