GPH Real Stories - Betty's Story

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June 04, 2020

betty low res

Betty is a lovely 92-year-old lady who has lived on her own since her husband died. Her only relative is her son John, who lives in Tasmania.

Betty struggles with bronchiectasis, ischaemic heart disease, hypertension and glaucoma and was admitted to hospital four times in six months before being referred to the Connecting Care program via the Aged Care Assessment Team (ACAT) - as she required assistance to coordinate services and care options.

Betty had refused to receive any in home services, preferring instead to rely on the goodwill of her neighbour Jill. At the time that Connecting Care received the referral Betty was in residential respite in a local Aged Care Facility.

 The first thing her Care Coordinator did was conduct a Mini Mental State Examination (MMSE). While Betty seemed like she was coping pretty well on the outside, she scored 15/30, showing there was certainly room for improvement.

Her son and neighbour had raised concerns about her ability to cope on her own. Jill was experiencing significant carer burden, stating that she could no longer provide the level of care to Betty that she required. John wanted to use his Enduring Guardianship authority to have Betty placed in permanent care. 

Betty’s wish however, was to return home. 

Due to COVID-19 restrictions at the time of referral and lockdown procedures in place at the Aged Care Facility (ACF), all Connecting Care activities were conducted by phone.

It also meant her son was unable to leave his home State.

The GPH Connecting Care Coordinator Liz, liaised with John, Jill, the ACF, the Illawarra Shoalhaven Local Health District Aged Care Clinical Nurse Consultant (CNC) and a local Homecare Package Provider.

Liz and the Aged Care CNC arranged for an urgent Geriatrician review, which took place at the ACF under strict infection control protocols. Betty was deemed to have the capacity to make a decision regarding where she lived, and it was agreed she would be discharged back to her home following a few more weeks in respite.

Liz liaised with a local Service Provider, who provided her with a Homecare Package Level 2 in the community immediately following discharge from respite.

Liz, said Betty’s autonomy was respected at all times:

“While John and Jill’s concerns were heard, Betty will get her wish of returning home.”

“Her son and neighbour have been assured that contingency plans are in place in the event that Betty’s return home fails,” added Liz.

The Aged Care CNC and Geriatrician have confirmed that if Betty is unable to cope at home with community services, she will be fast tracked to hospital under the care of the Geriatrician.

Betty’s son John says the coordination of services has been helpful, particularly during the lockdown:

“There has been a great deal of support that I have not had before.”

“I would have been at a loss when it comes to service providers and different packages, especially being based here in Tasmania,” added John.

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