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A day in the life of...An elderly care facilitator

Soline Jerram

My day starts around 6am, when I often put in an hour on my MSc - I am on the last leg and working on my thesis.

Between 8 and 8.30am I arrive at the first of the three GP surgeries that I work with - I have an office at one. and I lodge at any spare desk in the other two. I cover 14 nursing and residential homes, for which I am the first contact from 9 to 5 on weekdays for any medical or nursing concerns, and I also have a number of others that contact me ad hoc for advice.

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In my area there are about 40-45 nursing and residential homes situated in the town. Many of these have patients registered with at least three of the five GP surgeries in the area. There can often be two different district nurse team members and two or three doctors visiting on any one day. To reduce this overlap, to have some continuity and to ensure access to specialist nursing, the nurse practitioner service was developed to work with three GP surgeries across 14 of these homes, with the aim of extending this service at some stage.

When I get to my main office I check my answerphone and return a call from a nurse specialist who would like to discuss setting up services to homes in her area. I have built up a wonderful network of colleagues across the country in the past three years and often have people ring or visit for information.

I also return a call from a senior carer in one of the residential homes asking for some advice about Mary, a 96-year-old female resident. Mary has decided that she does not want to take her diuretics anymore, even though they are keeping her heart failure under control. I make a note to visit later in the day.

At each of the 14 homes I cover I hold a regular three-weekly clinic, and today it is the turn of one of the elderly mentally infirm (EMI) homes. This protected time allows for care staff to discuss care concerns, and for me to monitor residents with chronic diseases such as diabetes and to review medication regimens.

I also like to meet new patients and complete a new patient assessment; this is a good opportunity to introduce myself, establish a relationship, and identify any present or potential health or caring concerns. When I am in a care home for a clinic, I will also undertake any of the routine work, such as dressings, that would normally be done by the staff nurse on the team.

First, however, my mobile phone rings and I am called to see a 97-year-old lady who is very unwell with abdominal pain. This visit results in my admitting the lady to hospital, and involves ringing the bed manager of the acute hospital and girding myself against another inquisition as to the appropriateness of a nurse referring a patient for admission instead of a GP. Although advanced nursing practice is highlighted as an integral part of future service delivery, many medical and nursing professionals remain reluctant to embrace this.

I finally head off to the EMI home and deal with a range of problems, including a patient with increasing episodes of aggressiveness, a lady with a chest infection, and a tissue viability risk assessment.

I return to my office at about 12.30pm after visiting the other two surgeries to check for messages, update the computerised notes of the patients I have seen that morning, and have a quick word with one of the GPs.
Working across three surgeries cuts down on the number of individual professional visits that a home needs in a day; however, it has its problems for me as I need to regularly visit all three surgeries to record consultations. I just wait expectantly for good IT support.

I am not good at stopping for lunch, but I often recharge my batteries by driving to the seafront and taking some deep breaths of sea air. However, today I am at a meeting of the steering group for a medication compliance aids project. This has been running for the last year, and we are planning the evaluation process.

After the meeting I nip round the wards of one of the three community hospitals on my patch and update the ward sisters on the changes to the structure of the staffside union representation since our recent move to becoming a PCT.

I have been an RCN steward for 14 years, and since the formation of the PCT, and our split from the psychiatric ­service, at present I am the only steward in the PCT.
I leave the hospital and drop in to see Mary about her diuretics. I give her a physical examination to check her present health status. She is feeling down and is fed up with having to keep struggling to the toilet. We often have this chat, and we share a few thoughts; we make each other laugh and then she agrees that she will keep taking the pills for "a bit longer". While I am there I check on an 80-year-old who is unwell and off her food. After a physical examination reveals nothing of note, I ask the staff to get a urine specimen, and reiterate my usual advice about encouraging fluids. Urinary tract infection is a common cause for an elderly person feeling unwell with no specific symptoms.

I visit two other homes and then return to my office to complete some notes from the day and to refer a stroke patient to the community rehab team for assessment. It is now 5.30pm and I am feeling weary. I get home and check my emails (I am not linked at work). Not too many today, but an invitation to be part of a Department of Health advisory group on care of older adults looks very interesting.

I feel lucky to have my job. Care of the frail older adult has a poor reputation with some, but it demands the highest personal skills and clinical knowledge to sort through the myriad of vague symptoms and the multipathology that most of my clients live with. Caring for this population is about understanding complexity, but it is also about kindness, patience, honesty - about quality of life and providing comfort.

If you would like to comment on this article, or if you have an issue you wish to discuss, email NiP@campden.com