Mr E
Background
Mr E is a 70 year old man with chronic alcohol abuse (over 40
years). He lives alone in public housing with no supports as he has alienated
himself from friends and family. Mr E has no current Doctor and “Doctor
shops”. Over the last 5 weeks he has had 3 admissions to hospital.
Each time he was found on the floor by neighbours. The hospital has
referred Mr E to the Royal District Nursing Service (RDNS) - the local
nursing service - for a nursing assessment.
MR E needs a number of services and a coordinated response.
Actions
The RDNS undertook initial needs identification and a Service Specific
Assessment and put into place the following:
- A new Doctor who was willing do home visits.
- Daily visits by RDNS for
medication management.
- Referral to council for
home help, personal care and meals on wheels.
- Referral
to Healthy at Home (a HARP program) for case management.
- Referral
to a detoxification unit so Mr E can access this service at a later
date if he wants to.
Referrals were made in accordance with local PPPS.
Outcomes
As a result of the assessment and subsequent Service Coordination,
the following outcomes have been achieved:
- Mr E has had no new presentations
to hospital.
- The client is eating at
least one meal a day.
- In place is daily monitoring
by RDNS and weekly monitoring by his Doctor.
- Mr
E’s unit is clean.
- A Case Manager is in place and undertaking
monthly monitoring.
- His mobility
has improved, and he is able to walk to shops.
- The client
is medically stable.
Key Service Coordination Principles:
- Competent staff
- A central focus on the consumer
- Partnerships and collaboration
- A duty of care
