Case Studies – Team up Derbyshire » Joined Up Care Derbyshire

This set of case studies shows the positive impact of NHS Derby and Derbyshire’s flagship Team Up service for patients.

The examples show how the team improve people’s health – this includes helping them with issues such as housing, debt and isolation as well as clinical and medication issues.

Team Up Derbyshire is one team across health and social care in Derby and Derbyshire who see all the people in a neighbourhood who are currently unable to leave home without support.

Team Up helps complex canal boat resident find suitable home and reduces hospital admissions

A lady with significant medical problems who was living on a canal boat and struggling to engage with NHS services was helped to find a suitable property and reduce her healthcare needs.

The lady had been known to the GP for many years but her health was clearly in decline and she did not have any regular package of care to help her cope.

The lady was referred into the Team Up complex needs service by her Local Area Coordinator after it was noticed she was contacting the surgery 2-3 times week with unmet health needs.

She had also been admitted to hospital 5 times over the course of a year.

Once Team Up got involved, their social prescriber contacted the local area coordinator at the council who was able to find her a suitable property to live in.

The Team Up multi-disciplinary team discussed her case and ensured the right professionals were helping her, including registering her with a new GP, the social prescriber to look at her life and needs more holistically and the council to help with her housing needs.

She has since reduced her calls to the GP by 90 % and has not been admitted to hospital since.

Team Up pharmacist removed eight bags of medication from patient with NHS trust issue

A Team Up pharmacist removed eight bags of prescription medication from the home of a complex patient who was refusing to show anyone her medication.

The lady, who had complex mental and physical healthcare needs, was referred to Team Up after her GP and other NHS services noticed an increase in calls for help to the GP and transfers to hospital.

Through looking at the East Midlands Ambulance Service data provided to Team Up, they were able to see an increase in her patterns of need.

After discussing her case at the Team Up multi-disciplinary team a range of professionals became involved including the local area co-ordinator, adult social care, the social prescriber and the pharmacist.

The Team Up pharmacist visited her at home once a fortnight, but it took a month of weekly visits before she would share any information with health professionals.

Once the pharmacist accessed her medicines, she discovered the lady could only manage to take them twice a day and had been hoarding them instead.

Since then, plans have been put in place around her care, including mental health support for her and guidance for clinicians, organisation of her medication and key information about her for other professionals.

She still needs considerable help, but this is now co-ordinated and unnecessary admissions and tests can be avoided saving the patient unnecessary stress, the NHS money and freeing up space for other patients.

Man with waist down paralysis helped by Team Up to stay out of hospital
A man with waist down paralysis was being admitted to hospital frequently until he was referred into Team Up.

The man, who had been a keen sportsman before his accident, had had unsuitable housing and was using taxis to get to public toilets because his home needed adapting.

He was referred to the complex care team where, following their multi-disciplinary team meeting, the local area co-ordinator, social prescriber, pharmacist and health and well-being coach stepped into help him.

The GP, social prescriber, health and well-being coach and pharmacist all visited him and helped with housing, mental health, finances and medications.

He has since reduced his use on NHS services, been found some new accommodation with a suitable toilet and has not been taken to hospital since he moved house.

He is now trying to get back to some mobility with his health and wellbeing coach.
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Team Up help alcoholic evicted from YMCA with heart failure become sober and take medicines

A patient who did not speak English and was addicted to alcohol was supported into rehabilitation and helped to take their heart failure medicines after being referred to Team Up.

They had been evicted from the YMCA due to drinking alcohol and were unable to take medicines dispensed in blister packs as they could not understand the English instructions.

They were referred into Team Up’s complex needs service and a range of professionals stepped into help. This included: GP, Social Prescriber, Pharmacist, and Heart Failure Team/Drug and Alcohol Services via wider Multi Disciplinary Team Meeting.

The pharmacist supported the patient to start taking their heart medication, preventing hospital admissions, and they were admitted to Centenary House.

One example of the personalised care the team delivers, was when the patient’s medicine was not available on time. The Team Up pharmacist knew the likelihood was hospital admission if the patient did not take it that day and picked up the medicine and delivered it to Centenary House.

Without the connections from Team Up this patient would have been admitted costing the taxpayer and using a hospital bed.

Team Up Admiral Nurse ensured man with dementia died at home avoiding unneeded admission

A man who had dementia was able to die at home with his wife, who also had dementia and would have struggled in hospital, thanks to the careful planning of the Admiral Nurses from Team Up.

The couple were referred into Team Up after concerns from their GP that the care package was not servicing their hygiene needs.

The nurse was able to increase their care package and refer the man to palliative support having seen a decline in his health.

Having previously done some end-of-life planning with the family, the nurse was able to prevent an end-of-life hospital admission and he was able to die at home with his family around him, as per his wishes.

His daughter was then supported to take her mum into their home and care for her and she is now thriving in her new setting.

Dementia patient supported to die in his care home surrounded by family and staff he knew thanks to Team Up

A man who had dementia and pulmonary fibrosis was supported to die at the care home that had become his home thanks to the rapid response and availability of senior decision makers in the Team Up team.

Following a hospital admission, the man was put under the care of Team Up, after becoming terminally ill.

Upon his return to the home, he continued to deteriorate rapidly and although care home staff felt strongly he should be allowed to remain in the home, the hospital ReSPECT form did not adequately support them in this.

Team Up and paramedics were called simultaneously by staff in the home.

The Team Up Advanced Care Practitioner arrived first, assessed the patient and spoke to care home staff and the family before calling the Team Up GP for support.

The Team Up GP attended within the hour and stepped down the paramedics.

The GP initiated community palliative care providing support to the family and care home staff.

This prevented an unnecessary end-of-life hospital admission, by keeping him in the care home.

He was able to die surrounded by his family and staff who knew him well, in line with his family’s understanding of what his wishes would have been.

The timely response also allowed the EMAS crew to be freed up to attend a more appropriate case in need of their specialist skills.

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