Case study: Detecting early signs of medical, social and mental problems in over-75s

Brigitte Knowles, Elderly Care Facilitator (ECF) at the Madeley Practice in Cheshire, developed an over-75 risk assessment project to detect early signs of medical, social and mental problems.

The risk assessments helped put appropriate interventions in place and improved the quality of life and independence of patients.

Brigitte provides annual health assessments to all over 85s and patients of any age who have dementia or are housebound. This includes making appropriate referrals and reporting back to the GP. She sends reviews and takes action on questionnaires sent to those patients between 75 and 84 years old as appropriate. Her most recent project has been the setting up and running of her own in-house carers clinic.

Brigitte links with local voluntary services; for example she worked with Keele University Psychology Department and a local school to develop personal biographies for older patients. She is a Dementia Friends Champion, has trained practice staff and was asked by the Dementia Action Alliance of Staffordshire to offer Dementia Friends training to other local practices. Brigitte has also provided Dementia Friends training in the community. She has been involved in the Beat the Cold Project, promoted appropriate awareness weeks within the practice, and set up a successful Age UK project to help patients with their claims for Attendance Allowance.

As well as short-term outcomes such as reduced attendance at emergency departments, other outcomes include increased detection, diagnosis and referrals for dementia, and increased social care provision and building resilience in older people.

The ECF role is now locally recognised as best practice and is being expanded to all North Staffordshire practices as part of a local improvement scheme. Brigitte led training of the ECFs and set up a social media group to network and provide support for them.