Scott's story

Pulse Community Healthcare's proactive approach to rehabilitation.

When he was 21 and studying at university, Scott was involved in a road traffic accident whilst crossing the road with his friends. He suffered a brain injury and, as a result, underwent a cerebral shunt and tracheostomy. Sadly the accident also triggered epilepsy and although Scott was able to make eye contact and smile, he couldn’t communicate verbally or respond to verbal stimuli, he also lost independent movement which meant he couldn’t eat and needed to be supported with full continence and urinary care.

After living in a rehabilitation facility for two years, Scott’s family was advised that no further rehabilitation was possible. Keen to get him home, Scott’s family purpose built an extension on their house suitable for his needs and applied to have him discharged. The application was successful and Scott came home. He had a physiotherapy programme but was still deemed ‘not fit for rehab’.

With immediate effect, we implemented a ‘care planning’ process, which involved creating a tailored package of care focused on Scott’s physical and emotional needs. We ensured that all stakeholders – including Scott’s family, hospital team, rehabilitation facility team and GP – were comfortable with, and confident in, our proposed service prior to him arriving home. When Scott did return home it was to 2:1 night support and 12 hour 1:1 day support which was doubled up four times a day for personal care and manual handling.

Because our packages are built around the needs of our clients and their families, we like to involve them in selecting their carers. This meant that, prior to the care commencing, Scott and his family were familiar with all members of the team, as well as knowing they’d been through our stringent checking process. Each team member received training specific to Scott’s needs and their roles and responsibilities were integrated with his occupational therapy and physiotherapy programme.

Importantly, the care team provided emotional as well as clinical support, for example, time spent talking about the impact Scott’s discharge would have on his family. They had spent so much time in the rehabilitation unit over the past two years and needed reassurance about handing over some of Scott’s care to their new support team.

As well as attending all outpatient appointments at the local hospital with Scott, the Pulse Community Healthcare team focused on improving his independence and quality of life. With this in mind the CCG reapplied for a specific turning bed – something that had originally been rejected – and within four months the bed was in place and day and night care could be reduced to 1:1. Scott’s family also applied for him to be reassessed by a physiotherapist so he could receive client-centred physio to improve his mobility. Initially, this request was refused by the brain injury team, who wanted to see some signs of improvement in Scott’s condition before committing to these sessions. In response to this, Scott’s care team kept a diary on his daily progress in order to monitor how he was doing. The diary clearly displayed slight improvements in his condition and, as a result, the brain injury team agreed to provide care.

To date, Scott, who has now lived at home since May 2012, has made considerable progress. Both his health and social well-being have improved significantly and his family members are now involved in all aspects of his care. He is now walking without aids, by holding hands with his carers, using a self-propelling wheelchair, washing and shaving himself and communicating in small sentences through a talking valve in his tracheostomy. He attends the local swimming pool for hydrotherapy and, most importantly for Scott, he’s able to go with his family to watch his beloved team Manchester City play football.