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Engaging with a client - A support facilitator’s story

08 Sep 2017

A Support Facilitator’s story of a PIR Client
Julie is a middle-aged lady with a diagnosis of schizophrenia who was referred to PIR in September 2016.  Julie, who was diagnosed in her early 20’s, believes this condition began as a result of a relationship breakdown.  Other challenges Julie was experiencing at the time of referral included:  poor diabetes management, poor compliance with medication, social isolation, poor engagement with therapeutic interventions, and limited insight into her chronic physical and mental health conditions. Julie has always lived at home with her parents.

Julie’s parents are elderly and are from a non-English speaking background with limited English fluency.  Her parents have been the primary carers for Julie throughout her adult life, with very limited community support services other than monthly visits to see Julie’s psychiatrist over the past 15 years.  Julie’s interactions with her psychiatrist have been minimal.  Her psychiatrist was unaware of the family struggles in managing Julie’s behaviours, and did not liaise often with Julie’s GP regarding her health care management. Julie’s involvement with Monash Health has mostly been related to her physical health issues.

Julie’s daily activities include sleeping a lot during the day and staying awake during the night, binge eating at night, leaving the front door open, ruminating, yelling, verbal lashing out at her parents, hiding medications, misuse of medications (both psyche and insulin), and mostly watching TV. Julie very rarely leaves the home other than to go shopping with her father; she has no friendships or social activities, and is entirely reliant on her parents to manage her activities of daily living.
Julie was initially referred to PIR by a home nursing service.  The home nursing service became involved with Julie through the Diabetes Clinic for support in the community to manage Julie’s unstable diabetes. Initially, a diabetes educator was visiting Julie twice a week as Julie was non-compliant with insulin and unable to comprehend the impact of non-compliance with both insulin and anti-psychotic medications.

Due to Julie’s unstable diabetes and lack of insight and understanding of mental illness by both Julie and her parents, she was at high risk of death by misadventure. There have been incidents where failure to call an ambulance could have had fatal consequences. The home nursing service intervened in the home and arranged the necessary medical assistance for Julie, and she spent a number of weeks in hospital recovering from acute physical health issues.

PIR worked closely with the home nursing service and provided intensive outreach, assertive case management, and crisis response management in liaison with the home nursing service until linkage to a community mental health support service could be implemented. Due to the significance of Julie’s needs, PIR recently had Julie’s referral to the Mental Health Community Support Service upgraded to “urgent” need.  PIR have developed a strong and trusting rapport with all the family.

PIR implemented consultations with the GP, diabetes clinic, and the home nursing service which resulted in daily morning visits by the home nursing service to administer insulin. To date, there has been an improvement in Julie’s diabetes management, and a slight improvement in her sleeping patterns.

PIR liaised with Julie, her mental health worker, her parents, and her psychiatrist, and advocated for commencement of depot injections. PIR provided psychosocial education about medication options to all the family.  Depot injections were commenced and this has resulted in some improvement in Julie’s mental health, and in improved quality of life for the whole family.

Gentle respite planning for both Julie and her parents has been an ongoing task, and it is hoped suitable respite accommodation, and then permanent placement for Julie, will occur in future.
The recent addition of the Mental Health Community Support Service to the care team has been highly beneficial to everyone involved.  The Mental Health Worker from the service initially liaised with PIR to complete their assessment process.  The Mental Health Community Support Service and PIR assessments and planning goals have been highly compatible, and the working relationship is excellent. 

For example, during Julie’s most recent stay in hospital to stabilise her physical health, both the Mental Health Community Support Service Worker and the PIR Support Facilitator worked collaboratively to voice their concerns to the nursing staff and social worker about the need to better manage Julie’s mental health as well as her physical health. The Workers were able to advocate with Julie’s treating GP that more intensive care was required for Julie and her family.  This was implemented with the GP increasing Julie’s visits to the clinic, and through monitoring Julie’s medication management. Importantly, Julie’s GP notes that since PIR has been assisting Julie and her family, she has seen a marked stabilisation in both Julie’s mental health and in her diabetes management.

The Mental Health Community Support Services team have provided PIR with ongoing extensive support, and it has been a pure pleasure to work collaboratively with them.
PIR is collaborating with housing services to locate a suitable respite/long-term housing option for Julie, as well seeking carer support for her parents.
Julie and her family have developed a trusting and cooperative professional relationship with PIR, the Mental Health Community Support Service, and the home nursing service, and have significantly improved communications with the psychiatrist and GP.

The PIR Team Leader continues to provide supervision to the Support Facilitator through regular case reviews, by providing flexible funding for the neuropsychological assessment, and in advising the facilitators to be proactive, rather than reactive, to better assist Julie.

There’s still a lot of work to do to assist Julie and her family, but with the ongoing support of the Mental Health Community Support Service, the home nursing service, carer supports, housing services, GP, and psychiatrist there is renewed hope for a better quality of life for Julie and her family.

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