This means all the doctors, nurses, care co-ordinators and other professionals which their needs require are in the same place, working together, to provide the necessary support to keep them well for longer and out of hospital.
The service is aimed at people aged 60 and above who have two or more long-term conditions, such as diabetes or chronic heart problems. People in this category can often find themselves seeing the doctor regularly about a number of different conditions and can feel confused, frustrated and uneasy about where to go for medical help.
They feel disempowered, as though they lack control over what happens to them. When things go wrong, they may get anxious that they do not know what to do and will often call 999 for help or go to their local hospital.
This adds pressure to the local NHS service as people end up in hospital when they would really be better cared for elsewhere.
‘Margaret’ is one of these people. She is 87 and suffers from multiple illnesses. She lives on her own and she doesn’t really understand her care and doesn’t like troubling the doctor. She doesn’t manage her conditions very well, gets steadily more ill, goes into hospital where they rescue her and then they put her back in her own home, living on her own where she deteriorates again and she bounces in and out of hospital.
This is not good care for Margaret and it is not good for the public purse either.
Under the Extensive Care service, support is tailored to a person’s individual needs. People like Margaret are invited to sit down with the service team so that they can carry out a full assessment of her conditions and any other things that are causing problems for her on a daily basis.
The Extensive Care team then take what is discussed and develop a ‘My Plan’ with Margaret. As well as helping Margaret understand and confidently manage her conditions, this care plan focuses on what’s important for her and her carer(s). It involves setting a number of achievable goals related to Margaret’s health but also other things which can be personal to Margaret.
Margaret is also allocated a wellbeing support worker who keeps in touch with her on a regular and sometimes daily basis to help her achieve the goals set out in her care plan. Should she have a problem, Margaret is able to contact her wellbeing support worker, who working with a care-coordinator, is able to respond quickly to any changes or issues with Margaret’s care.
Margaret’s care is monitored and reviewed throughout her time with the extensive care service and her GP is kept informed of Margaret’s progress. If Margaret is achieving all of the goals in her care plan and it is decided that she can be transferred out of the service, a phased transfer plan will be developed. This will include detailed discussions with Margaret and her carer(s), as well as her GP to ensure continuity of care.
- Our Extensive Care Service: http://www.youtube.com/watch?v=wD8JqxhSIyI
- Extensive Care – A Patient Story: http://www.youtube.com/watch?v=_wL56CIdcVo
www.yourcareourpriority.nhs.uk |
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