These accounts show how the Esteem Team's co-ordinated care approach works and the positive impact that well co-ordinated care can have for patients and service users. Some details have been changed to protect the patients' identity.
The Esteem Team care process
A male client in his 40s was referred to the Esteem Team by his probation officer. He had a traumatic youth with a history of sexual abuse by his father. Following the breakdown of his marriage, he lost contact with his children and was left heavily in debt as a result of divorce. During the assessment, he confessed to having suicidal thoughts and no hope for the future, despite being in a new supportive relationship. He also displayed agoraphobic tendencies, stating that he would rarely leave the house without his partner, and that he would avoid going into crowded places or socialising with friends. He described being in low mood, having no confidence and low self-esteem. He also suffered from erratic sleep patterns. The patient was diagnosed with depression and anxiety, and he received medication to treat these problems.
Following the assessment, the Esteem Team worker supported the client with one-to-one confidence-building sessions, allowing him to express his thoughts and feelings. He was referred for hypnotherapy and emotional freedom techniques therapy. After six months, the link worker encouraged the client to receive counselling to address the trauma and abuse he experienced in his childhood. The client also agreed to start to tackle his agoraphobia and self-imposed isolation, and the link worker accompanied him to local cafés to re-orientate and slowly integrate socially. He also began writing down his thoughts and feelings, which turned into a narrative of his life story. He would now like to change careers and go back to work.
He is volunteering as a befriender in the Sandwell Wellbeing Hub and is in the process of moving home and settling down with his new partner and her children. The Esteem Team worked with him over a 12-month period.
The interaction of counselling services and the Esteem Team
A female patient was referred to a therapist in an extremely distressed state and at risk of suicide. The patient stated that this distress was caused by her partner who was highly controlling – she had to account for her daily movements. There was also a history of physical abuse. The patient had to hide her attendance at therapy from her partner. The therapist described the patient as lucid without latent psychological problems, so his therapeutic efforts concentrated on treating her suicide risk. After a few therapy sessions, the therapist suggested to the patient that she might be referred to the Esteem Team, which she accepted.
The link worker assigned to the case was able to quickly build a rapport with the patient. Together, they developed perspectives and solutions to free her from the tight grip of her partner, such as taking days off work and using the time to socialise, and to plan moving away. Soon after the involvement of the link worker, the patient’s Core 10 scores improved and her measure of suicide risk dropped to below the clinical risk threshold for the first time since she had started to receive counselling. The combination of therapy and the input from the link worker increased the patient’s confidence to a level where she felt able to leave her partner. The therapist stressed that without the link worker’s input, his ability to treat the patient would have been very limited.
See more of our work on co-ordinated care
- Read the full case study on Sandwell's Esteem Team
- Watch our video to find out more about the Esteem Team's approach to care co-ordination
- View our organogram showing the Esteem Team's care planning/co-ordination process
- Find out more about the project: Co-ordinated care for people with complex chronic conditions