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A Patient Journey

A Patient Journey. Marianne Plater Community Geriatrician. Referred by physio due to Fall Domiciliary Assessment: History Examination Belief Structure Family Investigations OPC follow up. Confirmed diagnosis: Cerebella Stroke Secondary Prevention considered

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A Patient Journey

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  1. A Patient Journey Marianne Plater Community Geriatrician

  2. Referred by physio due to Fall Domiciliary Assessment: History Examination Belief Structure Family Investigations OPC follow up

  3. Confirmed diagnosis: Cerebella Stroke Secondary Prevention considered Osteoporosis risk factors addressed Rehab = plateau Refused SS help Support from daughter

  4. GP discussed at a surgery meeting (2 years later) Concerns re increasing falls and frailty Patient refusing SS ref Outcome: ref to Community matron Gained trust with patient and family Introduced POC personal hygiene Nutritional needs addressed

  5. Admitted SGH 1 year later Pneumonia Confusion Prolonged Hospital Stay Marked deterioration in function Marked deterioration in cognition Discharged home QDS POC

  6. Ref by social worker Due to on going deterioration Carers struggling to manage needs Moving and handling issues Ongoing falls Medication review Outcome Multi-infarct Dementia Unavoidable falls due to Cerebro Vascular disease Longstanding immobility Risk taking behaviour DW Health and Social care team re prognosis / anticipatory CP

  7. Issues: Capacity assessment re care needs Best Interest Meeting EOL management plan D/V assessment Bed bound Bilateral pneumonia Both daughters present Mx plan die at home

  8. End of Life • MDT discussion • GP on holiday patient not known to locum • Com Matron • OT • SW • Wider team • Pressure relieving equipment • POC / CHC funding • Moving and Handling • Night needs • OOH / ambulance form

  9. What went well Fast and flexible approach from a previously ‘routine’ service Integrated working with SS Families thank you letter = ‘seamless service’ What went wrong GP slow to offer syringe driver for symptom control Ambulance staff wanted to admit patient

  10. Conclusion • Cultural change in referral process • Working with people who are disengaged with health or social care • Attitudes / beliefs • Dementia • Monitoring / early warning of deterioration • Prognosis / identify dying phase • Involving the right people in decision making

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