Amanda’s story: Assessing the impact of a specialist care pathway
By SweetTree Home Care Services
How do we ensure that the right care is always delivered at the right time…with resources used in the most efficient way to achieve the best possible patient outcomes?
That is the challenge faced by social care teams, case managers and court appointed deputies across the country, who are under increasing pressure when it comes to budgets, resources, rising caseloads and staffing.
The answer has to be, timely trusted intervention and informed decision-making, which is exactly what SweetTree’s model of technology enabled care achieves, as can be seen in the case study below.
As a CQC-rated Outstanding home care provider that works closely with multi-disciplinary teams, SweetTree must navigate the wide-ranging priorities faced by clients, commissioners, family members and its own team members daily.
The one thing that our two decades plus of experience has shown us is that the best way to satisfy everyone’s needs is to provide as close to real time, transparent and objective information as possible to the client’s circle of support to facilitate good, cost-effective decisions to be taken which are in the best interest of the individual concerned.
By combining SweetTree Outstanding home care services with the SweetTree Connect system, we have been able to develop a technology enabled care platform that helps keep everyone within a client’s circle of support up to date with regards to how the individual is doing and make data informed decisions as to what care is required.
For Amanda, who is cared for by our specialist Learning Disabilities team, this collaborative approach led to the best possible outcome, following a fall.
It aided timely action and intervention, an efficient use of resources, and prevented an escalation in her care need, avoiding costly residential care. Here is her story.
Amanda’s story
Amanda is aged 60 and lives alone in West London.
Born with a learning disability, Amanda has been receiving daily care and support from SweetTree’s specialist learning disabilities team for more than 14 years.
The care provided is focused on supporting her daily living and community access, including making regular visits to the company’s dedicated care farm, SweetTree Fields Farm, in Mill Hill.
The primary goal of the care team is to ensure Amanda’s wellbeing by keeping her active, mentally stimulated, engaged, and connected with her local community.
Emergency care package
In March 2025, Amanda’s condition became more complex following a fall that resulted in fractures to her right arm, a hospital admission and her arm being placed in a cast.
Upon discharge, Amanda’s dedicated SweetTree Care Manager Karleen, worked with Amanda’s social worker to initiate an emergency care package to support her recovery.
Pragmatically, Amanda’s Social Worker helped to ensure that the care package included re-enablement support and the deployment of SweetTree Connect, SweetTree’s in-house falls prevention and environmental monitoring technology, designed to help individuals remain at home, safely and independently.
Technology enabled care – how SweetTree Connect ensured the right amount of care was provided, when it was needed.
The SweetTree Connect system employs sophisticated sensors to monitor Amanda’s daily activities.
As Amanda’s needs changed, so did the amount of care she required.
Shortly after Amanda’s return home, the data gained from SweetTree Connect revealed that Amanda was largely sedentary during times when she was alone, spending nearly all her time in bed or in a chair.
When reviewing the data with Amanda, SweetTree’s Care Manager discovered that Amanda was afraid of falling again, to the extent that she often delayed eating and using the toilet until her next carer visit.
This behaviour posed several risks, including increased physical debilitation due to muscle atrophy, the potential development of a UTI, and a continued loss of confidence.
With the above knowledge in hand, the SweetTree team worked with Amanda’s social worker to put in place a comprehensive re-enablement programme aimed at improving Amanda’s mobility and confidence.
Although the extra care associated with this resulted in additional cost, it was only short term and was much less expensive than Amanda having another fall with an additional hospital stay or becoming so debilitated from lack of movement that she needed an admission to a care home.
Evidence-based interventions and timely support
Once Amanda’s cast was removed and she quite quickly became more active thanks to the re-enablement put in by the SweetTree team.
Indeed, the data from the SweetTree Connect system started to reveal that Amanda was moving extensively around her apartment unobserved and unsupported, which created the risk of another fall.
Most worrying however, was the fact that Amanda was now getting up in the middle of the night and moving around her apartment, which was unusual for her and heightened the risk of her having another fall.
