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Case scenario, Mrs S for Care Co-ordination

Case scenario, Mrs S for Care Co-ordination. Sally Pearson, based at Central East ACAS Ph 1300661141. Case summary. Escalating delusions probably associated with dementia. Mrs S is an 80 year DVA gold card holder who lives alone and she has a caring son.

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Case scenario, Mrs S for Care Co-ordination

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  1. Case scenario, Mrs S for Care Co-ordination Sally Pearson, based at Central East ACAS Ph 1300661141

  2. Case summary • Escalating delusions probably associated with dementia. • Mrs S is an 80 year DVA gold card holder who lives alone and she has a caring son. • She believes neighbors are drug barons and going to kidnap her. She fears for her life and phones the police on average 3 times per day. • The locum GP phones APAT, on day 1, he and the son do not believe that Mrs S is safe at home and they do not know what to do. • APAT requests urgent referral to HARP to prevent a hospital admission.

  3. Contributing FactorsU = urgent action; H = high importance; M = medium importance

  4. Contributing FactorsU = urgent action; H = high importance; M = medium importance

  5. Client’s perception of her problems. • Her reality is that the neighbors are trying to kidnap her. (The neighbors are actually a young couple of Dr’s.) • She would like to go to live at a particular hostel as she has friends there. (However they have a very long waiting list.)

  6. The most significant immediate actions.

  7. COMPLEX NEEDS IDENTIFIED • Health issues • Social issues • Cognitive issues • Vulnerable (in living situation) • No effective support from family or friends • Difficult behaviours • Does not recognise need for assistance • Frequently changing and fluctuating needs • Communication/relationship problems • Situations with two ‘clients’ • Acute decline in ability to self-manage • Police problems

  8. SERVICES INVOLVED IN THIS EPISODE • Local GP • DVA • ACAS • HARP Aged Care Stream • SRS GP • Referring GP • Geriatrician • Psychiatrist • APAT Triage • SRS Manager • SRS Admissions • Son • Police

  9. Outcome, by Day 6 • Settled at SRS, DVA funded for 1 month • Medications to manage behaviours commenced and being monitored by SRS • Permanently waitlisted for 3 gov. funded LLC • Son educated and then able to self manage situation. • Client discharged, son able to contact me if not able to manage.

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