Mavis Ann Connors, 88, was rushed to the emergency department at The James Cook University Hospital after having two falls within 24 hours and noticing a sudden change in her mobility.
After receiving care in the emergency department, Mavis was discharged and sent home with support from Middlesbrough Independent Living Services’ Hospital to Home Team.
The specialist service offers support to aid a patient in returning home to a safe environment whilst providing equipment to promote their independence and is available for patients living in Middlesbrough.
Due to Mavis suffering from high blood pressure and early stages of macular degeneration, which is a common condition that makes things like reading and recognising faces difficult, she was referred to the Hospital to Home Team.
The prevention liaison officer from the specialist service carried out a holistic assessment of Mavis and discussed any concerns and risks with her family.
Due to concerns with memory and the ongoing risk of falls, Mavis was offered the telecare service, which is a personal monitoring system that helps individuals like Mavis to stay safe and independent at home.
It included a specialised fall alarm, a wristband that can automatically detect when someone falls and send an alert to a call centre without the user needing to press a button, providing immediate assistance in case of a fall.
A key safe was also put in place for emergency access. This means her family or emergency services can get into her home if Mavis is unable to get to the door.
Flood, heat and smoke sensors were also installed as part of her care that ensured she had adequate support and helped reduce risk to both Mavis and her property.
Mavis said: “They were all lovely and absolutely brilliant. Thanks to all these adaptations, I can live without any worry and I am truly grateful for the help that I have received from so many teams.”
She has been receiving ongoing support from Middlesbrough Community Reablement service, which is a personalised, home-based service that helps individuals to live as independently as possible.
The reablement service is provided by Middlesbrough Council, who also works very closely with the trust to support the discharge of people from hospitals. Reablement includes a mix of social care professionals including the occupational therapy team.
Mavis’s children, Jeanette and Billy, have been with their mother since the start.
Jeanette said: “Mam received excellent care whilst she was in the emergency department. They were very patient, kind and thorough with her.
“The reablement team was first class, responding so quickly to adapt mam’s house and make it much safer. She loved everyone from the Hospital to Home Team and has never complained once about any of them, they were all very kind and lovely to her. No complaints at all about the first-class service and care mam received.”
Strategic system lead Rebecca Shea works for the trust and the council in a ‘system’ role – which aims to improve working relationships and improve system ‘working’ to improve outcomes for the people in the Middlesbrough area.
She said:
South Tees Hospitals is fully invested in this model of care that enables discharge and all staff work closely together on this pathway. The team members of the prevention services work together often coming on-site to work with the transfer of care hub and the site command centre to support discharges.
“These exemplar services are a valuable resource to help support the whole health and social care system to not only expedite discharge into people’s own homes, following the ‘home first’ ethos but also work hard to prevent people going into hospital in the first place.
“Both social care and South Tees are constantly developing and exploring more ways to work more seamlessly together to benefit the local populations that we all serve.”
Suzanne Hodge, Middlesbrough Council’s head of prevention, provider and support services, said: “This is a great example of the sort of partnership working that enables people to live independently for longer.
“Middlesbrough Independent Living Services work closely with South Tees Hospitals to support people to return to their own homes as they leave the hospital.
“Our reablement service supports people to regain independent living skills while our telecare service offers people like Mavis and their families the peace of mind that help is always at hand.”