The following article highlights the case of a woman helped by North Norfolk CCG's Integrated Care Programme. The story demonstrates the very real difference that Integrated Care can make to individuals and the importance of everyone working together to achieve the best possible outcome for the patient:
"In October last year, Ali received a referral which came to her via our Integrated Care Hub for an urgent assessment of falls / admission avoidance and Red Cross older people's team assessment.
The referral concerned a woman - who we will call Mrs B - who had lost her husband six months earlier and was finding it very difficult - and very scary - living on her own.
Mrs B had fallen many times and needed another falls assessment to see why her balance was so bad. Part of the problem was that her house was very large - with many steps and a vast living area - and rather than using mobility aids, she was using the furniture to help steady herself.
Following the referral, Ali contacted Mrs B for a chat and very quickly realised that she was still grieving for the loss of her husband and felt very lonely and isolated. A few tears were shed but Mrs B agreed a falls referral to the phyio would be a good place to start.
Ali duly requested an urgent visit by a physio, and this was organised for the same day as the occupational therapist's visit to find out what sort of equipment Mrs B was using. The physio went to see her and spent a long time chatting and looking round the house. She also concluded that Mrs B's problems stemmed from being terribly upset and very lonely after he husband's death and that this had caused her to become housebound and very withdrawn.
As a result of their assessments, the community team had a chat and spoke to Ali to see what they needed to do to ensure Mrs B could remain living at home while staying safe and well. This led to Ali referring Mrs B to the local Red Cross older people's team.
Being a voluntary organisation, it can carry out very thorough assessments in people's homes for up to 2 hours - spending valuable time with the patient and listening to their concerns.
After the assessment, Ali had a call from the Red Cross with an update. This information was shared with the community team. The physio was able to refer Mrs B to a group called Extend which runs a free six-week class designed to encourage better mobility - and, of course in Mrs B's case, socialising. Ali has maintained contact with Mrs B to check her progress and establish if she required any further support. This resulted in a referral to Cruise for counselling to help with the loneliness and isolation.
However this is not the end of the story........
So inspired was Mrs B by the help and support she received, she has decided to become a volunteer herself through Voluntary Norfolk."
Ali Campling Brown - Integrated Care Coordinator for Cromer, Mundesley, Aldborough and North Walsham