0191 561 3328 atb@nhs.net

Betty Smith* is one Sunderland resident who is receiving better care thanks to information sharing that means she only had to tell her story once, and still got care wrapped around her needs.

Betty has a range of conditions including a long-term respiratory condition and mobility issues.  She had been to see her GP and was started on new medication and a nebuliser to help her breathing, but the next day Betty became very poorly, finding it hard to breath and her carer called an ambulance.  At A&E, the team could quickly access her records, saw her medical history and the new medication that had been prescribed and could act quickly to treat her.

During the examination Betty’s family said that she was not managing at home and was struggling to get dressed, move around the house and prepare meals. The medical staff asked the Recovery at Home OPAL (older person’s assessment and liaison) team to assess Betty to see if she could be supported at home rather than be admitted to hospital.  Because the team also had access to Betty’s records they could quickly respond.  The OPAL nurse used a tablet device to access additional information and could see that Betty was receiving care and support from the Community Integrated Teams – newly formed area-based teams of health and social care professionals who deliver care to people at home.

The OPAL nurse called Recovery at Home– the newly formed team of health and social care professionals designed to step up home-care to support people who may otherwise end up in hospital – and gave some basic details to the staff taking the call.  The care coordinator they spoke to had access to view more details on the patient’s record, previous medical history, current medication, allergies and the current level of support required and a short-term package of care was agreed, including daily visits from a nurse and a referral to the Reablement Team for daily support at home. Betty and her family were also given the Recovery at Home number to call 24/7 if she felt she needed more support once she got back home.

The following day Betty called Recovery at Home saying they felt short of breath, the nurse logged into the new system and could see what support was in place, and was to reassure Betty that a nurse would be with her soon and that she would not need to go back to hospital.

Over the course of a couple of days, Betty was monitored by the Recovery at Home team and an electronic referral through the new system was sent to the Community Integrated Team to take over her ongoing care at home as she settled back in.

An electronic note was made on the system during every stage, which means the most up to date medical information is instantly available to the professionals who need, it as well as Betty’s GP.

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