Getting it right for everyone (GIRFE)

Situation

• Older female, Anne, was admitted to community hospital from Accident and Emergency with a fractured left humerus for rehabilitation.
• Anne is normally independent with a walking stick and uses a mobility scooter to visit friends and do her shopping.
• Anne began to experience reduced mobility with falls at home and her family report increasing frailty with reduced ability to cope.
• She hoped to receive rehabilitation care at home, rather than in hospital, so that she could be near her family and friends.
• Due to frailty, occupational therapy recommended a period of intensive rehabilitation, which required inpatient care.
• Anne was not receiving health and social care support at home.

Risk

• Reccurrence of falls and hospital admissions due to poor mobility.
• Delayed rehabilitation and discharge from hospital.
• Social isolation, lack of social and community networks.
• Series of falls reduced Anne’s confidence and independence.

Action using the GIRFE approach

My team

• A team was established, including Anne, occupational therapy and physiotherapy, nursing team, integrated care team (community rehab), family and advanced nurse practitioner.  The team worked together to formulate a rehabilitation plan.

Team around the person

• A team around the person meeting took place between senior advanced nurse practitioner, occupational therapy, physiotherapy, and integrated care team. Anne and her family also attended this meeting, and Anne was able to share her views on her care provision. Although Anne preferred to receive rehabilitation care at home, the intensity and level of care needed was discussed with her which required inpatient care.
• Senior advanced nurse practitioner discussed with Anne whether rehabilitation could take place within a care home environment rather than in the hospital.
• This enabled collective decision making between Anne, her family and the professionals involved in her care and rehabilitation.

Co-ordinator

• Following the team around the person meeting the senior advanced nurse practitioner agreed to act as care co-ordinator as the most appropriate person and main point of contact for Anne and her family.
• This enabled effective communication between Anne, her family, and the team of professionals involved.

My plan

• Anne was included in planning her move from hospital to a local care home to receive rehabilitation following her recent fall.
• Ongoing care and support at home for Anne post discharge was discussed and included in her plan.
• GIRFE principles were applied to Anne’s plan enabling her to be involved in the decision-making process, make informed choices, and have her views heard.

Outcome

• Anne worked with her team, including professionals and family members, to plan her rehabilitation within a care home environment.  This enabled her to be discharged from hospital earlier. This also respected Anne’s wishes to be close to her local community, enabling her family and friends to visit.
• As a result of collaborative working between professionals, where Anne and her family were involved in planning her care, Anne experienced a seamless and timely discharge from the hospital to the care home, and then ongoing care and support at home by the immediate care team when she was discharged from the care home.

•  Anne’s emotional and physical well-being needs were understood by everyone in her team and her needs were met.

• Collaborative working between the professionals involved, using the ‘Team Around The Person Approach’, ensured ongoing support and care for Anne post discharge to reduce the risk of, and avoid, readmission to hospital. 
• Use of the GIRFE Team Around The Person Toolkit reduced hospital inpatient length of stay, avoided potential discharge from hospital delays and the risk of readmission to hospital was reduced.

Situation

• Brian is a young adult who has experienced adverse childhood experiences and significant disruption throughout his life.
• As a result of these adversities, Brian was cared for by the local authority in several long-term care settings.
• Brian received a Community Payback Order and at this point became involved with Adult Justice social work.
• At the time of becoming known to justice services, Brian was receiving support from an Intensive Support Social Worker as a care experienced young person.

Risk

• The way in which Brian responds, approaches and manages life events, are significantly impacted by his experience of trauma.
• Brian has experienced a breakdown of significant relationships and feels socially isolated.

Action using the GIRFE approach

Team around the person

• Brian had multiple agencies and professionals involved in his care and support. To ensure an effective team around the person approach a planning meeting was held with Brian and all those involved in supporting him to understand his needs and involve him in planning his own care and support.
• Team around the person meetings were attended by children and families social work, justice social work, housing and employability services.
• The meeting was arranged to enable Brian to be present too, but on the day, he unfortunately was not able to attend this meeting, however his views were shared as a central part of the discussion.

My plan

• A plan was developed taking in Brian’s views and agreeing each services’ role in providing support. 
• The discussions at the meeting and the plan were shared with Brian and his views and agreement sought in relation to the contents of the plan.
• The team worked collaboratively with Brian to agree and co-ordinate the plan.
• Within Brian’s team each person’s role was clearly defined within the plan to avoid duplication of work and help build good working relationships to support him.

My team

• The team working together and sharing Brian’s views in meetings prevented Brian from having to attend multiple appointments and retell his story multiple times.
• Different professionals and agencies brought diverse opinions and perspectives on how best to support him which helped shape an effective plan. This was crucial to improving outcomes for Brian.

Outcome

• Brian’s views were listened to and formed the basis of his support plan.
• As Brian’s team shared information and worked collaboratively, he did not have to retell his story multiple times, which may have caused Brian to have to relive traumatic experiences.
• Clear roles and shared accountability between professionals were established by engaging in team around the person meetings and formulation of Brian’s support plan.
• As a result, information was shared between relevant agencies and support was put in place to reduce the risk of Brian reoffending in future.