Proactive care

Resident Profile

Mrs H, is a 79-year-old female. She was identified as someone with multiple Long Term Conditions (LTCs): Type 2 Diabetes Mellitus (T2DM), Depression, Hearing Loss, Chronic Back Pain and moderate Frailty by the Proactive Care Team.
A review of health records showed she was at risk of future crisis and ill health as had missed several appointments, including an Annual diabetic health check, and a medication review.
Support Offered: The Care Coordinator reached out to client using a combination of telephone, text and letter to book and remind of initial appointment.
A “What matters to you?” approach was used in initial session to build trust and develop an understanding of her priorities.
The resident said she felt alone and isolated due to her hearing loss, as she disliked wearing her implant. She also reported significant back pain and inadequate pain management, contributing to her feeling overwhelmed and not attending to her health. The Care Coordinator listened to her concerns, and was able to get agreement to work together to identify ways she could manage her health better.

HealthLiteracyProactiveCare.wav

Care Coordinator built trust using a “what matters to you?” approach to engage and assess her priorities and needs.
Communication strategies were used to share information about her missed appointments and the reason for these.
Additional time was provided to generate curiosity and hope for the resident that her current health issues could be better managed, and understand what support was available.

Information was provided using a combination of visual aids, verbal, and written information to enable understanding and retention of key information.
A Personalised Care and Support Plan was used to empower Mrs H to have control over her health needs and have something to refer to outside of sessions.

A consensus was reached with the resident on what self-management could look like for her.
A brief and clear action plan was given to client to allow her to carry out independent fact-finding before follow-up sessions.

Information was given in manageable chunks during sessions.
Medical terms were explained in simple language, with understanding confirmed by having the resident repeat key information in her own words and phrases.
Information provided previously was revisited in follow-up sessions, with the written action plan used to help prompt recall and clarify information before moving on to new actions.

The personalised care and support plan co-produced with the resident, included a guide on finding an in-person sign language/lip reading class, as well as information and support to access Together Better classes at her GP practice.
Over time Mrs H gained a greater understanding of her conditions and factors affecting these. This increased knowledge and support empowered her to self-advocate, and she has been able to independently contact a pharmacist for a medication review to support with pain control and attended an annual diabetic health check. She said she is pleased to have “taken the leap”, and having greater satisfaction with her life and health.

Page updated

Report abuse