Version 2.1 (27.06.10)
Client Name: Susan ‘Sue’
CJP Staff: Katelynd CJP Staff: Kelly
Annual Review and new plan development date:
Formulation statement:
Sue is a 41 year woman with an intellectual disability and Phelan-McDerrid Syndrome. Her level of disability has been assessed over time from borderline to moderate, with later assessments indicating declined functioning. Sue was an adoptive child ......... She also experienced significant violence and sexual assault in her accommodation upon leaving boarding school and experienced a great number of accommodation changes. From reports, it appears her level of disability, genetic disease, frequent loss of relationships, poor attachment history and traumatic and possibly neglectful early environment interacted to result in severe emotional dysregulation and fears of abandonment. This is consistent with her diagnoses of Intermittent Explosive Disorder and more specifically Borderline Personality Disorder. Her poor emotional regulation stemming from her BPD, in combination with the traumatic losses, such as the loss of her daughter also explains her periods of Major Depressive Disorder with Catatonic Features. Her reported psychotic features are also consistent and common in those with BPD.
Sue currently resides at Kanangra Centre in Unit 4. Sue lives by herself in a self contained unit but has the ability to interact with other clients of Unit 3 during the day. Sue has recently experienced a period of generally positive mental health and behaviour following a number of sessions of Electro-Convulsive Therapy subsequent to a period of catatonic depression. Apart from the ECT, which alleviated the depression, it is suspected that her improved functioning revolves about her environment and pharmacotherapy, which includes the use of mane, nocte and pro re nata psychotropic medication.
A number of environmental factors at Kanangra appear to have been instrumental in Sue's improved functioning. Kanangra provides clear physical boundaries. This includes the ability to socialise and have day activities without leaving the grounds. It also includes reinforced fixtures which reduce risk of property damage, injuries to self and staff and absconding. These reduce risk of criminal justice involvement, relationship breakdown and consequential service breakdown, (which has historically reinforced some of her Borderline thinking and coping styles). A key element to the success of Kanangra has been the experience of staff in supporting people with severe challenging behaviour. This expertise revolves about their ability to quickly de-escalate critical incidents using distraction, environmental manipulation, communication strategies, PRN medication (including IMI) and applying effective and safe restraint procedures. Of great importance has been their non-dramatic appraisal of incidents which can reduce the function of the behaviour and thereby reduce the reinforcing value of the challenging behaviour. Staff have also been very consistent, with most having been there the entire time Sue has been at Kanangra. This has provided a degree of stability in her relationships that undermines her core belief about abandonment.
To ensure Sue does not regress or have the progress she has made squandered, it is imperative that she be supported in a model where there is a clear validating environment with stable, secure staff and other clients she relates well towards. These and the service recommendations from the SNRG assessment are strongly reflected in the accommodation and support model identified at Quakers Hill.
Relationship /Position Name Relationship /Position
Katelynd Casework Specialist CJP Carol Nursing Manager
Kelly Team Leader Case Management Julie Sister
Ellie RUNM Kanangra Peter Legal Guardian, OPG
Janine Psychologist Kanangra
1 Family
Objective / Rationale Actions Responsibility
Timeframe
Liaise with Julie and Sue’s mother regarding Sue’s transition into the community through invitations to meetings and the provision of regular updates CJP
Kanangra Ongoing
Maintain current schedules regarding contact and parcels (this includes food parcels to be reviewed by staff and provided to Sue in stages)Lifestyle Solutions Post Transition
Provide opportunities for visits between Sue and her family Lifestyle Solutions Post Transition
Assist Sue to display her photographs etc in her unit CJP Kanangra Lifestyle Solutions Incomplete
Memory book to be developed for Sue about her life at Kanangra Kanangra Incomplete
2 Physical Health
Objective / Rationale Actions Responsibility
Timeframe
Continue to monitor Sue’s weight Lifestyle Solutions Post Transition
Utilise ‘Light n Easy’ or similar to maintain her healthy eating as well as a means of meal preparation Lifestyle Solutions Post Transition
Regular Dietician review Lifestyle Solutions Post Transition
