|At the heart of the Neighbourhood team model are the people we care for. Here, we
learn how the Meanwood Neighbourhood Team helped Mr and Mrs J achieve their
goal – to stay at home together.
Imagine you are a carer… Your partner has dementia and you take care of both your
day to day lives. Lately though, you’ve been struggling with your own memory…
Mr J has dementia and Mrs J is his carer. They are both in their late eighties. Concerns have been raised by their GP as to how regularly they are taking medication.
Mr and Mrs J believe they can manage their own care but even their neighbours are concerned. They have no children and are supported by Mr J’s brother who lives some distance away. They have limited mobility; neighbours have been buying food and providing meals for them for some time. They have previously declined domiciliary homecare assistance.
There are indications the couple are not able to manage their medication independently. Although Mrs J says she is taking her medication, she doesn’t use a dossette box to organise this. There is evidence that little, if any, is being taken. There are concerns about
her memory too, as both she and Mr J have stopped most of their medication as they don’t know what it’s for.
Pharmacy Technician, Lesley involves Belinda Connolly a Memory Support Worker who works in support of the Neighbourhood Team. Belinda calls in to Mr and Mrs J to assess them in their home.
Mr J is well looked after by his wife. He knows he has memory problems and is accepting of this. He is clean and dressed, although slightly unkempt. Mrs J doesn’t appear to be quite as healthy. She shows signs of poor personal hygiene and isn’t dressed properly. There are concerns that neither is eating regular meals.
Mrs J is reviewed by Community Matron, Lesley McDonald. She is found to have very high blood pressure (210/98). She is also diabetic and this is poorly managed. It is not clear how often she is taking pain relief. As carer for her husband, she has been making small adjustments to her day in order to function; she does not acknowledge her own memory issues.
The team have a case management meeting to work out together how to best support Mr and Mrs J.
The bring in the Reablement Team who can assess Mr and Mrs J’s ability to function and determine what support is required in their home. The wider team consider the couple’s ability to complete daily tasks and manage their own medication. They also discuss what support will be required around memory issues. Mrs J is referred to a memory clinic and allocated a social worker.
A care package is put in place for the couple. This involves three visits every day, including a lunch time call to make sure they have eaten. A dossette box is considered appropriate to prompt Mrs J about medication.
The team want Mrs J to be involved in the couple’s care, to avoid alienation from the service. They work carefully to promote her confidence in the team. Not long afterwards she is diagnosed with vascular dementia.
The Neighbourhood team work with Mr and Mrs J to set goals. Their main goal is that the team support them to be as independent as possible within their home. The team get to know the couple better; they discover Mr J is a talented painter with a lifelong love of railways.
By April the couple are improving. Almost two months after their first referral, Mr J’s paintings are showcased in a celebratory exhibition, organised by his brother in the Lake District. At one point Mr J would not have been able to attend but due to the team’s intervention Mr
and Mrs J are able to travel to the exhibition. Paul Atterbury, an Antiques Roadshow expert, comes along and sees Mr J’s work.
While the Reablement Team assess the social side of the couple’s care. Community Matron, Lesley is able to focus on the medical and
nursing aspect. By May, Mrs J’s blood pressure has reduced to a normal level and she is using her dossette box to take her medication twice a day when prompted by carers.
In June, Mrs J sustains a fracture and is admitted to a Community Intermediate Care bed. While she is recovering Mr J is admitted
for respite at a care home. The team is concerned at first but Mr J loves it!
Mrs J returns home at the end of June and is reunited with Mr J at their home. The Neighbourhood Team provide day to day
support until an ongoing care package is available. When an Occupational Therapist from the team visits they find Mrs J already up, dressed and lunch prepared. By July, her blood pressure is back to normal. An ongoing care package is put in place that allows Mr and Mrs J to remain in their own home with support, something that was so very important for both of them.
Community Matron Lesley from the Neighbourhood Team continue to see the couple on a monthly basis to support their wellbeing and their health goals.
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