The following case study is from the Salford area, but the name has been changed to protect the patient’s anonymity.

 

John* from Salford was admitted to Salford Royal Hospital for loss of mobility and hip pain. He was found to have a fractured neck and received surgery.

John, who has learning disabilities, found his rehabilitation programme confusing and difficult and was reluctant to stand and walk. So the hospital physiotherapist contacted the Learning Disability (LD) physiotherapist team, part of the Salford integrated care organisation team.

The LD physio joined forces with the hospital physio to offer support by engaging with John and using incentives such as cups of tea and by giving a clearer indication of what he was being asked to do to aid his rehabilitation.

Common subjects of discussion were suggested to help engage with John. He was particularly fond of his fish tank (He missed his fish and would respond to pictures and discussion about them) and this proved to be helpful to engage him in conversation and motivate him through his interests.

Working with his supporting social care staff who attended some of the physio sessions, helped to keep John focused on returning home and to get as much from his rehabilitation time when on the ward. It also meant his carers were able to engage more fully with the rehabilitation process when visiting John on the ward and he responded well to this.

The LD physio also visited John’s house with the carer team and a hospital occupational therapist (OT) to gather more information to help build the relationship with him. An initial assessment was also made of the environment he was returning to ensure that the maximum was done to achieve a suitable home environment for John and to act as a guide to his future rehab needs.

In discharge planning meetings with his case co-ordinator it was thought that a move to an intermediate care facility was likely not to be suitable for John as he was likely to find a new environment and unfamiliar staff members confusing and distressing.

Returning home with extra support was thought best for him when he was ready to be discharged from hospital.

How was this achieved?

A joint home discharge visit including John and his social care team took place to ensure he settled in well at home and to ease his transition from hospital to home.

The social care staff were able to ask questions, especially to the attending Hospital OT. The therapists were able to get a clearer picture of how John interacted with his environment and could make adjustments to his home.

By thinking in a person centred way and by adopting a joint working approach this gave John the best possible chance to return home and to help him settle in.

Follow up was by the LD physio and the care coordinator. John very quickly settled and normal levels of support resumed shortly afterwards.  The follow up visits highlighted other needs as his mobility increased and liaison between Community OT, care coordinator and LD physio has resulted in improvements at the house which will hopefully allow John to stay there in the future.

John has recovered so well that on the most recent visit by his care team, they could help him get in and out of his car so he is now fully engaged in his normal day-to-day activity. A great result.