Preparation - What this means for Kathy

What preparation means for Kathy - Senario 1

Preparation for the process:

Megan the local Dementia Advisor, talks to Kathy about the care and support planning process and what to expect when they first meet.

Kathy had lots of questions about dementia and her job and wants more information. Megan talks this through and shares information leaflets and the dementia guide.

She asks her how she would like to get her personal information as part of personal care and support planning. Kathy asks to have information emailed to her rather than letters. She has already had a range of tests that resulted in confirming her diagnosis.

Megan asks Kathy if she will complete some information before the conversation about what is important to her and what is working and not working for her. She also asks about her overall health, what she wants in the future and any ideas or suggestions that she has.

Megan asks Kathy if she would like someone to help her do this. Kathy said that she would like Sue, her daughter, to be involved. She also likes the idea of involving a Dementia Advisor volunteer. She looks through the file of volunteer one-page profiles and photographs and thinks she would get on with Joan.

Preparation by the practitioner:

Megan takes the lead on preparing for personal care and support planning working in close partnership with the GP. They discuss the additional information (over and above the reflective prompts that are always included) that will be needed to assess her overall health, and activities of daily living and checks with the social worker that she is currently unlikely to be eligible for social care so she doesn't include financial assessments at this stage.

Preparation by Kathy:

Joan contacts Kathy and arranges a time to come and talk after work, when Sue is available at Kathy's house. They look at what is working and not working for Kathy now and what is bothering her. They then make a start on capturing what matters to her talking about her relationships and who the most important people are in her life.

They also talk about aspirations and Kathy talks about her anxieties and fears about telling work and how important her relationships are. This took place over three meetings, going at Kathy's pace, as Kathy was still coming to terms with her diagnosis.

What preparation means for Kathy - Scenario 2

Preparation for the process:

Kathy has just come out of hospital after a UTI and a fall. She has developed a small foot ulcer while she was in hospital.

She is at home with an emergency package of support (and has an appointment with her GP) and is finding it difficult to look after herself and her house. The GP asks Megan to suggest an early review of her care and support plan, including reviewing all her assessments and reflective prompts.

Kathy now meets the criteria for Integrated Personal Commissioning and is likely to be eligible for a personal budget. Megan and the team makes all the arrangements for the new documentation and appointments including arranging for the social worker to visit Kathy and Sue, in the evening when Sue is available.

Since Joan has moved away Megan and Kathy discuss other volunteers who could help and pick Alison who lives locally. Alison is given Kathy's personal profile as an introduction.

Preparation by the practitioner:

Megan reviews the new situation with the GP, practice nurse and social worker. The GP is worried about her foot ulcer - and suggests the district nurse goes over with her how to dress it - but pops in to check and also to take glucose tests - in case she needs changes to her tablets.

They discuss who is best to talk about advance planning. Megan talks to the social worker who wants to meet with Kathy and Sue to assess her and to help her complete a financial assessment. This will inform the calculation of an integrated personal budget to help meet her health and social care needs.

She has a copy of Kathy's current one-page profile to learn a bit more about her before the meeting.

Preparation by Kathy:

Alison contacts Kathy and Sue to arrange a time to talk when Sue is available as well, at Kathy's house.

They look at what is working and not working for Kathy now and what is bothering her and they update her one-page profile.

They also talk about aspirations, and Kathy found this harder. She wanted to be able to carry on at the club and garden again, to stay at home and to feel useful.

The social worker started with the information Kathy and Alison had developed and this helped to inform the assessment process.