Current Model of Care
Graham and Anns story. Graham is 85 years old and lives on his own as he recently lost his wife. Graham lives in Freshwater.
He has memory problems, high blood pressure and breathing difficulties. He is unsteady on his feet, sometimes he forgets his
stick and then he unfortunately can have a fall. Graham feels isolated as he struggles to keep up with the friends he has and
the appointments he needs to keep, sometimes forgetting the right day and time, so he prefers to stay at home rather than
have embarrassing moments, like being told he came on the wrong day for his club meeting.
His daughter Ann, is a great support to him, but she lives on the other side of the island, in Bembridge, and he feels she has
her own problems to deal with, so he would rather not ask too much of her.
Ann, is a single mum and although very happy to help her father, she also has a son, Carl, who was born with cerebral palsy.
This means that Carl has both difficulty with his walking, needing a wheelchair, and assistance with communicating. Carl is
under the care of the paediatricians both on the island as well as needing to travel to the mainland for specialist appointments.
This leaves Ann, who is a full-time carer for both her father and her son, with very little time to look after herself and no time to
hold a job. She has no time go to the gym, or think about her diet, shopping needs to be done as quickly as she can possibly
manage. She has no time to catch up with friends of her own and she is also feeling isolated, despite being around people all
the time. She has no time to see her GP to discuss that she is feeling more and more depressed and getting more and more
anxious. And when she does, the option of having regular counselling sessions is just too much to fit in her world. The idea of
exercising and losing weight, having the right diet to void getting diabetes or high blood pressure is good, but the reality is just
too complicated. After all Carl’s and Graham’s health problems are always more important…
As you can see the services are not as joined up as they could be and there are needs in common for the family that need to
be addressed.
How can we change the lives of these people, who are maybe our neighbours or our friends?
How can we empower Ann to take charge of her health, to realise that maintaining her health is as important as looking after
her family? How can we help Graham not feel isolated because of his memory or decreased mobility? And how can we help
Carl live a fuller life despite his ongoing disabilities?
Now let us revisit this family 1 year down the line, when we have managed with the help of the Vanguard to improve
their lives through our new model of care.
Future Model of Care
Ann used to spend a lot of time on the phone trying to coordinate appointments for both Carl and Graham, she tried to make
sure Graham has all the right assessments and as much help in the house; she also tried to get Carl involved in as many
activities as she can so he is included in his community. She had found the Isle Help shop and call line helpful in the past, but
now the ‘Isle Find It/Community Directory’ has made a huge difference in her life. She has even managed to get help for her
finances. The family has a My Life co-ordinator* to help them work with opportunities and teams in her area.
She is now part of the volunteer community of the Island and has found support for herself and is in turn helping others. She
has joined her local exercise group and as she has a fellow volunteer stay with Carl at times. She has found Silver Cloud,
through the Isle Find It Directory, an online psychological support application for the Isle of Wight, which she used in her own
home, and it really is working.
The new digital care records have significantly improved the communication between all the professionals and volunteers
involved in Carl’s care.
Even better is the fact that he does not need to travel to see his specialist on the mainland for his appointments as he can now
have these consultations via Skype on the Island in his community hub or at home. This has made a world of difference to Ann
as well. The My Life Co-ordinator” helped Carl find new activities he can be involved with and has made new friends, with and
without disabilities. He now feels more a part of the community and not just a member of the group for people with cerebral
palsy.
Graham has been supported too. He has a volunteer visiting him, helping him with remembering appointments and even
helping with getting there. He is still using the Freshwater, Yarmouth, Totland (FYT) bus, which provides him transport to his
activities and appointments. The driver is more aware of Graham’s memory problems through the Dementia Isle initiative and
his co-ordinators input.
If he were to fall, he is not necessarily rushed into hospital. 111 are able to co-ordinate care by offering crisis team support
and then they seamlessly hand over the care to the local team that are in his electronic records that is visible to them. This
includes his local pharmacist who completes his emergency medication review. He will be visited and monitored by his
emergency care practitioner (this is the paramedic that works in his locality) and they have mobile equipment to aid quick
recognition of physical changes so adjustments can be made to help him.
This in turn enables the local GP be really efficient when they visit.
Graham has telehealth at home, which helps his GP with monitoring his health and the GP is in turn able to share these results
by contact with the hospital doctors or outreach nurses by the touch of a button without Graham needing to go in hospital for
review. Social care assist Ann and Graham organize his personalized care budget to reflect what they need.
The team in the community have helped Graham design a plan for the future of his wishes, everyone relevant to graham can
see his plan through connected IT and review and develop it as things change. Graham does not want to be resuscitated or be
taken into hospital; he wants his life and care in his own home with his family and community by his side.
These are all achievable because of the way we have developed our teams in our community, designed by our community
supported by our community.
We are focussing on keeping people happy and healthy through self-care and supported care and prevention.
We are not far from what has been described. With VANGUARD support we can get there faster!