Integrated Care partners have jointly developed a number of fictional case studies to help tell the story of the benefits of joining up care.
The patient stories below show how we aim to improve things for patients by working in a more co-ordinated way and delivering more care closer to home.
Julie, 42, is health conscious, regularly researches health concerns online and sees her GP several times a year. She goes on her practice website as she is feeling tired and, after completing an online form which helps assess her risk factors and lifestyle, she is able to have a blood test to check for Type 2 diabetes without waiting to see her GP.
The test indicates that she is “prediabetic”. Julie is provided with information and guidance on how to help reduce her risk. She is also signposted to a number of self-help groups for people who are at risk of developing diabetes.
In the future, this will be supplemented by links to enable her to learn more about the condition and how to manage it as well as apps focusing on diet and lifestyle so that she can continue to monitor and improve her health.
Julie is retested six months later and is well within normal limits. She reports that she has more energy and that her wellbeing has significantly improved.
Recently retired Martin, 60, has suffered from anxiety and depression for many years. He also suffers from the lung condition COPD.
Martin has attended A&E three times in the last month and, although he is in touch with his GP and the community mental health team, he struggles to cope.
Martin’s partner died a few years ago and he lives alone in a rural part of Cheshire West. He is not particularly familiar with the internet or how to use technology.
With integrated care, Martin is identified as being at “higher risk”. His case co-ordinator meets with him to discuss his care plan and a multi-disciplinary team agree to review his medication, but also consider his wider wellbeing.
Martin attends self-help groups about both COPD and coping with depression. He also joins a walking group as well as a group that helps people to develop their technology skills and makes some new friends. He is provided with a stand by course of antibiotics and steroid tablets so that he can start treatment early should he develop a chest infection and advice on how to use them.
Six months on Martin reports to his case co-ordinator that he feels much better and has not attended A&E at all. He now helps with a COPD group supporting other people with the condition and sharing his experience of how it affected his mental health.
Harry, 72, lives alone in a one-bedroom council flat. A few winters ago, he was admitted to hospital with pneumonia. He was supported by social care when he left hospital and has since recovered, but receives little ongoing support. This winter he catches a cold and decides to get it checked out.
Previously, Harry would have gone to see his GP. With integrated care, Harry is instead able to speak with his case manager, who asks a social care assessor to check him out.
During this visit, the social care assessor notices patches of mould in Harry’s living room and discovers that the windows of his flat don’t shut properly. A home assessment is arranged and the case manager ensures that the windows are fixed.
The social care assessor also ensures that the voluntary sector is engaged as Harry is feeling lonely and would benefit from getting involved with some of Age UK’s local community events. Harry is also shown how to find local community services online.
Harry is reassured by the visit and feels he can manage the cold himself, however his case manager rings him later that week to check he is feeling better. If he wasn’t they could arrange an appointment for him to be seen by his GP.
Jane thinks she has severe cystitis. She is busy at work, so uses an app on her mobile phone to start a chat with an assessor, Mark – a qualified nurse. She tells Mark that she has had cystitis in the past and has researched the condition online using NHS Choices. In the past she had been treated with an antibiotic, and this had worked well.
Mark discusses her case with other health professionals and, after looking at her integrated case record and medical history, it is agreed that she should be prescribed the same antibiotic. A prescription is sent electronically to her nominated pharmacy. This whole process takes just five minutes. She picks up the antibiotics that day and, within just three days, she feels much better.
Elaine is 72 years old and lives with her husband. They are both well and enjoy walking. However, in the last year, Elaine’s right hip has become quite painful after walking and she and her husband are unable to go out as often as they used to.
Elaine’s hip is now causing pain most nights and disturbing her sleep. As she is now walking less she has also put on a bit of weight and sees less of her friends.
Elaine calls her local health centre to book an appointment to see a physiotherapist later that week. The physio is able to show Elaine some exercises, but her hip is still too painful for her to go out walking with her husband. The physio arranges an xray of her hips and it shows quite advanced arthritis.
Elaine is given some information about a hip replacement and sees a specialist who answers her questions and helps her decide if an operation is the right choice for her. She also starts an exercise class designed for people preparing for an operation.
Unfortunately, that winter, Elaine slips on a patch of ice and lands on her hip. She is taken to hospital by ambulance and has an x-ray in the emergency department. This confirms she has broken her hip. She is seen by a specialist who talks her through a hip replacement operation.
Elaine has the operation at the local hospital. Before going home she meets her case manager who arranges to call her a week later. Elaine’s case manager arranges for a nurse to remove her stitches and arranges for Elaine to go back to the exercise class to help strengthen her walking. The case manager also ensures intensive short-term support is in place to help prevent re-admission to hospital.
