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Case Study - Improving Clients overall Health and Wellbeing

In September 2017, TPG Complex Care began working with a client in the Midlands who suffers from MS and requires care and support from carers 24 hours a day, seven days a week.

When we started working with our client, he was in an Acute Care setting having been hospitalised due to his condition and had no appropriate discharge plan or care team in place. The client’s family were given the option of placing the client in a nursing home upon discharge; something neither they nor the client wished to happen.

TPG Complex Care assessed the client and his condition to create a tailored care plan specifically for the client and an appropriate discharge plan. Our discharge and care plan meant that the client would be able to live in his own home, with his family, once again.

Our nurses and carers then started shadowing the client’s Acute Care teams and received practical training, whilst the client was still in the hospital, to further their knowledge and expand upon their training already completed with TPG Complex Care. This training allowed our Clinical and Operational Managers, as well the client, his family and clinicians to assured that those looking after the client, when he was discharged would be able to meet all of the client’s clinical needs. Our team’s time spent in training in the hospital also meant that they were able to build a relationship with the client and his family prior to him being discharged.

Before the client was discharged, our team assessed the client’s home environment and made all necessary changes to the environment to allow a safe discharge from the hospital.

Since being discharged from Acute Care, our client’s overall health has greatly improved and we have been able to ensure that he has not needed to be readmitted to an Acute Care setting. Likewise, we have been able to see a huge advancement in the client’s communication. Our client is now able to smile, laugh and use of forms of non-verbal communication such as hand-movements and nodding; something his Acute Care Team did not think he would be able to do again.

We are now exploring options with the local Speech and Language Teams to come and review the client with the aims of supporting him in developing verbal communication skills; giving back the client more control and choice within his life.

We have been able to reduce the number of PEG caused bouts of sickness the client experienced by adapting PEG usage and timeframes, working with specialist clinicians to alleviate the client’s nausea. Reducing nausea has greatly improved the client’s quality of life and has allowed him to be happier in his own home.

High-quality and proactive care has allowed our client to remain comfortably in his home, for example, our carers picked up on some respiratory issues which are now closely monitored by our carers and reported to specialist clinicians. Without our carers identifying and addressing these additional healthcare needs, the risk of our client being readmitted to the hospital was high. TPG Complex Care has received extremely positive feedback from the local Continuing Healthcare Team regarding our high-quality care and support to the client, and from the client’s family; who thought the complexity of the client’s care needs meant he would never the able to live within his family home again.

Our service design and structures allow us to provide the best care and support possible; reassuring our clients, their families, clinicians and our commissioners that our clients really are in the best hands. We believe that TPG Complex Care exists to actively improve our client’s quality of life and stories such as this one reinforce this belief.

Further Information

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