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Tom was referred to the Connecting Care Program through his local GP.
Tom has a history of congestive cardiac failure, diabetes, mild emphysema, labile blood pressure and increasing renal impairment. More recently Tom had sustained a skin tear on his leg that was being dressed by the community nurse and had a troublesome cough.
When Karin, the GPH Care Coordinator first contacted Tom, he and his wife Janice declined a home visit due to the COVID-19 pandemic and were wanting to keep Tom physically distanced as much as possible. They were however, happy to have a discussion regarding Tom’s health over the phone.
An initial assessment identified that Tom was having difficulty in traversing the hob in the shower, he was also struggling with mobility in general, was due to have renal stents replaced but had not been able to have the necessary surgery due to COVID restrictions and was at risk of wound infection with multiple comorbidities.
Karin encouraged Tom to follow up with his GP regarding his cough and arranged a visit with an Occupational Therapist to review his home for improved safety measures. A letter was also sent to Tom’s GP advising of the outcomes.
Unfortunately, the wound on Toms leg became infected and he developed significant oedema in his legs and was admitted to hospital.
Karin met with Tom at the hospital along with his GP to discuss his discharge plan and ongoing care. She then met with Tom and Janice to discuss a home visit post discharge, which was readily accepted.
Karin was able to help secure a ComPacks package for Tom to help with his return home from hospital and provide domestic assistance.
“We feel really well supported by the systems put in place, said Tom and Janice “Now we are looking forward to going home,” they added.