Provide regular schedule of physical activity to support a healthy weight range Lifestyle Solutions Post Transition
Identify suitable location where Sue can continue to enjoy walking Lifestyle Solutions Identified
Need Risk Assessment
Handover from current MO to community based GP who is able to provide home visits Kanangra Lifestyle Solutions Incomplete
Ongoing GP reviews Lifestyle Solutions Post Transition
Completion of CHAP tool (as necessary) Lifestyle Solutions Post Transition
Develop appropriate and effective Reactive Strategies to be used in the place of PRN - IMI CJP Lifestyle Solutions Psychiatrist Incomplete
Handover current Webster Pack Kanangra At Transition
Fill new prescriptions Lifestyle Solutions As needed
Mental Health
Objective / Rationale Actions Responsibility Timeframe
Identify appropriate community Psychiatrist CJP Lifestyle Solutions Dr Sophie Kavanagh
Handover from current Psychiatrist to community based Psychiatrist CJP
Kanangra Lifestyle Solutions Community Psychiatrist Incomplete
Develop mental health response plan based on identifying early warning signs and providing appropriate early intervention CJP Lifestyle Solutions Complete
Monitor mental health status through ongoing data collection Lifestyle Solutions Ongoing
Re-engage services for ECT/other appropriate treatment as indicated in mental health response plan Lifestyle Solutions As Required
Brief local community mental health team (Blacktown)CJP Lifestyle Solutions Incomplete
Accommodation Objective / Rationale Actions Responsibility Timeframe
Sharing Information consistently:
o1 Meeting with Sue’s family
o2 Meeting with OPG
o3 Meeting with Kanangra staff
o4 Meeting with Sue
CJP Kanangra Lifestyle Solutions Sue and her family OPG Ongoing
Transition to community accommodation:
o1 Staff buddy shifts at Kanangra Lifestyle Solutions Kanangra Ongoing
o1 Photographs of new home and discussions with Sue Lifestyle Solutions Incomplete
(Proposed for: 25.07.11)
o2 Visiting new Unit at Montrose Kanangra Lifestyle Solutions Incomplete (Proposed for: 02.08.11)
o3 Pack belongings
o4 Farewell Party at Kanangra Kanangra Sue and her family Incomplete (Proposed for: 03.08.11)
o5 Move into new Unit at Montrose CJP Kanangra Lifestyle Solutions Sue and her family Incomplete (Proposed for: 04.08.11)
o6 House warming party Lifestyle Solutions Kanangra Sue and her family Incomplete
(Proposed for: 05.08.11)
o7 Document key clinical indicators that Sue is ‘not coping’ with the transition. The transition can then be modified accordingly based on Sue’s needs e.g. increase / decrease the speed of the transition into the community if there is clinical evidence that Sue is ‘overwhelmed’ CJP Kanangra Complete
5 Education Objective / Rationale Action Responsibility Timeframe
Investigate formal adult learning opportunities for Sue if interested Lifestyle Solutions Post Transition
Continue informal learning opportunities through Activities of Daily Living (ADL’s) Lifestyle Solutions Post Transition
Continue with literacy and numeracy ‘lessons’ (1/2 hr/wk) that Sue currently enjoys Lifestyle Solutions Post Transition
7 Recreation Objective / Rationale Actions Responsibility Timeframe
Follow similar structure as current daily planner as far as is possible Lifestyle Solutions Post transition
Ensure Sue continues to have the opportunity to enjoy current preferred activities e.g. music therapy, walking, concerts Lifestyle Solutions Post transition
Continue structured community access activities Lifestyle Solutions Post transition
Provide Sue with the opportunity to develop new recreational activities Lifestyle Solutions Post transition
Maintain opportunities to visit peers and staff at Kanangra Lifestyle Solutions
Kanangra Post transition
8 Religion/Cultural beliefs Objective / Rationals Actions Responsibility Timeframe
Sue has attended Church at Kanangra of a Friday. She enjoys the music and the singing. Investigate ongoing contact with Church if Sue wishes to continue attending Church Lifestyle Solutions Post transition
9 Social Relationships Objective / Rationale Actions Responsibility Timeframe
Maintain Sue’s peer relationships at Kanangra with regular planned visits e.g. attending concerts Lifestyle Solutions Kanangra Post Transition
Maintain Sue’s relationships with Kanangra staff e.g. phone calls, staff visits Lifestyle Solutions Kanangra Post Transition
Provide opportunities for ongoing development of social interactions with peers in the community setting Lifestyle Solutions Post Transition
10 Functional Skills Objective / Rationale Actions Responsibility Timeframe
Continue to provide opportunities for informal learning regarding functional skills Lifestyle Solutions Post Transition
Utilise Individual Planning process to identify specific functional skills to target formally Lifestyle Solutions Post Transition
