Case Study Two: Working Together Proactive Care A case study showing how integrated care is working across Eastern Cheshire. Presented at the Caring Together Stakeholder event 20 July 2015 at Poynton Civic Centre www.caringtogether.info

1. Louise Rycroft
Care-Coordinator

2. Priorslegh Medical Centre
McIlvride Medical Practice
The Schoolhouse Surgery, Disley
Bollington Medical Centre
33,000 patients
Our elderly population is 50%
higher than the National average

3. “Vulnerable patients who
may need extra support”
Patient Criteria

4. • To support and coordinate care for patients with complex medical
conditions who are discharged from hospital.
• Making contact with outside agencies on behalf of the patient should it
be required.
• To improving the quality and efficiency of the current discharge
processes.
• To make better uses of resources in Primary Care and the community.
• To develop better partnerships working across the peer group and across
agencies.
• To alleviate any worries or concerns a vulnerable patient may have once
home aiding their recovery.
Our Aims

5. • Discharges from GP surgery
• Clinicians who have visited patients and feel extra support is needed
for the patient or their family/carer
• Friends and family of patients expressing concern
The care coordinator will then make contact with
the patient within 3 days.
Referral Process

6. Care Coordination Input
GP Visit
Referral to Community Matron District Nurse Visit
Ambulance Booking
Find out appointment details
Referral to Macmillan Nurses
Organise Respite
Help organising carers
Providing telephone numbers Referral to Social Services
Help with medication
Carer’s Support Signposting to voluntary services

7. The wider team…
I n t e r m e d i a t e C a re
Pa t i e n t J o u r n e y Te a m
G P S u rg e r i e s
M a c m i l l a n N u rs e s
D i s t r i c t N u rs e s
C o m m u n i t y P hy s i o / OT
C o m m u n i t y M a t ro n s
C a re A g e n c i e s
Vo l u n t a r y O rga n i s a t i o n s
S o c i a l S e r v i c e s – S t o c k p o r t , M a c c l e s f i e l d ,
W i l m s l o w, D e r b y s h i r e a n d H o s p i t a l Te a m

8. Case Studies

9. • Mr S is a carer for his wife who
has Alzheimer's Disease.
• He is managing her care by
himself and is happy to
continue to do this.
• He was concerned about what
to do/who to contact in an
emergency.
• We have provided him with a
list of local agencies who he
can contact should he need to.
• We make contact once a week.

10. • Mr H lives alone and has memory
problems.
• He has no family locally – his Power of
Attorney is his niece who lives in Wales.
• He has been referred to the Memory Clinic
for a formal diagnosis.
• We liaised between the Memory Clinic
and his niece to organise this
appointment.
• We have also arranged transport for him
to attend an x-ray appointment.
• We called him regularly throughout the
morning to remind him who his driver will
be, when he will be picked up and the
reason for the appointment.

11. Video
Co-ordinated Care case Study – Mr Young
• https://www.youtube.com/watch?v=6gF9_SKGm4M

12. Feedback
I’m so lucky to
have this in my
area
That’s a brilliant
idea and could be
really helpful.
Thank you!
This is so
reassuring
I think you are
both stars!
You are a god send and I am
more than impressed with the
service
This is so helpful it
will be great for me
and my husband
You’ve been
ever so helpful,
thank you
It’s very nice
that someone
is thinking of
me
Everything has been
sorted thank you so
much for your help.
What a fantastic service