Janet is 81 and lives alone in the Lichfield area. About 18 months ago, her daughter, Kate, noticed that her mum’s memory didn’t seem so good, and that she was having a lot of accidents around the house. Janet’s personality seemed different, and she got angry when Kate suggested she ask for help. A few months ago, Janet was taken to A&E after a fall, after she took an overdose of prescription medication. 

Support before leaving hospital 

While staying in hospital for treatment for the fall, Janet was assessed by a consultant psychiatrist, because there were concerns about her mental health. She was diagnosed with probable early dementia. The hospital referred her to MPFT’s Access team. This team makes sure that older adults get the right support to live safely at home. 

Because of Janet’s mix of needs, she needs support from different teams that work together to give wrap-around care. A community mental health nurse met with Janet and Kate to discuss all the help that could be put in place. 

Help to stay at home safely 

During the week, Janet has daily phone calls or home visits from the home treatment team (the community nurse and a healthcare support worker). The support worker has looked for community groups for Janet to get involved with, and Janet has been stabilised on medication for mood. 

The nurse knows that things can be difficult at weekends, and that Kate cannot always be there to help her mum. So she has asked the Hospital Avoidance team (HAT) to support Janet and Kate out of hours and at weekends. HAT has supported with phone calls and one home visit when staff were concerned after phoning.  

Positive outcomes  

Since HAT started supporting Janet, she has had no further episodes of self-harm, and hasn’t needed to go back to hospital.  

The community nurse has contacted social care to arrange a carer’s assessment. A care package is in place to support Janet with independent living. This includes a carer visiting to help her with washing and dressing.   

What is a care package? 

A care package is a combination of services put together to meet a person’s assessed needs as part of a care plan. The services could include things like: 

• help with cleaning and shopping 
• help with personal care, like washing and getting dressed 
• adaptations to your home to make everyday living and activities easier to manage.