Marion’s Story: Integrated Health and Care

“Communication is key, the right hand has to know what the left hand is doing.”

Marion is a woman in her 30s who has Multiple Sclerosis (MS) and lives in Salford with her husband and two cats. In 2017, Marion experienced a five month stay in hospital following a relapse. This is the story of how health and care teams worked together to meet her needs.

Marion was diagnosed with MS several years ago and has lived in her own home since then. Unfortunately last year, due to a relapse with her MS, Marion had a five month stay in hospital after which there was a change in her ability to manage her daily life as independently as before.

Before Marion could be discharged from hospital several things had to be put into place at home. These included equipment such as a hoist, an electric wheelchair and a suitable bed as well as home carers visiting on a daily.

Marion was seen in hospital by an occupational therapist who ensured that she was assessed for the right equipment for her needs and lifestyle and also a community social worker who created a care plan to ensure she could go home with the right support.

“It was important to me that the social worker came to see me in person, it was important that we forged a link before I went home.”

The social worker liaised with the community neurological-rehab team, the equipment suppliers and the home care agency to ensure that everything was in place in order for Marion to get home as quickly as possible.

“It is key that the social worker is involved in person and not just via emails”.

Marion was anxious at first about coming out of hospital.

“It’s all very well someone saying this or that is in place but you do feel anxious.”

However Marion felt she had confidence in the people who were working to ensure that appropriate home care was in place and that the equipment was delivered and set up.

“I felt people were genuinely working hard to make my situation better.”

After being at home for three months, Marion said she was very happy about the way things worked out.

“Everything seemed to go pretty smoothly, better than I was expecting.”

The situation still feels quite new to Marion, it has been a big adjustment to her life. At first she found things difficult with strangers coming in and out of her home, but felt it was important to give herself a month to become accustomed to it.

“Who are these people coming in and out each day”.

There has been no further need for Marion to be admitted to hospital and she has a monthly appointment for treatment. She now feels able to manage her own condition at home with the support she has available.

Good communication between the health care professionals and the social care professionals involved in her care was very important to Marion.

“Communication is key! The right hand has to know what the left hand is doing.”

As was the fact that she was involved and informed about everything that was happening to ensure that she could go home and continue with her life safely.

“I need to be kept in the loop and up to date, this is my life at the end of the day.”

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