Elaine is soon back walking with her husband and is pain free.
Peter, 55, used to be a heavy smoker but has recently cut back. He notices that he is suffering from shortness of breath – especially after he’s been on a brisk walk around the park. He also coughs quite a lot, especially in the morning, and his breathing is generally more difficult. Peter thinks he has a chest infection which he just can’t shift.
Peter decides to ring NHS 111 to seek advice as his cough won’t clear. A nurse provides advice and arranges for him to see a GP the next day via an electronic booking system. The GP examines him and reassures him that he doesn’t need antibiotics.
He is given a spirometry test by a healthcare assistant. Later that week an x-ray is also taken of his lungs at a mobile unit near his home. Peter is diagnosed as having COPD and is given an inhaler.
His case manager, who is now overseeing his care, arranges for him to access smoking cessation support and an exercise class at his local community centre tailored for people with lung problems.
Peter gives up smoking and loses weight. Although his condition is not cured he feels fitter than he has for years and rarely needs to use his inhaler.
Peter also uses an app that allows him to record his symptoms and to record when he uses his inhaler. It alerts both him and his case manager if his chest is getting worse. Peter has a course of medication which he can take if he develops a bad chest and the app prompts him when to start and alerts his case manager automatically so a check-up can be booked with a clinician.
Thomas lives alone following the death of his wife a few years ago. He normally manages around the house but gets his food delivered and has a cleaning lady once a week.
Thomas has diabetes, kidney disease and has started to become more forgetful. His cleaner worries because he seems to be getting thinner and is not moving as well when she visits. The cleaner takes Thomas to see his GP who arranges some blood tests and introduces him to a community nurse, Jackie, who is going to be Thomas’ care co-ordinator.
The GP and Jackie discuss Thomas’ case at their weekly team meeting. The blood tests show that his kidneys and diabetes are getting worse and they are worried about how well Thomas is managing at home.
Jackie goes out to see Thomas at home with one of her Occupational Therapy colleagues. They find that Thomas has been sleeping downstairs and snacking on biscuits because he struggles with cooking. Thomas is a bit forgetful but recognises Jackie and is pleased to see her.
Jackie speaks to a social worker in her team who arranges for carers to visit three times a day. The Occupational Therapist arranges for a stair lift and rails to be fitted to help Thomas move around the house more easily. They also arrange for Thomas to join a group at his local church hall that includes gentle exercise classes and cooking advice.
Over the next three months Jackie keeps in touch with Thomas and checks his bloods again. His diabetes is better now that he is eating properly. Thomas feels better and is a bit less forgetful.
He enjoys visiting the local group and some of the friends he makes there occasionally visit him at his home. As his condition improves, carers no longer need to visit as often and Thomas still has Jackie’s contact details should he have any problems with his health.
Jim, 83, lives with his wife Sally. They have been married for 56 years. They have no children but have a niece who lives in Scotland. Jim suffers from memory loss but has not received a diagnosis. Sally has bowel cancer and is currently undergoing treatment. She tells her GP about Jim’s memory loss, but they agree it’s probably just due to “old age”.
Physically, Jim is able to carry out his normal daily duties – but Sally has to remind him to do so. Unfortunately, Sally’s condition takes a turn for the worse and she is admitted to hospital. Jim takes a taxi to visit her in hospital, but Sally has moved wards. Jim tries to find the new ward, but gets upset as he can’t.
Due to his confusion, he becomes increasingly agitated. Staff are concerned for his welfare and take him to A&E. Blood tests show he is dehydrated and has a water infection so he too is admitted to hospital.
Jim is on a different ward from Sally. As he is not able to visit her, he tries to leave the ward. As he appears to be refusing care and treatment he is seen by an on-call psychiatrist and social worker and is detained under the mental health act and transferred to a psychiatric inpatient unit.
With integrated care, Jim’s local GP is able to speak to the community mental health nurse from the local neighbourhood team to ask about Jim’s memory problems. The community mental health nurse sees Jim and Sally at home to undertake a memory assessment. The needs of both Sally and Jim are then discussed at a team meeting.
A mental health nurse asks a consultant psychiatrist to visit so that Jim can be started on memory medication and ensures Sally has support from the Alzheimer’s Society. The mental health team work with the GP and social services, when Sally is admitted to hospital, a package of care is put in place at home to support Jim with his medication and meals.
A volunteer driver takes Jim to visit Sally. The volunteer goes into the hospital with Jim to make sure he can find the correct ward to see his wife.