The choking woman

Abstract

Background There is a small, but significant cohort of patients that receives inappropriate care, in the wrong setting, and that utilises a disproportionate amount of healthcare resources. People with multiple co-morbidities and often-undetectedmental illness fare better with integrated care and case management approaches. Setting In North West London, we have been working in the ‘Integrated Care Programme’ for four years to try to improve the care this cohort receives. Question Can psychiatric intervention with case management improve outcomes for this cohort? Methods We describe the case of a 64-year-old woman who presented at an Emergency Department (ED) with functional dysphagia 25 times in the space of eight weeks. During that time, she was referred to numerous specialists, and had multiple invasive investigations even though her symptoms were not suggestive of organic pathology, and were in fact suggestive of anxiety.Results Her pre- and peri-psychiatric intervention healthcare costs were, on average, £3330/month. These reduced to an average of £276/month after three months of psychiatric intervention. Conclusions/discussion We reflect on the possible reasons why the story unfolded in the way it did and suggest generalised implications for clinicians caring for this cohort and for service delivery in future.