Meet Jim - an elderly person with complex health and social care needs

Jim is 80 years old and was previously married to Mary, who died nine months ago. He has two daughters who are both married and live a few counties away and they have three children between them.

Although now retired, Jim used to work as a fitter in a local engineering firm. When he was younger he loved bikes, DIY and family trips. He is a member of the local church, having once been a lay preacher.

He was admitted to hospital with a stroke four weeks ago.

In the following case study, we describe two scenarios for personal care and support planning for Jim. The first assumes a lead role for the GP in supporting Jim through personal care and support planning, while the second describes the process where the social worker plays the lead role.

Both of these scenarios are plausible and viable for Jim and help to demonstrate the flexibility of roles and approach advocated in this resource.

What's Important to Jim

  • Loves his cat, which reminds him of Mary
  • Doesn't want to go into a home or be a burden on his family
  • Going on family holidays
  • Spiritual well being and getting to chapel once a week
  • Personal hygiene and a smart appearance

Daily living

  • Less-able to get around and do things
  • Not going out as much as he has a fear of falling
  • Has his shopping delivered or uses ready meals
  • Sleeps badly since Mary died and is often woken by shortness of breath
  • Can't manage to dress or bathe by himself since his stroke

Events, issues and concerns

  • Shortness of breath
  • Pain
  • Poor sleep
  • "Taking all these medicines"
  • Falls happening more frequently
  • Feeling "up and down"
  • Poor use of left hand and uses a stick to get around the house
  • Feeling "useless"

Annual 'health' tests

  • Pulse oximetry
  • Peak flow
  • Spirometry
  • Blood pressure
  • Cholesterol
  • INR
  • Smoking status
  • Depression screening
  • MRC scale
  • MUST/FRAT scores
  • Frailty index
  • Blood tests; LFTs. Uand Es, FBC, TFT, glucose
  • ECG
  • Chest examination

Resources / Assets

  • Son in law, who does small jobs around the house such as fitting a ramp and a hand rail for garden access
  • Jim is also a practical problem solver
  • His family previously bought a mobility scooter but it remains unused in the shed.
  • Has worked out he could get a bath at a local home
  • Friends from chapel come and offer support and communion at home

Health concerns and provision

  • COPD
  • Heart Failure /CKD stage 3
  • Atrial Fibrillation
  • Falls and leg ulcers
  • Osteoarthritis
  • Ex smoker: teetotal
  • District nurse visits to do dressings and occasional blood tests
  • Attends cardiology clinic since diagnoses with heart disease three years ago


  • On 12 different medications including
    • Six pills for his heart
    • Three inhalers
    • Two pain killers
    • Warfarin to thin the blood