Journey to Greater Independence Community Health & Local Government in Partnership 18 June 2014

1. Journey to Greater Independence Community Health & Local Government in Partnership 18 June 2014

2. Background • Mira was 42yr old Malaysian lady • CVA (Stroke) while visiting Malaysia 7 years ago & no rehab or post stroke education provided • Prior to her trip she was an active single lady working as a music journalist and yoga teacher • On return to Australia she had minimal supports from her only family member • She was living alone in a private rental unit, at risk of eviction • Client was initially referred to Frankston Council for shopping assistance due to mobility issues

3. Frankston Council’s Initial Broader Needs Assessment Strained relationship with sister & wanted to be independent from her Found to have extremely poor mobility (bottom shuffling). Frequent falls. Sleeping on the floor with minimal basic household items Underweight, isolated & vulnerable Risk of Eviction Clear goals of what she wanted to do

4. Outcome Commenced Unescorted shopping Information provided on multi purpose taxi card, Open door for Medical transport, disabled parking permit form Referrals to Community Health through the Active Service Model OT Case discussion at ASM Partnership meeting

5. OccupationalTherapy Assessment Unsteady gait, high falls risk, no gait aide No rails or assistive equipment. Infrequent showers and meal prep. 5 front steps- bum shuffling up and down as a result of frequent falls No reliable strategy for managing community access and finances No social support (apart for fourtnightly visit by sister to “drop” her at the shops) Mild Dysphagia and underweight Expressive language impairment Cognitive issues-poor insight, memory, processing, judgement, planning skills Limited understanding of cause, impact and management of stroke

6. Client Goals To improve balance and increase confidence Increased mobility with no falls, be able to climb steps Get back to shopping & library at Seaford To become independent from her sister Cook Malaysian Meals To feel safe To return to driving or ride a bike

7. Interventions Joint Assessment with Physio for gait aids and home based exercise program. ASM equipment Funding Assistance. PADL’s and DADL’s- SWEP equipment and home mods undertaken by Frankston Council Home Maintenance Service, education on alternate techniques Extensive travel training with Allied Health Assistance Speech Pathology referral - dysphagia, communication and cognition Community Health Counselling referral- grief and loss, assertiveness Advocacy – Support to change GP & become independent from sister PH Stroke Education package undertaken by OT & PT over several sessions Future planning - Assisted with options for housing (Office of Housing Application), Enduring Power of Attorney, Support groups, Neighbourhood House, and taxi application appeal Mira declined Vulnerable persons list

8. CollaborativeReview 9 Months Post Referral: Mobility/physical capacity- using walker and pick up frame No recent falls, undertaking home exercise program and grading Monash gym circuit independently PADL’s and DADL’s – Managing independently at home. Preparing preferred Malaysian meals. Had gained some weight Community Access - Managing all bills and moved from unescorted to escorted shopping Has ½ price taxi card Speech Pathology – education and compensatory strategies provided. Cognition has significantly improved with understanding of deficits. Medical – Mira is now seeing a GP who’s values mesh with her own alternate philosophy. Safety and self management – Mira has separated from sister and has an alternate Enduring Power of Attorney. Reports feeling more able to deal with difficult situations threatening her safety and wellbeing

9. Outcomes of ASM Collaboration Where is Mira today: • Mobility – mostly mobilising with a walking stick. Progressing to the CH Pilates group and investigating local yoga classes. • Community Access – Further training by AHA in catching public transport very successful. Visiting various shops, library and social groups across the Peninsula. • Frankston Council’s Community Transport/Bus – take’s Mira to the shopping centre • Specialist review provided clearer understanding of prognosis – follow up education regarding preventing further strokes and cognitive strategies undertaken by OT. • Mira now proactively self managing all affairs to the point she has put a pre paid funeral in place so she has “control over everything”. • Mira planning a trip to Malaysia to visit her father. • Mira now thinking of becoming a volunteer –perhaps at a CH exercise group.

10. Agency Experience Highlighted extensive skills within both agencies Required commitment of staff more than funding Case conferencing was critical to the success Client was motivated and had clear goals Seemed time consuming initially but cost effective given minimal intervention required now Rewarding to see Mira achieve most of her goals and improve her quality of life and overall wellbeing

11. Thank you Lisa Manser – Program Manager/Occupational Therapist Community Health, Peninsula Health (LManser@phcn.vic.gov.au) Gretchen Strauss – Coordinator Community Care Frankston City Council (gretchen.strauss@frankston.vic.gov.au) Amy Robertson – Assessment Officer Frankston City Council (amy.robertson@frankston.vic.gov.au)