Case Studies

Case Study One

Rose is a 64 year old female resident who was offered a unit under social housing and has been an Anglicare resident for over 3 years at Calli (Liverpool).

When her Tailored Support Coordinator (TSC) completed Rose’s needs assessment, the following information was disclosed and identified; trauma experienced as a child, disconnected from her 3 children and no other family support, socially isolated and experiencing significant loneliness, disclosed mental health – depression and anxiety, bariatric – mobility issues, incontinence Issues, no informal or formal support and financial hardship.

Rose kept herself isolated even though she had expressed several times that she was feeling lonely. Rose initially kept to herself and did not engage with her TSC. For the first two years, TSC focused on building rapport and trust with Rose. As a result, TSC identified that Rose is in receipt of Jobseeker Allowance and is required to look for work. Rose has previously submitted medical certificate to apply for an exemption due to her mental health condition and mobility restriction. This mutual obligation with Centrelink causes Rose significant anxiety and distress.

Rose’s goals in 2021-2022: TSC was able to help her connect with a new general practitioner, referral to Anglicare Food and Financial Assistance to assist her with managing her financial commitments and linked her with a counselling service including One Door Mental Health to provider her support with her mental health and wellbeing.

Rose’s goals in 2023-2024: she wanted to address her social isolation and spiritual connection. TSC supported Rose by encouraging her to attend various Anglicare Community Engagement events including Arts and Craft where she developed strong friendships with other residents. This led Rose to build on her self-esteem and confidence to run a bible study group and to start attending the St Luke’s Anglicare Church; Rose and other residents would meet on the weekends and walk to the church together. To date, Rose has joined our resident volunteer group who are invited to assist the Calli Housing Team when planning and delivering joint events such as Biggest Morning Tea, Christmas Events.

Most recently, her TSC received great news that Rose’s Disability Support Pension application has been approved. The perseverance from her TSC to get the support for Rose to obtain the evidence she needed to strengthen her application was crucial. TSC wrote a supporting letter and advocated on Rose’s behalf for Flourish to also provide a supporting letter. TSC then made a referral to Services Australia Social Worker to ensure that Rose’s voice, situation and circumstances were clearly represented.

Since April 2024, TSC’s consistent advocacy and regular follow up, means that Rose no longer required to look for employment – resulted in reducing heightened anxiety in having to meet unrealistic expectations to look for work to receive much needed government assistance. This will also strengthen Rose’s application to apply for NDIS and increase the likelihood of being approved. This will enable her to access to much needed mental health support services as well as supports to undertake activities of daily living to

Case Study Two

Lotus Reign (LR) is an 80-year-old Filipina woman, she has been a resident at Minto gardens since December 2021. LR started her tenancy independently however in the last year she presented with poorly managed diabetes which led to disorientation and increased confusion.

In the last 6 months there was a significant change in her general health, mobility, and visible weight loss. During this time, the disorientation has further increased. Tailored Support Coordinator (TSC) reached out to NOK/daughter to negotiate and keep her aware of the residents changing needs. The daughter did attend to the unit a few times and call an ambulance due to the residents presenting symptoms needing urgent medical attention with TSC’s assistance.

Both family and staff agreed that it was in the resident’s best interest that whilst she is managing the blood sugars with her general practitioner, to look at options for respite. This recommendation was not taken lightly, and the resident declined, advising that she will make changes to her diet and take medications on time and manage her blood sugars. This went on for a few weeks, the resident was doing well until one day she rang and advised that she has been diagnosed with cancer of the thyroid requiring surgery. The resident and her daughter spoke to TSC, and they were confident to manage the process independently. TSC was advised that it would be around 8 weeks before she could have surgery.

During this wait time, residents’ health declined severely whereby she was disoriented daily, incontinent, and aggressive. TSC with assistance from the daughter was able to convince resident that she needed medical attention and care. This was the final hospital admission, this time the TSC worked closely with the social worker, daughter, and resident to organise respite initially with the intention of fulltime residence at a care facility. The hospital team, including the medical doctors in conjunction with the social worker were determined to have the resident transfer to a nursing home given her status however the resident was equally determined to come back home to her independent unit.

Problem/Challenge: Inconsistent diabetes mismanagement, leading to fluctuating blood sugar levels. Her condition has been further complicated by episodes of disorientation and confusion, which became more frequent and severe. These symptoms raised concerns among the retirement village staff and her family.

Solution:

1. Medical Assessment: Resident underwent a comprehensive medical evaluation to assess her overall health, focusing on her diabetes management and cognitive function. This was over multiple hospital admissions for the same condition whereby the hospital was able to recognise the reoccurring episodes.

2. Diabetes Management Plan: A new diabetes management plan was developed, including:

• Medication Adjustment: Her medications were reviewed and adjusted to better control her blood sugar levels.
• Regular Monitoring: Blood sugar levels were monitored more frequently to ensure they remained within a safe range.
• Regular GP appointments

This resident has since undergone cancer surgery successfully with a through cognition review before being discharged to return to her independent unit. LR is now managing like she was when she first moved in and is thriving in her community.

Results: This case study highlights the relationship between staff, a resident and their family whereby knowing the changes in an individual can both identify a health condition and potentially save a life. After persistent emergency call outs for an ambulance and hospital admissions, LR’s blood sugar levels stabilized, and her episodes of disorientation and confusion decreased. Post cancer surgery, she showed improvement in her cognitive function and overall well-being. Returning to her unit, regular routine and supportive environment helped her feel more secure and less anxious.

Conclusion: This case highlights the importance of comprehensive care in managing the health of elderly individual with multiple health issues. By addressing both her diabetes and cognitive challenges, LR’s quality of life improved significantly.

Even though a transfer to a care facility was not successful as the resident returned to independent living, this case study outlines the importance of recognising a decline a health and working with various networks and the hospital system to provide the best possible care and outcome to an ageing individual.