By providing Amanda’s physio team with the data from the SweetTree Connect system, which showed her movement and progress over time, the physio was able to use the evidence to make an emergency referral for mobility aids and equipment to be installed in Amanda’s home.
Ensuring the best possible patient outcome
Together, the SweetTree team, Amanda’s Social Worker and her Physio continued to monitor Amanda’s progress, adjusting the level of support as needed.
As her ability to access the community increased, additional care was authorised to support this, to keep her mobility and rehabilitation improving.
As Amanda’s strength and confidence improved, and her ability to manage independently increased, her care package was reduced back to its normal level.
SweetTree’s deep knowledge of Amanda, combined with the use of SweetTree Connect, provided an accurate and dynamic understanding of her condition.
Real-time data enabled the MDT to make informed decisions throughout this period of ill health, ensuring timely and appropriate interventions.
The risk of a further fall, which in the UK is estimated to cost the NHS £2500 – £5,000 without surgery or £13,000 – £15,000 with surgery) was minimised, and the potential need for residential care was eliminated.
This collaborative approach, where Amanda’s Social Worker, Physio and SweetTree worked flexibly together ensured the best possible outcome and recovery for Amanda proved to both save public funds and achieve the best possible outcome for Amanda.
The approach prevented further complications and promoted Amanda’s recovery, highlighting the extremely positive impact that SweetTree’s flexible model of technology enabled care can have for individuals with complex needs.
Amanda commented:
“All the ladies that come and look after me are lovely. Everybody’s different and has their own way of doing things. They take me to appointments at the hospital, things like that. We have a good chat.
“When I hurt my wrist, they helped me around the place because I couldn’t do a lot because my hand was in the bandage.
“SweetTree has very nice people working for them. I’ve been with them for a long time and they’ve helped me do a lot of things. When I needed them most, they were there.”
Benefits of the SweetTree model for MDTs
The SweetTree model aligns with the aim of MDTs to improve patient outcomes through comprehensive, coordinated, and patient-centred care.
It does this by:
Ensuring the right care is delivered at the right time
The SweetTree model sees detailed care assessments and person-centred care, combined with real-time data to monitor patient activities and conditions, allowing teams to make informed decisions and provide timely interventions.
Providing accurate data-driven insights
The use of the SweetTree Connect system, provides valuable insights into patients’ daily routines and potential risks. This enables targeted interventions that are timely and appropriate.
Reducing the need for social worker and physio visits
By providing clear visual representations of patient progress and movement, the SweetTree model helps reduce the frequency of visits from social workers and physiotherapists.
Preventing the risk of further hospital admissions and long-term residential care
The collaborative approach between SweetTree, client families, and healthcare professionals ensures comprehensive care plans that adapt to changing needs, preventing further hospital admissions and the potential need for long-term residential care.
Speedy recovery and reduction in care need
The integration of innovative technology and specialist services promotes positive outcomes and reduces the burden on the wider social care system.
Clear communication and knowledge share between all parties
The SweetTree model facilitates clear communication between the care team, patients’ families, and healthcare professionals, ensuring that everyone is kept informed and updated.
SweetTree’s Learning Disabilities Service
SweetTree’s specialist learning disabilities service provides high-quality care and support at home and in the community for individuals with mild, moderate, and severe learning disabilities, in addition to other neurodevelopmental disorders.
The service is designed to help clients live independently and achieve their personal goals.
SweetTree recognises that it is often the restrictions in the community, rather than the learning disability itself, that prevent individuals from taking on new challenges or living more independently.
The service includes enabling successful living at home, skill-building to manage money, travel training to gain confidence and independence, CV preparation, job searches, role play for interviews, support with medication and health appointments, discovering new hobbies, accessing vocational training and work experience, managing correspondence and bills, working towards independence with personal care tasks, and building social skills to develop friendships.
SweetTree’s approach is person-centred, focusing on what individuals can do rather than potential obstacles.
