Case Study on Care In The Community

University Degree Subjects allied to Medicine

Case study

My name is Rose and I am a Trainee Assistant Practitioner working in a busy General Practitioners Surgery within Trafford. For the purpose of this assignment I will present the case of “Hilda” whose name has been changed in order to protect the identity of the patient and to keep in line with the Data Protection Act (1998) and the Nursing and Midwifery Council’s code of conduct (2004)

The background to this case will be presented firstly in relation to the holistic needs of Hilda. The Roper, Logan and Tierney (2000) model of nursing stresses continual patient assessment, facilitation of the patient's normal activities of living and individualised care. I will then identify the relevant services that are available to meet Hilda’s needs which will also include Hilda’s and her carer’s views of the services that are being provided. I have chosen to highlight Hilda’s case as I have been involved in her care for a number of years.

Background History

Hilda is a 73 year old woman who came to be in need of the services after a fall in her bathroom resulted in a fractured neck of femur. The BBC news on Health (2008) reported that hip fractures occur in about 60,000 people a year who fall, cost the NHS £1.7bn and are associated with up to 14,000 deaths. The government introduced the National Service Framework for Older People in 2001 (NSF). It outlines 8 national standards to improve care for the elderly. One of the main emphases is on falls. It transpired during her stay in hospital that she had had a few “unexplained falls” lately but no injury was sustained that required hospital treatment. Hilda has a history of Osteoporosis for which she has been taking medication for many years. The National Osteoporosis Society defines osteoporosis as having ‘porous bones’. Our bones are made up of a thick outer shell and a strong inner honeycomb mesh of tiny struts of bone.Osteoporosis means some of these struts become thin or break. This makes the bone more fragile and prone to break. It often remains undetected until the time of the first broken bone. Broken wrists, hips and spinal bones are the most common fractures in people with osteoporosis (NOS 2008) Hilda spent two months in hospital recovering and returned to her bungalow two weeks ago.

Hilda has been widowed for 14 years and lives alone in a one bedroomed council owned bungalow. Her income is made up of a weekly state pension which is topped up with pension credits, she has minimal savings. Hilda has 2 children who live nearby and whom she sees regularly, both are in full time employment. Hilda had never used the services before the fall, having previously been a very fit, active, and fiercely independent lady.

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The initial care assessment took place before her discharge from inpatient care to assess her needs in order to help her maintain her independence as much as possible. With the help of the community services, a care plan was put in place. The Aim of the NHS Community Care Act (1990) is to help people live safely in the community. Social Services assess the needs of people and arrange for the provision of social care services to meet these needs. This Act came about in response to the governments white paper “caring for people” (1989) and the Griffiths report (1988). Local authorities (LA’s) must arrange the provision of care to meet the individual. The Single Assessment Process (SAP) was introduced by the government in 2002 and the aim is to ensure that health and social care professionals work closely together to provide the right care and services at the right time.

Hanvey & Philpot (1994) define “community” as geographical areas and locality (e.g. social services or primary care catchment areas). Means & Richards (2008) defines care as providing the right level of care to enable people to achieve maximum independence and control over their lives. The initial assessment of needs involved Hilda, the Occupational therapist, Social worker and her son and daughter. Hilda was in agreement with the care plan which was put in place while an inpatient.

Holistic needs: Social

Hilda still has considerable pain with her hip which is controlled with analgesia, but needs the help of a support worker to help her with personal hygiene, cleaning and shopping. Due to the hip fracture she has lost her self confidence and is afraid of going out on her own without her family or support worker and help is needed to build up her confidence. Her son and daughter had stated that they will care for Hilda at weekends so no support is needed at the moment but is subject to review. Hilda needs support during the week with attending her flower arranging class which she thoroughly enjoys and looks forward to immensely.

Physical Needs.

Hilda’s physical needs are moderately impaired at present due to continuing pain, although this is lessening. She uses a Zimmer frame provided by the local authorities and a wheelchair which her daughter purchased second hand, for getting out and about, especially for attending church. Hilda needs help with personal hygiene e.g. getting dressed, especially putting on her underclothes and her support worker helps with these activities of daily living. Adaptations were made to the bungalow in the form of a bath seat and grab rails by the toilet which has made a huge improvement in maintaining her health and safety. These adaptations were funded for by the local authority as Hilda was unable to fund these changes herself. While Hilda was in hospital, the occupational therapist visited her home with both her son and daughter and with the permission of Hilda. Recommendations were made as to what changes should be implemented.

