8 September 2021

Hypothetical Case Study of a client with co-occurring needs (including mental health, alcohol and other drugs and other support needs) attending a future Local Mental Health and Wellbeing Service

Preamble

This case study was written to provide another kind of conversation about how the new Victorian Mental Health Centres (see below) might provide whole-person support (including for alcohol and other drug treatment needs). It is hoped that it will indicate how several of the recommendations in the final report of the Royal Commission into Victoria’s Mental Health System (RCVMHS) relating to integration between alcohol and other drug support and mental health, might manifest in practice. The perspective is from one of the proposed Adult and Older Adult Local Mental Health and Wellbeing Centres (Royal Commission has mandates approx. 50 in Victoria)

The Alcohol and Other Drug (AOD) sector is aware that much of the work of the Local Centres will be in the mild-to-moderate space, and feels that basic AOD Counselling (or better still, integrated counselling that includes AOD support) should be part of the Local Centres service offering. As complexity and comorbidity increase, most people expect the 3 models of integration outlined in the final report of the Royal Commission to come to the fore: multi-disciplinary teams, co-location and partnership. This case study depicts what the AOD sector would describe as moderately to highly complex, without being severe.

Most of the principles outlined in this hypothetical case study would apply just as much to an Area MH & WB Centre, but are envisaged in this case study for a Local Centre.

Damien (hypothetical client)

DAY: 1

Damien, a man in his 30s, experienced a high number of traumatic childhood events including abuse and neglect, homelessness and poverty. As an adult he has occasionally experienced homelessness and often experienced of unemployment, though Damien is currently housed and working. He has been drinking heavily and using illicit drugs on at least a weekly basis since his teens. Damien is consistently very unhappy and believes that he is in grave danger of losing his relationships, his job and more if he can't improve his mental health and at least reduce his drug and alcohol use. After thinking about seeking help for years he takes a deep breath one day and steps inside his Local Mental Health and Wellbeing Centre (the ‘Centre’).

Damien mills around in the waiting room for a little while, trying to look at the various publications on the wall, but not taking anything in. After a couple of minutes a member of the welcome team finishes chatting with another client in the waiting room and walks over. Lenny, a paid staff member with a lived experience of mental illness who manages a team of volunteers in the Welcome Program, smiles broadly and introduces himself. Damien is surprised to have been approached, but it’s done with such gentleness and skill that he finds himself talking pretty freely. Lenny learns that Damien is here because of concerns about his own health (not that of a family member) and that he worries about his use of alcohol (that’s all he’s disclosed for now). Lenny says how nice it has been to meet Damien, and explains that he’d like him to have a chat with one of the assessment workers. He thinks it’ll be about a 10-15 minute wait. Damien is fine with that. Lenny gets him a coffee.

Fatima comes out to the waiting room, greets Damien warmly and ask him to come with her. They move into a spacious intake room with more printed materials/resources and a comfortable seating arrangement; casual but professional. Fatima explains that she’d like to note some things on her iPad as she talks with Damien and asks if that’s okay. He says it is. To do that, she explains, she will need him to sign the new patient form, and she points out that the form states that staff of the Centre have his permission to share his medical details with other staff members at the centre (in writing or verbally), but not with anyone else. The good thing about that, she explains, is that he won’t have to tell his story multiple times. Damien consents and signs.

NB. All client data is stored within the one Client Management System. Psychologists, doctors, social workers, AOD therapists etc, all record client data in a centralised system. The integration sought is not possible without a centralised/universal data system.
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A note on Fatima (assessment worker): Fatima has years of experience, as well as formal qualifications or training in 1) mental health, 2) substance use disorders and 3) psycho-social assessment and support. She is able to provide trauma-informed, person-centred care. Fatima has a dual role as assessment worker and then counsellor as she maintains contact with the clients she has assessed. She is fully capable of not only conducting initial whole-person assessment (including administering assessment tools for MH and AOD) but also delivering immediate interventions and advice. Her goals at this first meeting are:

- To ensure that Damien feels welcomed and respected at the Centre
- To begin to establish the norms of his relationship with her, and by extension the rest of the staff at the Centre: respectful, consultative, honest.
- To begin to paint a fuller picture of Damien so that she can learn if the Centre is the most suitable place for his care, and if so, who is the support team likely to consist of (of course this picture will grow and change over time).
- To get a quick win or two today in terms of advice, support and freebies (dental hygiene kit, MYKI cards, supermarket vouchers, relevant handouts, help him download a mindfulness app etc) as appropriate
- To begin to piece together and record the information that will be needed in the likely event of the formulation of a Care Plan for Damien
- To collect that data necessary for Damien’s care and for the Department of Health
- To have Damien leave feeling and being safe and connected.
- To have Damien completely across of the next steps and recommendations for the period of time before the next consultation (possibly in writing for his reference).
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BACK TO THE CASE STUDY

