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Partners in Recovery: case study (consumer perspective)

This case study provides an example of how Partners in Recovery (PIR) may work in practice to meet the complex, multi-agency needs of consumers.

Partners in Recovery: case study (consumer perspective) (PDF 122 KB)

The following case study is presented to highlight the complex and multi-agency needs of the clients targeted under this initiative, and how PIR might operate to ensure the full range of an individual's needs are met and to support the integration and coordination of service provision at a systems/cross-sectoral level. Actual models may vary from one region to the next depending on population and service delivery system contexts.

Andrew is a 48 year old man who was admitted to a local hospital after presenting with serious physical injuries and acute auditory hallucinations following an assault. Hospital staff ascertained Andrew had engaged sporadically with crisis services over several years in three different states. Andrew said he had been diagnosed with schizophrenia and that he tended to lapse into "old ways" of drinking binges when he felt down or when the hallucinations were strong. When things "went bad" he would try to escape in the hope of a new life. Consequently, he had difficulties sustaining housing, and community mental health services had experienced difficulty with sustaining engagement with Andrew due to his transient lifestyle. Services were often only engaged after his discharge from hospital following alcohol or psychosis-related crisis interventions. It appeared Andrew had been in contact with clinical mental health services, homeless services, police, Centrelink and drug and alcohol services but when he moved interstate, contact would be lost. Andrew said he was tired of living like this and wanted a more sustainable solution, but that he intended to move back to a larger metropolitan area following discharge.

The hospital social worker, Sally, contacted the regional PIR organisation and local state clinical mental health team within days of Andrew's admission, noting that discharge planning could be complex and involvement of the PIR organisation may be beneficial. Sally completed the PIR referral form.

Upon review of the referral from Sally, the PIR support facilitator, Miriam, met with Andrew and Sally while he was in hospital to talk about how the PIR initiative may assist. Andrew agreed participation in PIR may be of benefit to him, and agreed for Miriam to gain information (assessments and management plans) from services he had been in contact with to gain a better understanding of his history. Through this process, Miriam was able to confirm Andrew had been diagnosed with schizophrenia.Top of page

Following consideration of the information gained, Miriam met with Andrew to assess his full range of needs. Based on this assessment, Miriam worked with Andrew to develop a PIR action plan which identified the clinical and other support services he required, and outlined a step by step plan to access the services. These included:

• community mental health to re-engage clinical case management (including any necessary clinical assessments and medication reviews)
• a GP to monitor Andrew's physical health and assessment of readiness to engage with alcohol rehabilitation services
• drug and alcohol services to provide support to manage his alcohol and drug concerns and refer to drug and alcohol rehabilitation
• the local Personal Helpers and Mentors (PHaMS) service to support Andrew's recovery
• a local supported accommodation service (for short term housing solutions)
• public housing (for long term housing solutions) and
• Centrelink to ensure Andrew receives the correct payment and entitlements and to ensure nominee and Centrepay arrangements were in place where appropriate.

The PIR organisation had previously established Memoranda of Understanding (MOU) with all of these agencies within which they had agreed on principles they would each adopt to work in partnership to best support the PIR clients in their region.

Using the partnership arrangements the PIR organisation had in place (including the MOU), Miriam took Andrew's case and the draft PIR action plan to the PIR working group, which included representatives from a range of services within the region. The working group reviewed Andrew's history and the draft PIR action plan, discussed options to support Andrew upon discharge, and also discussed ways to ensure Andrew could receive the services and supports he needed when he needed them. The working group refined the PIR action plan to ensure the delivery of services was scheduled in a prioritised and coherent way for maximum benefit to Andrew. All services involved in the working group signed the PIR action plan, formally committing to their identified role in supporting Andrew. A copy of the PIR action plan was provided to Andrew and the relevant services.

The working group agreed the local community mental health worker, Shane, was best placed to be Andrew's lead clinical case manager and Shane agreed to work closely with Miriam to make sure the required clinical and other supports were available to Andrew in a coordinated and seamless way.

Miriam and Shane met with Andrew and Sally at the hospital to discuss his discharge planning. Andrew agreed to work with Shane on a daily basis following discharge. Upon discharge, Andrew moved into supported accommodation which Miriam had organised through the PIR working group.Top of page

The PIR working group had identified a case coordination team was available within the local Centrelink service centre. Miriam connected Andrew to the Centrelink case coordinator, Pat. Pat was able to meet with Andrew at the supported accommodation to review his Disability Support Pension (DSP) arrangements. Andrew's DSP status and payments were all up to date, however, Andrew advised he had not actually accessed his bank account for over six weeks as he had lost his ATM card and had not gone into the bank to get a new one. Pat supported Andrew in contacting the bank and in working through what needed to be done to obtain a new card.

