1. CASE STUDY Colin was a 66 year old gentleman who was diagnosed with motor neurone disease in August 2011. He lived at home with his wife and carer H. There were a large number of professionals involved with Colin following his diagnosis, health, social care and the 3 rd sector all played a part in Colin’s story. Colin and H understood the severity of Colin’s condition and had a desire to make Colin’s remaining time as comfortable as possible whilst maintaining his independence for as long as possible. As predicted Colin’s condition rapidly deteriorated over a short space of time before he finally passed away in June 2012 shortly after an emergency admission to Stafford Hospital. This case was studied to understand the issues faced by Colin during his period of working with multiple services. COLIN

2. Community OT GP Organised chaos.. CIS Non Partnership Partnership ASC SALT Dietician Dom Care Agencies Multiple assessments/plans Referral Central Telephone directory Chase, chase, chase!!! Duplication of information Invisible information Delay / Rework Confusion “Who do I call..?” COLIN Social Care Assessor District Nurse Physiotherapy Social Care OT Wheelchair Services Katherine House Hospice Assistive Technology Social Worker Respiratory Physio “What’s going on with..?” “Who’s coming today..?” “I thought I told you that before..?” “So what happens next..?” KEY

3. A different way..? Care Co-ordinator OTNursing Partnership Trust – Integrated Care Team GP Social Work Physiotherapy Patient/user ‘Expert’/’Champion’ Patient/Family/Carer/ Professional contact Team around the patient/carer “I felt that people really got to know me and understood what mattered to me.” “I always knew the next steps.” “I’d always contact xxx” “I never had to repeat myself and everyone who came knew so much about me and my situation.” “I know what the plan is as I helped put it together.” “Everything happened really quickly.” “It felt like I was helped by a single organisation.” Understanding of Colin, what he wants and how he wants it. One holistic assessment of all need & one plan. ‘Pull’ not refer. Single point of contact (expert) for patient/family/carer/ professionals Professionals capable of doing what makes most sense to Colin Transparency of all information relative to Colin & his help/support ‘PULL’ support ‘PUSH’ knowledge COLIN Non Partnership Partnership KEY