Mina and the Heart Failure Nurse agree that Mina and Joe need help and support to enable them both to remain at home for as long as possible. The nurse explains how this might be achieved through an integrated health and social care model of care.
“Health and social care integration is about ensuring that those who use services get the right care and support, whatever their needs, at any point in their care journey.” (Scottish Government, 2015).
The Heart Failure Nurse calls a multidisciplinary team meeting to discuss how Mina and Joe can be offered the care and support that they currently require. Given the complexities involved in providing healthcare for people with multiple conditions, who have a number of different specialist and health & social care professionals involved in their care, it is essential that someone undertakes the role of key co-ordinator. In Mina’s case this is the Heart Failure Nurse. Mina and Joe’s son manages to get time off work and accompanies his mother to the meeting. Following discussion Mina agrees on the following options:
Please enable JavaScript in your browser to see this interactive content.
“People with multiple long term conditions often experience disjointed services that focus on a particular condition in isolation” (Many conditions, One life: Living Well with Multiple Conditions).
It is essential that all the healthcare & social care professionals involved in Mina’s care liaise effectively and work together with her to ensure that her care is person-centred, safe, effective and timely, in line with the ambitions of the Quality Strategy (Scottish Government, 2010).
Reflect on the multidisciplinary management of heart failure patients, with multiple conditions in your area of clinical practice. How effective is communication between the different teams and specialists? How often does everybody involved in the care of a patient meet to discuss management of care?
Integrated Care for Mina
PHYSICAL
MINA: I would like to be seen again by the cardiologist, to see if my heart failure can be managed better with different tablets. I really don’t want to go into hospital to have any treatments or have any operations as that would mean being away from Joe. I am struggling with getting around the house and caring for Joe, as I am so breathless and tired all the time. Perhaps I could have a chest review, as well, to make sure that they can’t do anything for my breathlessness? The Heart Failure Nurse is really helpful and I would be happy to have her visit on a regular basis.
Actions
- Review at cardiology clinic;
- review at COPD clinic;
- review of medications by pharmacist;
- regular visits by Heart Failure Nurse scheduled;
- one-off visits by Occupational Therapist/Physiotherapist/Dietician;
- care package for ongoing personal care for both Mina and Joe
- meal preparation.
PSYCHOLOGICAL
MINA: The Heart Failure Nurse mentioned using a Distress Thermometer to look at what my main worries were and I would like to do this. With being so tired recently, I feel like I have lost control of my life and I would like to do something more to help myself and Joe.
Actions
- Heart Failure Nurse to support Mina to complete Distress Thermometer;
- introduction to concept of self management.
SOCIAL
MINA: I can’t leave Joe on his own in the house as he can’t manage on his own. I can’t even get out to do my shopping as I have no way of getting to the shops now that we don’t have our car. I really do miss going to church and meeting my friends for coffee and a chat. Sometimes the whole day goes by without me seeing anybody apart from Joe.
Actions
- Key Social Worker to discuss possibility of day-centre care for Joe;
- information on CHSS support groups/Alzheimers Society;
- Dial-a-bus service for shopping.
Pulse point
Given her deteriorating heart failure and other multiple conditions, Mina is at risk of requiring hospital admission. The Scottish Patients at Risk of Readmission and Admission (SPARRA) calculator is a risk prediction tool which predicts an individual’s risk of being admitted to hospital as an emergency within the next year. Early identification of at risk patients and of their level of risk allows health and social care professionals to manage individual care to prevent this, as far as possible.
There is a growing recognition of the need to shift from a healthcare system geared towards reactive, hospital-based treatment of acute conditions to one that is more community based with a preventative and anticipatory approach (ISD Scotland).
The SPARRA Risk Calculator can be found at http://isdscotland.org/Health-Topics/Health-and-Social-Community-Care/SPARRA/Calculator. Mina’s SPARRA score is 46%, suggesting that she might benefit from an Anticipatory Care Plan and a Polypharmacy Review.
Page last reviewed: 28 Sep 2020
