Everybody needs good neighbourhood care
Neighbourhood-based care is at the forefront of the Government’s 10-Year Health Plan, helping to change the way people are supported in their homes. We met Tony and Carol Trott to find out how integrated neighbourhood care works for patients.
Carol and Tony Trott
When 79-year-old Carol Trott started to become unsteady on her feet and frequently falling, the cosy home she shares with husband Tony in Capel-le-Ferne, near Folkestone, started to feel more like a prison.
The fiercely independent couple had enjoyed 10 years living and working in Spain, managing holiday apartments. But after Carol suffered three strokes, they decided to return home.
Tony, 72, a former policeman and electrician, said: “We went away on a mini-break and within the first two days, Carol had fallen twice. One of the times a lady stopped to help, and Carol took her down too. The hotel manager suggested we would be safer at home.”
“Things were so bad that it put us off doing anything. Going out with Carol made me feel anxious and the constant worry about whether she was going to fall was exhausting.”
Tony and Carol were frequently finding themselves at their local urgent treatment centre, as Carol, who also has dementia, was falling and hurting herself. Just as things were starting to feel critical, a ray of light in the shape of Multi-disciplinary Team Co-ordinator Jodie Harnden, stepped in.
Jodie works for the Total Health Excellence East Primary Care Network – a group of GP practices supported by Channel Health Alliance on the south Kent coast. Her job is to support the one per cent of patients in her area who are most at risk of serious illness or injury, bringing together health and care services to help people to stay at home and out of hospital.
Carol had been flagged to Jodie because of the numerous falls and hospital attendances and she quickly set about meeting her at home to assess the situation.
Jodie said: “Carol’s frequent attendance at the urgent treatment centre meant she was flagged on our system as needing extra support, so I contacted them and arranged a visit. When I go in to assess a patient, I look at everything. How are they coping? What could be impacting their independence? What is important to them?
“The first time I met them, Tony said to me, ‘we have lost all our confidence when we go out. We just want to be able to go for lunch again without having to worry.’
“I took my assessment back to the multi-disciplinary team, which includes services from the GP surgery, community and social care and we quickly identified that Carol’s medication needed to be reviewed, which could help reduce her risk of falling.
“We agreed to refer Carol to our pharmacist and to the community frailty team for a specialist assessment.”
Multi-disciplinary Team Co-ordinator Jodie Harnden and Frailty Specialist Dr Joanna Seeley
Jodie’s role is vital in making sure all the services are connected, by proactively reaching out to high-risk patients and wrapping care around them, before their condition deteriorates or they become more vulnerable, and inevitably end up in a hospital bed.
Next, one of KCHFT’s frailty specialists, Dr Joanna Seeley, visited Carol. As part of her assessment, Jo referred Carol to our community rehabilitation team for some physiotherapy to support her mobility.
Jo also noticed that Tony was struggling to manage his own health, due to devoting so much time and energy to care for Carol.
Jo said: “Ten years ago Tony had kidney cancer and unfortunately a few years ago, it returned and spread to his lungs.
“I noticed Tony, who uses crutches to walk due to a damaged knee, was really struggling to breathe and any kind of activity would leave him very breathless and worn out.
“Both Carol and Tony were becoming frailer and were at risk of being hospitalised if their conditions were not better managed. Knowing how important it is to them to stay at home, we worked across NHS and social care organisations to put help in place to make life easier for them.
“This is what is at the heart of integrated neighbourhood care. The NHS is difficult and complicated to navigate, and different organisational systems do not always talk to each other. Making that connection as a group of health and care professionals means we are creating a team around our patients. We can do the navigation for them.”
Medication reviews, rehabilitation, practical care to help Tony order meals and advance care planning, which is the process for documenting preferences for future healthcare and end-of-life planning, have all been put in place. But the care doesn’t end there.
“It is important we identify what would make an immediate impact on supporting people to stay at home, but we also take an assessment of what is likely to happen and what care people need as they progress,” said Jodie. “For Carol and Tony, as well as their medical needs, there is a social care aspect.
“Where they live right now may not be the best place to support their health needs and we include the wider family in these discussions. Our input doesn’t stop until I know they are coping without us.”
For Tony, the difference has been huge. He said: “Now, things are so much easier. I know I can pick up the phone to Jodie and she will make sure we get the help we need. Carol has been steadier on her feet and is getting used to walking with a zimmer frame. The team regularly checks in on us. We feel much more confident to go out and enjoy life.
“Jodie and Jo have been brilliant – I would trust them with our lives.”
