Case 1 – Maggie, Central Manchester, October 2020 – January 2021
Maggie* is an 84 year old lady referred to Kate* at Focused Care by the Care Navigator (social prescribing team) due to concerns around her living situation. Maggie had no white goods so was only eating food which did not require cooking, had very poor home conditions, and was building up debt.
On checking surgery records Kate discovered that Maggie had not attended the GP surgery in over 22 years and on assessment found that Maggie did not have any heating, had poor home conditions, and had not opened her mail for several months and so had been unaware of the bills coming in. She no longer knew how to access her pension, so had been living off her savings to pay for food. Maggie was unable to explain how this happened and so Kate noted concern around memory issues. She had one friend who visited frequently but no other known friends or family, and Kate found no evidence of financial abuse from this friend.
Kate booked Maggie into the surgery for a full health check and was able to get her flu vaccination and whilst she had no significant health concerns was able to arrange a referral for a memory assessment at the same time. She also contacted housing to arrange repairs to the boiler. Kate contacted the DWP to find out where Maggie’s pension was being paid into, as Maggie had forgotten that she had opened a different account, and the passwords to it. Wendy was able to successfully apply for pension credit, and other relevant benefits as Maggie had been living on the state pension alone for years. This support has helped Maggie to pay off her debts. She also supported her with her housing and Maggie was rehoused in a new apartment under the Extra Care Support Scheme in time for Christmas, and now Kate is helping to furnish a new permanent home for her through local charities and donations. Kate also took Maggie to attend her memory assessment, CT Scan and her Covid-19 vaccination as she has no other family.
Maggie now has good routines, eats and sleeps well and has a warm, comfortable home. She is awaiting further results from the memory clinic, but is also part of a housing scheme which offers social opportunities (post-Covid!) and enriching activities. She has enough money to live comfortably, has a care package in place and the practice have taken Maggie under their wing.
Case 2 – Samia* – Oldham, Jan 2021- March 2021
Samia is a 32 year old mum with 4 children, the youngest being in primary school. She was referred to Becky*, Focused Care Practitioner, by the GP due to issues with social isolation. Becky found that due to severe agoraphobia Samia hadn’t been out of the house for 6 years. She didn’t attend appointments, someone else took the children to school and she had never had a cervical smear test.
Becky visited Samia for an initial assessment in January 2021 and told the patient that she wanted to help her with her issues. She cried and said that she had been waiting for someone like Becky to help her. Initially Becky worked extensively with Samia setting her small goals. She gave her the necessary visual and written information to help and set these targets. As well as verbal encouragement and practical support, Becky initially took small steps and supported Samia to stand outside, then moved to the bottom of the drive, and this progressed further and further as the weeks went by.
Samia is now physically more active, is accessing medical provision and has undertaken her first smear. She has also been to the dentist and had much needed work doing.
She is able to participate in her children’s education. She has enjoyed a family social outing, and is much happier and participating in family life. Samia is much less isolated which has also encouraged better self-esteem and mental wellbeing. This can only be better for Samia and the rest of the family.
*Real names have been substituted