Age UK Integrated Care: Nora's Story

Here's the shared example

Nora had once run a bustling B&B from her home.  Then, having lost both her husband and her sister in a short space of time, Nora grew concerned about being seen as a burden to others.  A comment from her friend’s daughter reinforced her fear.  Nora lost confidence and her mood was very low.  Nora had mobility difficulties and had experienced falls – she used a wheeled walker but felt less and less motivated to move around her house.  Nora had frequent, sometimes daily, contact with her GP and Community Matron because of her low mood and pain in her knee. Nora also has diabetes.

How we helped

With our help, Nora was able to pinpoint the main issues for her – being a burden and losing independence. She worked with us to create a management plan and identified that she hadn’t been attending podiatry appointments, despite having difficulties with her 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 Nora’s sleep pattern and prepared questions for Nora to take to her next GP appointment.  A medication review was also arranged and we talked about the importance of keeping on top of the medicines she was taking.

Nora was referred to the Age UK Postural Stability Instructor and had a functional assessment, joining a local balance and stability class 3 weeks later. Meanwhile, her wheeled walker was serviced.

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

Two months later..

Nora hosted a coffee morning in her home and subsequently joined the group of ladies who attended, so now they all meet fortnightly.  Nora has also joined a cinema club and goes to the ‘silver screening’ fortnightly.  She attended the Lane Theatre evening group a couple of times and is involved with the local charity knitting group, which meets regularly for a cream tea.

During her time with the Pathfinder, Nora did have a hospital admission due to pneumonia.  The integrated team was able to arrange an early discharge with support at home.  Nora’s wellbeing score has improved from 18/35 to 29/35.

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