Age UK Integrated Care: Mr A's Story

Here's the shared example

Mr A and his wife had once run a business from their home.  Then he lost both his wife and his sister in a short space of time.  Mr A lost confidence and his mood was very low.  He had mobility difficulties and had experienced falls and lost motivation to move around his house.  Mr A had frequent, sometimes daily, contact with his GP and Community Matron because of his low mood and pain in his knee.  Mr A also has diabetes.

How we helped

With our help, Mr A pinpointed his main concern, which was being a burden to others.  Together we created a management plan and identified that he hadn’t been attending podiatry appointments, despite having difficulties with his feet.  This presented a high risk for hospital admission and so an appointment was arranged for the following week.

We talked about pain management and Mr A’s sleep pattern and prepared questions for Mr A to take to his next GP appointment.  A medication review was also arranged and we talked about the importance of keeping on top of the medicines he was taking.

Mr A was referred to the Age UK Postural Stability Instructor and had a functional assessment, joining a local balance and stability class 3 weeks later.

Mr A worked with the volunteer to create a mood diary and used smiley faces to focus on the positives that he had achieved, which started to appear within a few weeks.  

Two months later...

Mr A hosted a social event in his home and subsequently joined the group who attended, so now they all meet fortnightly.  Mr A has also joined a cinema club and goes to the ‘silver screening’ fortnightly.  He is involved with a local charity fund raising group.

During his time with the Pathfinder, Mr A did have a hospital admission due to pneumonia.  The integrated team was able to arrange an early discharge with support at home. 

Population groups: 
Older people
People with long term conditions
Posted by...
Age UK Integrated Care Team