Developing Integrated and Enhanced Primary Care and Community Responses

Angus HSCP aims to deliver performance that meets the aspirations of Angus communities. This includes supporting individuals to stay at home when appropriate. If a hospital admission is necessary,

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Our Practice

Monifieth Integration Care
Case Study -Overview

Mrs P is a 74 year old lady, she was diagnosed with early symptoms of MS in 1977, she has lived a very independent life at home in Monifieth however, went to live with her daughter at the point of lockdown in March 2020. While living in Edinburgh she had a catheter fitted due to extreme nocturnal continence problems. After this was fitted Mrs P has suffered frequent urine tract infections causing her to experience delirium.

Daughter contacted H&SW in early August to refer for support as Mrs P was to return home. Following lengthy conversations between HCA, Mrs P and daughter to assess needs it was established that a long term service would be needed rather than referring to Enablement to support.

As social work staff and D/N are now co-located in the health centre, HCA and D/N’s were able to discuss the case at length focusing on the vision of prevent, detect and treat illness. The team were also able to discuss the case through daily ‘huddles,’ or communicating directly when additional new information was highlighted connected to Mrs P’s care, giving the team the most up to date information on the situation. This enabled the team to guide care providers in delivering and supporting Mrs P in meeting her personal care outcomes. This method of information sharing gave the team the opportunity to relay the same information to the daughter so she was fully aware of the situation.

As part of MIC the team have access via MDT on a weekly basis to a Consultant from Medicine for the Elderly, who can give expert medical advice on health and medication. The Pharmacist also attends this weekly meeting so we can discuss the right medication regime and how medicine is best dispensed. HCA and D/N were able to discuss case directly with physiotherapy who attend MDT and NHS Occupational therapy who are based in the centre also attend. The team work directly with NHS OT if any concerns are raised through their home visits.


Through discussion with Mrs P, D/N GP and Consultant that having the catheter in was detrimental to her health and wellbeing a decision was made with Mrs P to remove it and for her to use continence wear day and night.

As HCA was part of the discussions & decision making, HCA was able to discuss the new outcomes with the care provider to give them time to schedule the increase to support continence management when it happened.

Mrs P’s medication was thoroughly explored at MDT and it was recommended to move one of the tablets from morning to night time as it caused drowsiness which impacted on her abilities in the morning.

Due to Mrs P’s condition and a deterioration in mobility was felt she was at risk to carry out meal preparation and her care package teaks were extended to incorporate meal preparation lunch and tea time. Following from MDT discussion Physiotherapy were to visit the next day to assess mobility aids. Mrs P is very happy with the decision to remove the catheter and is working well with the care providers in meeting all her outcomes within her home.

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