Practical Needs

Hilda cannot go out alone at the moment but is walking around the bungalow and her garden with her support worker during the week and with her family at weekend. She finds this very beneficial to aiding in her recovery and becoming self sufficient again. Her support worker puts time aside every week day to help Hilda take some exercise. As Hilda’s flower arranging class is literally on her doorstep the support worker takes her, and a voluntary worker from the church picks her up and takes her home, this again fits with the Roper et al model of dependence/independence.

Cultural Needs

Hilda attends the local church on Sunday’s, and her family makes the necessary arrangements for transport to and from the church. Hilda has many friends there and feels this is beneficial to her psychological wellbeing. A prayer meeting in her own home is held one afternoon a week which she says makes her feel “on top of the world”. While the meeting takes place the support worker with whom she has built up a good relationship does some shopping for groceries and essentials.

Current Community Support.

Hilda currently has statutory and voluntary services involved in supporting and helping her maintain as much independence as possible, these include a social worker and support worker who are employed by the local authority. The voluntary services that support Hilda are from the local church where Hilda has attended sine she was a child. Hilda runs the “mothers meetings” and also helps out in the children’s “Sunday school”, the church wardens along with her daughter ensure that Hilda is able to attend.

The support worker currently helps Hilda for three hours daily. This consists of an hour in the morning, lunchtime and tea time. The social worker services and individuals offering support and care for the individual should aim to empower the client (Adams 1996) and also promote independence (Thompson 2005). The Practice nurse from Hilda’s GP surgery also visits Hilda once a month and takes her weight and blood pressure reading. While there she promotes healthy living, advising Hilda and her support worker on the importance of maintaining a healthy balanced diet. Depression screening questions are also asked and consist of four questions these are:

Are you basically satisfied with your life?
Do you feel your life is empty?
Are you afraid something bad is going to happen to you?
Do you feel happy most of the time?

Depending on the answers to the questions it may prompt further more detailed questions or may require a visit from the GP.

Multi-disciplinary review

Hilda has now been at home for approximately two weeks and the social worker requested that a review of the services provided take place. In attendance at the meeting were Hilda, social worker, support worker, Hilda’s daughter and the practice nurse from Hilda’s General practitioners surgery. Hilda’s son and daughter are not entitled to a carer’s assessment as they do not look after Hilda for more than 35 hours weekly. White and Harris (2001) strongly advocate this type of partnership approach to occur. It was noted that Hilda needed more help at bedtime with getting undressed as she had difficulty taking off her underclothes and was cautious of her hip becoming dislocated and ending up back in hospital.

The social worker reported that she would initiate the increase in support given. Also Hilda was informed of the benefits she would be entitled to and with the help of the social worker the appropriate form was completed. Hilda is now in receipt of Attendance Allowance at the lower rate. Hilda does not qualify for the higher rate as she does not need help through the night. “Direct Payments” were also discussed with Hilda and her daughter, but they felt that the services that were currently provided were adequate. An alarm pendant was also provided for Hilda by the local authorities, which she wears at times when she is alone. When pressed, it will alert the local community warden who can then visit if needed.

Hilda’s support worker stated that although Hilda has only been home for less than two weeks she has seen a big improvement in her mobility and expects this to improve further with time. She also reported that Hilda’s appetite and fluid intake were very good as she practically “ate like a horse”.

The practice nurse reported that Hilda’s weight, blood pressure, and nutrition were all satisfactory and she is concordant with her medication. The practice nurse stated that she would liaise with the community health visitor for the elderly and request a visit for Hilda to assess any other needs Hilda may have.

A referral to the “Falls clinic” has also been made but as yet no appointment has been received. The local pharmacy delivers Hilda’s medication weekly and also orders her repeat prescription for her from her GP surgery.

Hilda’s views

Hilda stated that she wouldn’t have been able to manage without the help and support she has received from the local authorities, and with the adaptations that have been made to her home. Hilda feels that having a support worker in the evenings will help her immensely as the thought of having to get undressed on her own and falling was of great concern to her.

Hilda’s daughter reported that she was happy with the support her mother received.

Hilda concluded that although she was a very independent lady before the accident, she now could not manage the activities of daily living without support. Her main concern was that the services provided will be taken away from her, therefore forcing her into residential care. The social worker emphasised the fact that this would not happen and “care in the community” is first and foremost about keeping individuals in their own homes. This fact was also re-iterated by her daughter who stated that if more support was needed and the statutory services were unable to provide, then she would use the private sector in order for her to stay in her own home.

Conclusion

With the implementation of extra support in the evenings being made to Hilda’s care plan it seems that the support and care received is more than adequate and does meet Hilda’s needs. It must be highlighted however that an individuals needs change constantly and the services need to be moulded to the individual rather than the individual being fit into a service. The Department of Health specified in 1998, Services should meet people’s specific needs and people should have a say in the services they get and how they are delivered.