The importance of MDT working a case

The importance of MDT working – a case study. Alison Watson and Zoe Stocker Adult Social Care

A journey through Adult Social Care Pat § 7/2/2014 : Referral to the Disability Services Team (DST) § 26/2/14: Allocated to OT § 4/3/14: Initial visit and functional assessment carried out

Pen picture - Pat § Social situation § Presenting symptoms and barriers to independence

Functional assessment 4/3/14 Issues identified: § Standing to prepare food in the kitchen § Transfers in/out of bed, toilet and bath

OT recommendations: § Perching stool § Dycem § Toilet frames § Bed stick § Powered bath lift

Zoopla Other search engines are available…. .

Result! 3 properties and several months later. . following OT viewings… Most of the criteria were met: § Bungalow § 2 bedrooms § Outside access adaptable (but not brilliant) § Internal circulating space for wheelchair § Adaptable bathroom

House move Delayed due to unforeseen circumstances. Offer for bungalow accepted on 20/10/14. Disabled Facilities Grant recommendation submitted on that day. Finally moved on 12/12/14

Visit 16/12/14 § Findings…. . § Pat agreed to a referral to the social work team

Meeting Pat. § 19/12/14. Allocated case. § Introductory visit. Explain services available. Leave self assessment paperwork. § Information on financial assessment.

Care Act 2014 § Managing and maintaining nutrition. § Maintaining personal hygiene. § Managing toilet needs. § Being appropriately clothed. § Being able to make use of their home safely. § Maintaining a habitable home environment. § Developing and maintaining family or personal relationships.

Care Act 2014 § Accessing and engaging in work, training, education or volunteering § Making use of necessary facilities or services in the local community including public transport and recreational facilities or services. § Carrying out responsibilities the adult has for a child.

Meeting Helen and Malcolm § Return with Support plan. § Approval of support plan. § Request services. § Finding a provider.

Introduction of carers. § 09/01/15. Introduced Allied Home Care carers to Pat. § District Nurses. § ‘PEG-gate’ § ‘Bed-gate’.

Review of Care needs. § A constant process which is informed by MDT. § Joint visits to avoid Pat having to repeat herself. § Copying in other professionals to email. § 23/06/15. Increase in care provision. § 07/10/15. CHC funding. Transfer to Joint care management.

People who are part of the journey… § § § § § Pat and family MND specialist nurse O. T. Physiotherapist MND wheelchair therapist. District nurses Speech and language therapist Respiratory team Social worker

Plus. . § § § § § G. P. Dietician and Fresenius nurse Tissue viability nurse Palliative care team, Wheatfields Hospice MND consultant MND association Home care providers. Continence services CHC assessor.

The final word. . § Over to Pat…….

Pat’s farewell gesture to everyone!