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‘HOME FIRST’ SUCCESS FOR 94-YEAR-OLD MARY

The aim of the Early Intervention approach in Birmingham is for health and social care providers to work in partnership, without boundaries, to provide the right care at the right time in the right place.

The following OPAL+, OPAL and EICT collaboration provides a perfect study in how this is working in practice.  Hats off to all involved.  We know ‘it’s just what we do’ but what a terrific outcome for Mary (name changed for confidentiality) and of course, a perfect example of achieving one of our EI goals – avoiding unnecessary hospital admission.

The story is told by Donna Ward, Senior Sister at the OPAL Team at Good Hope Hospital (GHH)  who received the original phone call  and Rachael Hannon OPAL Clinical Practitioner/Lead at GHH who saw Mary after her initial ED assessment at the hospital.

Donna: “We received a call from West Midlands Ambulance Service (WMAS) crew at 7.30am.  A  94-year-old lady had called an ambulance as she had tripped and fallen and had difficulty in mobilising. It was also noted that she had fallen last week as well and had a swollen hand which the WMAS crew were concerned about.  There were no family members, Mary lived alone and there was no package of care or any assistance at all.

“The crew felt that Mary needed to attend ED for an x-ray and that care was needed as she could not manage her personal needs at this time; she was requiring hand held assistance of one to mobilise short distances.

“However, Mary flatly refused to attend hospital.  The crew called OPAL for advice and assistance with care at home but also to see if we could explain the need to attend ED. They had been there for an hour and Mary would not agree to be taken to hospital, even for an x-ray.

“We discussed all the possibilities with the crew including involving the Early Intervention Community Team (EICT) at home.  We also explained to Mary exactly what the OPAL team did, who we were and what we could offer.  We suggested that we call back in ten minutes, giving Mary some time to think.

“The crew called back shortly afterwards and Mary had agreed to go to ED, but only for an x-ray then she was “definitely going home!” The x-ray showed no broken bone, just soft tissue injury. Mary’s main objective was once again “to get back home.”

Rachael: “Following Mary’s discharge from ED, OPAL GHH gave her a full assessment and suggested that a package of care would be the best support on discharge. Mary was anxious and worried about having support at home due to feeling she wasn’t treated well with a previous package of care.

“Her case become more complex when she informed us that she was sleeping on the sofa and struggling to climb the stairs to use the bathroom. She had a commode but unable to empty it, no food in her house and no one to do her shopping.

“Various services were offered such as therapy assessments and community physio which she declined,  as well as a stairs assessment and to bring her bed downstairs prior to discharge. Following a long discussion, we managed to complete a social worker referral to discuss a package of care.

“We advised for her to continue sleeping downstairs (risks explained) and to not use the stairs .Mary agreed and happily accepted a four times a day call from the EICT to assist her with her daily living needs.  She was discharged later that day with her care starting at 7pm that same evening. We also provided her with a food parcel to see her through until the shopping call could be arranged.”

Dr Teresa Quigley, SRO for the OPAL service across EI and Clinical Service Lead for Healthcare for Older People at UHB added:  “This is a perfect example of collaborative working and one that has made us all very proud.”

Pictured, some of the OPAL team involved in reassuring Mary that she was in good hands and helped her to return home the same day with full support thanks to the Early Intervention team approach. Left to right Dr Sophie Stewart , Rachael Hannon Clinical Practitioner/Team Lead, Charlotte Morby Band 6 Physio.

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