Mary's Story

Care and support in the community

• Well-being and personal outcomes
  
• Co-productions
  
• New models of care
  
• Voice and control for people
  
• Prevention and early intervention
  
• Information, advice and assistance
  
• Proportionate assessment, eligibility and care planning
  
• Integration, partnership and co-operation
  
• Safeguarding and protection
  
• Advocacy
  

• Care and support for older person living in the community

Mary is 75 years old who states that she has suffered from anxiety for many years, has poor health and that her conditions deteriorate over the weekend. Following the death of her son, there now remains limited family interaction. Mrs. X made multiple calls and visits to NHS Services. She was abusive towards health care staff and portrayed inappropriate behaviors towards other service users and is not responding to interventions to reduce use of services. She declines to accept any diagnosis and will attend other health care providers until she gets the response she wants. Mrs. X has had numerous investigations all with a satisfactory outcome.

Age Connects’ Community Liaison Officer (CLO) represented Mrs. X at a multi-disciplinary team meeting where she was able to discuss her actions. The team agreed to monitor the situation and initially there was a good response. However, the Community Mental Health Team deemed that Mrs. X had insight and capacity to make decisions. In discussions with South Wales Police the team felt that Mrs. X's behavior did constitute an anti-social element, and it would be reasonable, should things not improve, to pursue this course of action.

Age Connects’ (CLO) explained the ramifications of her behavior to Mrs. X and, due to her continued misuse of Emergency Services, an Integrated Management Plan was actioned for her care provision.

This plan required the Emergency Unit, the GP (telephone calls and weekly appointments), Welsh Ambulance Services Trust and Out of Hours services, to follow the plan with Age Connects to providing daily monitoring, weekly visits and research alternative service interventions.

Age Connects CLO intervention included:

• Accompanying Mrs. X to appointments, social activities, support groups and therapy sessions,
  
• Advocacy to rectify housing issues
  
• Explaining alternative housing choices and attending properties viewings
  
• Benefit check completed, applications submitted and successful.
  
• Private service intervention arranged.
  
• Referrals to third sector agencies and to relevant NHS teams
  
• Support to access and maintain shopping delivery services.
  
• Developing preventative coping strategies to reduce anxiety.
  
• Providing information on alternative transport options and holiday/respite breaks.
  

Mary has displayed an improvement in behavior and has refrained from using Emergency Services inappropriately. Mary's future goals are to be registered with the same GP practice and meet new friends. These goals appear to be motivating the change in behavior. Pulling together resources from a variety of agencies has contributed to Mary making some positive changes in her interactions, and has resulted in reduced A&E attendances and inappropriate demands on NHS services. Mary continues to have 'Daily Comfort Calls and a weekly visit from Age Connects.