DI has a long history of mental health difficulties which have, at times, affected her willingness and ability to engage with treatment, rehabilitation and support services.
In April, DI sustained a broken foot. This resulted in a lengthy hospital admission followed by several months in a rehabilitation setting. During this period, she was often reluctant to participate in rehabilitation and frequently declined recommended treatment and interventions.
Despite these challenges, one thing remained consistent: DI wanted to go home.
Throughout her hospital and rehabilitation stay, DI contacted the care office weekly to express her wish to return to her own home. This provided the team with a clear understanding of what mattered most to her and became central to planning her future support.
Achieving this was not straightforward. DI was bed bound and required full assistance with daily living activities. Her mental health needs affected her motivation and engagement, she had frequently declined treatment, and there were concerns about restricted dietary intake because of the limited range of foods she was willing to eat. These factors meant that returning home required careful planning and coordinated support rather than simply arranging a discharge date.
Once DI was medically fit for discharge, a comprehensive package was arranged to enable her to return home at the beginning of August. This combined live-in care with a team of visiting carers, providing the level and consistency of support required to manage her needs safely within her own environment.
Initially, DI was extremely anxious. She remained bed bound and was completely dependent upon carers for personal care. All care had to be provided in bed, and she was unable to roll or assist carers with repositioning.
The team recognised that achieving progress would depend on more than completing care tasks. Trust had to come first.
Consistency and familiarity therefore became important elements of her support. Regular carers provided reassurance and took time to rebuild positive relationships with DI. Rather than focusing solely on what she could not do, they encouraged her to participate in her own care whenever possible, while continuing to monitor both her physical and emotional wellbeing.
The impact of this approach has become increasingly evident.
Although DI remains bed bound, she can now roll with minimal assistance. This allows her to participate more actively in her personal care and represents meaningful progress from the complete dependency she experienced when she first returned home.
There has also been an important change in her engagement with medication. DI is now willing to take medication that she had previously refused. Alongside her increased participation in personal care, this indicates a significant improvement in her engagement with the support around her.
DI has also re-established positive relationships with her regular carers and appears to enjoy seeing familiar members of the team. Her anxiety has reduced and she is engaging more positively with her care and support. For someone who had experienced significant difficulty engaging with services during her hospital and rehabilitation stay, this represents an important emotional as well as practical outcome.
The team has not allowed these improvements to reduce its vigilance. DI’s nutritional intake remains an ongoing concern because she continues to restrict the range of foods she is willing to eat. Rather than accepting this as part of her usual presentation, specialist dietetic advice has been requested to explore how her nutritional intake can be improved while continuing to work with her individual preferences.
This case demonstrates the importance of looking beyond a person’s immediate presentation and understanding the outcome that matters to them.
DI had significant physical needs. She had experienced a prolonged period away from home, was bed bound, highly anxious and had demonstrated limited engagement with rehabilitation and treatment. It would have been easy for those challenges to dominate decisions about what happened next.
Instead, the team listened to what DI had consistently communicated: she wanted to return home.
By building the right support around that goal, rather than expecting DI to fit around a service, Trinity enabled her to return to familiar surroundings while maintaining the level of support required to manage her needs.
Since returning home, DI has not simply been maintained safely. She has made meaningful progress. She is less anxious, more engaged, participating more actively in her personal care, accepting previously declined medication and rebuilding relationships with people she knows and trusts.
Her journey demonstrates what can be achieved when discharge planning, continuity of care and person-centred support work together around an individual’s own priorities.
