Personalised care success

Personalised care means people have increased choice and control over the decisions that affect their own health and wellbeing.
There is no ‘one size fits all’ model for personalised care with the emphasis on empowering individuals who access health and care services in a way that fits them as an individual and the goals they set themselves.
Personalised care includes,
• Shared decision making – people are supported to understand the care, treatment and support options available and the benefits and consequences of the options

• Supported self-management – people are supported to develop the knowledge and confidence to manage their health and wellbeing through health coaching or peer support

• Social prescribing and community based support – people can access community connection projects to enable them to be connected in to community based support

• Personalised care and support planning – people have a personalised conversation and plan based on what matters to them including identification of their needs and their health and wellbeing

• Personal health budgets – an agreed  amount of money to support an individual’s health and wellbeing needs as identified by the personalised care and support plan

Here is just one case of how this has worked well:

Mrs A:

Client is a 93 year old female who lives alone in the North of the City.

She was referred to the Community Connector Service via the Red Cross.

Client suffered a stroke in 2017, after a long hospital stay she was discharged home with support from the Red Cross. Red Cross discharged and referred to the service.

Resulting from the stroke this client has reduced sight, which she finds frustrating. She has had a recent diagnosis of breast cancer and has had a bad fall in her garden; all this have impacted on her feeling vulnerable. The client has not been out of her home alone since July 2017. She is lacking in confidence and has anxiety.

Client’s mobility is restricted, she mobilises with a four wheeled trolley and walking stick indoors. She was issued a three wheeled walker for outdoors from hospital discharge but due to living on the hillslopes and having several steps to get in and out of her home it was restricting her to use the three wheeled walker, it was unused and kept in the shed.

There were several restrictions to her being able to get out of her home which creates a barrier for her to be able to access the community independently and safely. She has lived in her property for many years and does not feel that she would like to move from her family home.

Client used to mobilise independently, socialise with friends, enjoying shopping and having lunch, she was confident to use public transport but on referral feels lonely and isolated, having to rely solely on her friends to take her out.

Client does not feel safe to go out on her own and was anxious of falling again.

Goals

  • To regain confidence and reduce anxieties.
  • To join a new group and meet new people.
  • To be less reliant on her friends.
  • Improve her skills to use her walking aid.
  • To reengage with the Salvation Army Befriending service

Intervention

  • Community Connector assessed the property and arranged adaptations to be completed to the outside of the property to make it safer and accessible to get outside, this included installing clamp rails, grab rails, rehanging of garden gate and concrete infill to outdoor steps.
  • After discussion with client it was evident that she was unable to use the three wheeled walker due to its weight. A four wheeled rollator was ordered.
  • Supported to reengage with Salvation Army Befriending service.
  • Supported with walking practice with rollator and to regain confidence to use public transport and taxi service.
  • Mrs A was supported to join a new social group in the area she lives.
  • Mrs A was supported to arrange Meals on Wheels.
  • Referral to Good Gym for a befriender.

Outcome

Client’s confidence has grown to use the four wheeled rollator.

Using the newly installed rails makes her feels less anxious about falling and enabling her to access the outdoor space to the property independently also to be able to enjoy her garden again.

After confidence practice sessions to use the bus she felt that due to the distance to the bus stop and living on the hill slopes that she would feel happier to take a taxi

Client now attends a local social group, has met new people and enjoys the company, conversation and activities. She is now arranging to meet friends for lunch independently.

The Salvation Army Befriending service have reengaged and continues to visit, they have arranged for an old friend to visit for afternoon tea and client is waiting to be paired to a befriender from the Good Gym.

Client reports she now feels that she is enjoying socialising again, feeling less lonely and no longer feels that she is isolated. Client said that she feels a “great sense of achievement”.