Pendle West Case Study

September 2021

Reasons indicated on initial referral (GP or other organisation)

Patient B was initially referred by the INT in September 2020 due to social isolation, but it was decided that the Community Prevention and Engagement Team would work with her and they then referred to me in March 2021 when their support was completed. Due to the lockdown they had been unable to support her to access any groups to improve isolation and it was agreed that I would continue to look at this with B.

Background of client

B had a very complex history, she has learning difficulties and quite vulnerable. Lives independently, family are supportive, but not local. History of mental health issues and suffers from anxiety, some ongoing health issues that needed coordination by INT and has an issue with unnecessary overuse of 111 and 999 services. No formal package of care or any support other than a few friends. Isolated due to lockdown and mobility issues

Initial Assessment and Support Provided

I did a joint visit with CPET to meet the client and then was unable to do the initial assessment until a month later due to cancellations by B. In the meantime, the case was discussed at an INT meeting and there were a number of practical issues that B needed supporting with, including applying for PIP. I agreed to support with this.

Client wanted to get involved in activities, but due to lockdown the outdoor activities available were not suitable or of interest to her. We decided to revisit this once groups started reopening.

Along with regular sessions with the client, several case conferences took place which I attended. In time a package of care was put in place for social inclusion and general support. A lot of work has gone into supporting B and shows the complexity of some cases and the amount of people involved in their care. I have dealt with numerous calls from B when she’s been upset and from a family member. There have also been a lot of cancellations, which has made support difficult.

I have personally supported with:

Referral to the Integrated Therapy Team to look at exercises and aids to help mobility.

Referral to Medicine Support.

Support to apply for PIP, including referral to ICANN to complete form and gathering additional supporting documents and letters.

Joint visit with care agency and sharing information with them on social activities available in the area.

Application for Covid Winter Grant where B was awarded £200 to purchase continence products while awaiting assessment by continence team.

Support with application for a disability bus pass.

Support to contact and access health services and to understand information received about hospital appointments.

Client Outcomes

Client now has support from a named worker at adult social care and a package of care through an agency. Health issues are being dealt with more effectively and support has been more coordinated by sitting with the INT.

Although things are not perfect, the situation has improved vastly to what it previously was, and support is in place that B didn’t have before.

I have closed the case with myself, but B is still awaiting her PIP outcome. I have been informed by DWP that they will be making this decision without an assessment which hopefully means she will be successful. This extra income will help her a great deal, as she is currently on a low income.

Client Comments / Thoughts

"Thank you so much, Amy, for all the help you’ve given me. It’s really helped."