Focused Care

Healthcare generally relies upon patients contacting services when they are unwell and many services run so that the most vulnerable are pretty invisible to doctors and nurses. We have developed something different and called it focused care.

A Family's Story

A family joined the list, including a young mother who was pregnant. During the pregnancy she discovered she was HIV positive. Other members of the family were known to be HIV positive. The family had not engaged with the specialist hospital services. Ruth worked with the family and gained their trust. She spoke with the specialist nurses and agreed a plan that meant the nurses doing home visits and Ruth accompanying the mother to hospital appointments. When the beautiful baby was born it was found to be HIV negative. This is due to a high level of compliance with medication.

Life can be challenging, and for some of our patients, chaotic. Healthcare generally relies upon patients contacting services when they are unwell and many services run so that the most vulnerable are pretty invisible to doctors and nurses. We have developed something different and called it focused care.

If one of our staff, be it a doctor, receptionist or healthcare assistant, thinks that life is just too tough and unmanageable for a patient they go onto our focused care programme. Ruth, Adele, Josie or Jen will come and visit and find out what’s really going on with the patient, and whole family. From this basis a joint plan is made involving the patient, other agencies and the practice.

What’s the aim of the plan? To gradually unpick the difficulty and the mess bit by bit. This may be by establishing routine with children, getting help with addiction, counseling for anxiety, or going to meet the housing association to address rent areas.

Accessing childcare, completing job searches, managing anger courses. We have found double buggies, given out emergency food parcels, and written letters that have got families re-housed. Painted rooms, de-cluttered, cleaned… and encouraged activities that nurture social links.

Focused care patients are discussed by our staff, other NHS staff, and other agencies at a monthly meeting. When life is more stable you come off the list, and when your life is more stable you care more about health.

FOCUSED CARE AUDIT: PRESENTING PROBLEMS

The size of the shape illustrates the number of times that the problem was presented.

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