Consider skills assessment Lifestyle Solutions Post Transition
Develop skills development plans accordingly Lifestyle Solutions Post
Transition
Staff to assist with ADL’s as required in periods of depression Lifestyle Solutions
If and as required
11 Decision Making Objective / Rationale Actions Responsibility Timeframe
Liaise with OPG regarding Sue’s transition into the community CJP Kanangra
Lifestyle Solutions Ongoing
Provide documentation to assist in consent for move process CJP Complete
Obtain consent from OPG
Consent for Services, Exchange of Information etc (17.11.10)
Consent for Move (05.01.11)CJP Complete
12 Behaviour & Risk Management Objective / Rationale Actions Responsibility
Timeframe
Update current behaviour support and risk management plans in light of community accommodation and DBT model in collaboration with Kanangra CJP Ongoing
Review incident reports and data CJP Kanangra Ongoing
Provide staff training (see Section 13)(see Section 13)
Staff to have practical working knowledge of above plans Lifestyle Solutions
CJP Ongoing
Implement data collection and collation Lifestyle Solutions Ongoing
Regular review of plans as per policy (i.e. quarterly) Lifestyle Solutions Post Transition
13 Staff Provision & Training Objective / Rationale Actions Responsibility
Timeframe
Employ skilled staff Lifestyle Solutions Complete and Ongoing
Roster regular and stable staff Lifestyle Solutions Complete
Appropriate staffing levels not less than 2:1 (Staff:Sue) with additional back-up staff in immediate vicinity CJP Lifestyle Solutions Incomplete
Training recommended for staff working with Sue:
o1 CJP Establishment Training CJP Complete
o2 Client specific Training CJP Complete
o3 Restraint/Escort Training e.g. PMVA (Graham Davies) or similar Lifestyle Solutions Incomplete
o4 Buddy shifts with Kanangra staff Lifestyle Solutions Kanangra Ongoing
o5 Dialectical Behaviour Therapy Training (ongoing commitment) CJP Ongoing
o6 Behaviour Support Training CJP Ongoing
o7 Risk Management Training Lifestyle Solutions Ongoing
o8 First Aid Training Lifestyle Solutions staff Ongoing
o9 Mental Health First Aid Training Lifestyle Solutions Incomplete
14 Services Current Service Name / Contact Details Last Review / Attendance Date Community Based Service Complete Review Date
General Practitioner Dr Eric
Kanangra Centre
Hunter Residences
Department of Family and Community Services
Locked Bag No 3
Morisset 2264 Annual physical – 27 June 2011
Psychiatrist Dr Bruce 4 November 2010
Dentist Dr Wong 14 June 2011
Neurologist
Ophthalmologist
Psychologist Ms Janine 27 April 2011
Pharmacist Bowens Pharmacy
Podiatrist
Dietician Ms Wendy
Stockton Clinic 5 July 2010
Massage Therapist Mr Hedley 22 June 2011
Day Program Services Dilkara
Kanangra Centre Daily
Financial Services Leanne
Assistant Client Service Officer
Client Service Team 5 – Long Term
NSW Trustee and Guardian 27 May 2011
Outstanding Bills ? Pharmacy
15 Furnishings and Possessions
Indicate items, and actions by who and when Client Register Updated signed and dated by current manager
16 Clothing Register
Quantity: Date of
Purchase Item Description Signature
Transportation Company: Booked Date for Transport:
17 Clothing Register
Document Document Date Handover Date
Individual Plan (signed and endorsed and the resident/carer/family member and/or Guardian/Advocate) 4 July 2011
Health Care Plan (signed and endorsed by a doctor and the resident/carer/family member and/or Guardian/Advocate) 4 May 2011
Epilepsy Management Plan N/A
Nutrition and Swallowing Plan 15 June 2011
Oral Health Assessment/Management Plan
Comprehensive Mealtime Management Plan 5 July 2010
Asthma Management Plan N/A
Client Annual Health Review 24 June 2011
Key Health Issues 24 June 2011
Client Health Care Plan As above
Cumulative Medical History Ongoing
Client Risk Profile 4 May 2011
Client Risk Management Plan 4 May 2011
Client Manual Handling Plan (Mobility Management Plan) 15 June 2011
Transport of Clients Risk Review 15 June 2011
Guardianship Order for Banker arrangements and Financial Plan from NSW Trustee Estate managed since admission
Financial Plan – 27 May 2011
Person Responsible Public Guardian
Medical/Dental Consents 23 May 2011
Guardianship Orders 10 May 2011
Behaviour Support 27 April 2011
Behaviour Assessment December 2004
Comprehensive/Incident Prevention & Response Plan 27 April 2011
Lifestyle Review 27 April 2011
Skills Development Plan 27 April 2011
Communication
Communication Profile 15 June 2011
Communication Plan
Financial Plan 4 July 2011
Recreational Activity Preference 15 June 2011
Day Programme Assessment 6 July 2010
Client Profile 15 June 2011
Personal Belongings Inventory At transition
Personal Clothing Inventory At transition
Pension Card 30 Nov 2011
Medicare Card August 2011
Calender of forward medical appointments
Current funeral arrangements
0 Comments:
Post a Comment
<< Home