Pat also discussed nominee arrangements with Andrew. Andrew agreed having a correspondence nominee would be a good idea and Pam helped Andrew establish his brother as his nominee. Pat also explained that when Andrew was ready, she could help him access supported employment through a Disability Employment Service. Pat arranged to meet with Andrew after one month to make sure all arrangements were still working for him. An overview of this meeting and its outcome was sent to Miriam.

While in supported accommodation, Shane arranged for Andrew to meet with a psychiatrist and GP to review his medication and physical injuries, and discuss his alcohol use. Andrew agreed to attend a residential drug and alcohol rehabilitation service. Shane made all of the arrangements with the rehabilitation service, who were prepared for Andrew's referral given their initial participation in the PIR working group. Shane sent weekly updates to Miriam on clinical activity and progress against the PIR action plan.

During Andrew's time in rehabilitation, the public housing officer who had participated in the PIR working group contacted Miriam to advise that Andrew had been on the public housing waiting list when he had been in this state three years previously and that he had actually missed out on a flat about three months earlier because they were unable to contact him. It was likely accommodation would become available in the local area shortly, and it would be offered to Andrew. Miriam contacted Pat to assist Andrew to set up a Centrepay account to support automatic rental payments from his bank account once he moved into the flat.

The supported accommodation service had also contacted Miriam to advise they would no longer be able to accommodate Andrew when he finished rehabilitation, even if his flat was not available at that time. Miriam confirmed with the public housing officer that the wait for the flat would be no longer than one week from the time Andrew was to finish his rehabilitation. Miriam therefore drew on the flexible funding pool managed by the PIR organisation to purchase accommodation in a private hotel for Andrew for the week prior to the flat becoming available.Top of page

The local PHaMS service had attended the PIR working group meeting and was available to meet with Andrew when he was ready. Andrew decided he would like to meet with PHaMS on completion of the drug and alcohol rehabilitation program. A PHaMs worker, Julie, met with him prior to his discharge from the program. Julie worked with Andrew to develop an Individual Recovery Plan based on his recovery goals. Julie and Andrew worked together to ensure the plan aligned with Andrew's PIR action plan. Andrew's Individual Recovery Plan was provided to Miriam to be incorporated in to his PIR action plan. Upon discharge, Julie worked intensively with Andrew and supported him to move into the private hotel for a week and then his new flat, make social connections, and maintain his connection with clinical mental health services and drug and alcohol services. Julie worked with Andrew towards his goal to re-enter the workforce by connecting him with a peer support worker to increase his confidence, assist him to gain support for skills training, and help him seek employment. Julie and Andrew also worked with Pat (Centrelink case coordinator) to explore supported employment options through a Disability Employment Service.

Prior to his engagement with the PIR organisation, Andrew's contact with the services and supports he required was sporadic and patchy. He had been in contact with all the relevant services in an ad hoc way, but they had not been working together to sequence or coordinate their support to Andrew. In addition, once Andrew's accommodation arrangements changed, most services were unable to find him to sustain their contact. Through the collaborative development of the PIR action plan, each provider was aware of the planned nature and timing of Andrew's contact with other providers and was able to target and tailor their support to Andrew. Miriam's oversight of the collaborative efforts enabled her to keep everyone informed of how things were tracking and advise when variations to the PIR action plan were required.

Miriam was instrumental in gaining agreement by the services to provide intensive support for Andrew. This included sharing assessment of Andrew's concerns and needs, which meant Andrew didn't need to retell his story to each service. The PIR working group agreed Miriam would follow up with them every two weeks for two months and monthly thereafter for another six months to ensure Andrew was gaining the planned support, and make adjustments to the PIR action plan as needed.Top of page

Two years later Andrew decided to travel to a bigger city to explore further work options. This time, however, Andrew agreed to do this in a more planned manner that could allow him a greater chance to remain stable. Through PIR arrangements, Miriam was able to contact the PIR organisation in the city Andrew was moving to, and with Andrew's consent, share information about Andrew, including the PIR action plan. The PIR organisation in the city was able to use its partnership arrangements to connect Andrew with support services on his arrival and support him in the longer term.