03 December 2024
Within the catchment, there are approximately 129,000 people living alone*, and an estimated 38,432 people living with three or more chronic conditions*. Living alone can be challenging, especially when you are living with complex conditions that require compassionate, multidisciplinary care. This is the case for Ravi, an 86- year-old living in the catchment with a complex history of health issues.
Ravi** lives with lymphoedema, hypertension, GORD, hypercholesterolemia, and bowel cancer. Recently, he was admitted to the hospital for pneumonia and received new diagnoses of atrial fibrillation and heart failure. Ravi has also struggled with his mental health since his daughter passed away several years ago, which impacted him greatly.
Given the complexity of Ravi’s physical and mental health, his GP referred him to the Right Care Better Health program. Funded by EMPHN and delivered by EACH, the program provides wrap-around services to support people in the region with chronic and complex conditions, aiming to improve quality of life and lower rates of avoidable hospital admissions.
Ravi was assigned an EACH nurse care coordinator, who visited him at home. The nurse identified that despite a home care package and domestic support already in place, there were some areas that could be improved so that Ravi could live a healthier life at home and be armed with the information he needed to manage is complex conditions.
Upon his initial assessment, it was determined that Ravi’s main areas of concern were his mobility, confusion about his recent diagnosis of heart failure and how to manage the condition, difficulty using steps at his home to access the garden, and difficulty accessing transport to appointments.
During his four months with the Right Care Better Health Program, the nurse care coordinator worked closely with a multidisciplinary team to organise several referrals, appointments and education sessions, to help Ravi feel empowered at home.
This first involved the recommendation of a 75+ Health Assessment, which gave valuable insight into how Ravi was managing at home to his GP, who could utilise this as a baseline for future comparisons. A referral was then organised by the nurse care coordinator for a Home Medication Review, which enabled a better understanding of medications for Ravi.
Due to Ravi’s recent diagnosis of atrial fibrillation and heart failure, the nurse care coordinator also liaised with Ravi’s GP for a cardiology referral and pathology, to ensure he was receiving regular specialist care. On top of this, it was also organised that he receives heart failure education from another Right Care Better Health Nurse with a cardiology background, so that he could be armed and informed with the right knowledge to manage his condition.
Because Ravi did not drive, he had trouble accessing his medical appointments, and faced difficulty getting outside due to his mobility. The nurse care coordinator arranged and assisted Ravi to submit a Multipurpose Taxi Program application and also for an Occupational Therapy assessment for an accessibility ramp outside of his house, which was promptly installed. This access to accessibility allowed Ravi to have physical ease and a sense of independence in his own home.
Recognising that Ravi was living with grief and mental health concerns, the nurse care coordinator also offered referral for a Mental Health Care Plan.
Since joining the program, Ravi has gained a better understanding of his conditions and medication management, connected with specialists and allied health workers, accessed transport for appointments, received mental health support for grief and family concerns, used the accessibility ramp to access his garden, and developed an ongoing plan with his GP.
With the right plan in place and a multidisciplinary team, Ravi’s health and wellbeing has been greatly improved to allow him to live a healthier life in his community.
“I enjoy having the time to thoroughly listen and assess my clients, resulting in a comprehensive care plan that will maximise their health and wellness.”
Nurse Care Coordinator, Right Care Better Health
*ABS census data
**Name changed to protect identit
