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Team Up Derbyshire in action - a case study in providing person-centred care



The case study has been provided courtesy of Dr Natalie Craven of Arch Primary Care Network


Team Up Derbyshire received a referral for a patient aged in their late 90s suffering from acute vertigo. The person lived alone in a ground floor flat and had a package of care twice-a-day. In the 48 hours prior to the visit, the patient had been seen by three other teams – East Midlands Ambulance Service, out-of-hours GP and the surgery GP.


Team Up was able to assess the individual, chase up the delayed prescription for the vertigo symptoms and also discuss advanced directives regarding her care. This involved the completion of a ‘Respect’ form not previously considered or completed. The Team Up community GP was able to speak to the person’s family regarding this conversation as they were not living in the local area.


The patient’s neighbour had been staying with her all day and overnight for the last 48 hours as the patient was unable to walk to the toilet independently. Team Up liaised with the community access point and arranged an urgent therapy response for assessment, and delivery of a walking frame and commode, meaning the patient was able to safely remain at home while symptomatic. This was achieved within two hours of the Team Up community GP visit. The care-coordinators also received a referral.


The individual was booked for follow-up support from Team Up to optimise their blood pressure, and was forwarded to the multi-disciplinary team for an increased package of care. The patient made a full recovery within a week of starting medication and was managing independently at home with their new care package.


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