Fatima learns quite a lot about Damien in this initial session. With skill she encourages Damien to share his story, guiding only occasionally. She incorporates this listening approach with some clinical assessment tools also. She learns that Damien has occasional thoughts of self-harm, including a suicide attempt in his teens, and he describes himself as 'pretty sad a lot of the time.' In describing his childhood and adulthood she observes traits commonly associated with ADHD. She gleans information about his drug use (he didn’t raise that with Lenny in the waiting room) which it turns out is frequent, including periodically injecting drugs. She pauses to focus on that, learning about how, when, what and with whom Damien uses drugs. Because Damien seems comfortable with this focus Fatima decides to spend the likely remainder of the session today on harm minimisation education. She exhibits care and concern, not judgement, and discusses safer injecting practices, provides Damien with clean needles and syringes (she has them right there) and Nyxoid (a nasal spray delivery system for naloxone to treat opiate overdose). She asks if she can bring Lily in (peer harm min worker) for a couple of minutes to teach Damien how to use the Nyxoid properly. Damien is fine with that, and Lily undertakes a 10 min training in the room, explaining that he could save a friend’s life, and if he passes the training and the Nyxoid on, a friend could save his.

Both Damien and Fatima feel that this is enough for now. Fatima explains that she would like to make another appointment for him, this time with one of the centres GPs to look at his general health and drug use also, and assures him that she will attend at least part of that appointment. Fatima explains that now Damien will have a team of 2 here at the centre, and that it will likely grow bigger than that. She also explains that they will be here for as long as he needs them.

After Damien leaves, Fatima spends another 30 minutes writing up her notes, for herself, for the GP and for any future staff members who might need them. This includes an indication of possible future support needs:

- Ongoing integrated counselling including focussing on Alcohol and Other Drugs (provided by Fatima)
- Medical support for drug and alcohol use (possibly opiate substitution therapy)
- Clinical mental health support (eg. Mental health nursing, Psychologist, possibly psychiatry)
- Inpatient detox (this would be in partnership along a very warm referral pathway, eg. no retelling of his story, to an external AOD partner organisation). It’s too early to contact her assigned intake worker at the partner AOD agency, but she has a quick look at the wait list publicly available on the DirectLine website (she feels Damien is well into the contemplation stage of change).
- AOD support group, possibly LGBTQ+ (either one of the groups run at the Centre or NA or similar)

Because Damien has several support needs ('comorbidity') and his AOD use is consistently high, Fatima consults her supervisor regarding Damien’s suitability for care at the Centre. Due to the level of complexity that is emerging he may be too complex for the Centre, and should possibly be referred to the Area Adult and Older Adult Mental Health and Wellbeing Centre. Together they decide that given his current status as securely housed and also in employment, and the fact that he demonstrated cooperation and respect during his assessment, the level of risk demonstrated so far can be managed by the multi-disciplinary team approach put in place at the Centre. Between the team onsite (counsellor, mental health nurse, GP and others) and also through collaboration with the formal AOD sector (eg. for detox, specialist AOD groups and secondary consultation), there is a good chance that Damien and the team will be able to achieve incremental whole-of-life improvements for Damien over time, whilst helping him stay employed, housed and out of the emergency department.

Lastly, Fatima lists Damien for the next meeting of her multi-disciplinary team. It will be a brief mention as Damien is new to the centre, but she wants to flag that he may need a large team, and likely external referral also. Fatima consults the caseload list and assigns a care coordinator to him. The care coordinator, Kym, will be automatically notified by the system, and Fatima makes a mental note to have a brief chat also before the whole-of-team meeting. Being in the same multi-disciplinary team, Kym and Fatima’s offices are very close to each other and they usually bump into each other several times every day.
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A note on the multi-disciplinary teams: Because of its size this Centre has two distinct (and very similar) multidisciplinary teams, purpose-built for an inter-disciplinary approach to complex clients [the reason for multiple teams is to keep team size down for reasons of staff familiarity, logistics and focus on a not-too-large client cohort]. Individual disciplines communicate frequently with each other (eg. All the care coordinators know each other and collaborate to continuously improve care coordination at the Centre), but even more so staff know the members of their assigned multi-disciplinary team.

‘Complexity’ in a client is shorthand for a) a high severity of symptoms, and b) comorbidity - the client’s need for support across multiple areas (eg. MH, AOD and housing). Complexity is the expectation when a client attends the Centre, and new clients demonstrating complexity (or existing clients whose presentation becomes more complex) are fast-tracked for the development of an individualised support team including clinical and non-clinical elements. Each multi-disciplinary teams consists of one or more of each the following:

- GPs (with AOD quals/experience)
- Clinical mental health workers (eg. psychologists, mental health nurses)
- Family support workers (families engaged as early as possible)
- Peer AOD counsellors
- Peer mental health workers
- Care coordinators
- Social workers and/or psycho-social workers

Each Centre will have resources that must be shared across multi-disciplinary teams and the Centre generally due to expense, scarcity and level of specialisation, such as:

- Psychiatry
- Legal support (eg. Onsite clinics provided through a Health Justice Partnership arrangement with a local community legal centre)
- Support groups
- Onsite allied health clinics (likely through partnerships).
- Housing support workers (onsite clinics through partnership)
- Nursing (working with GPs)
- Intercultural workers
- LGBTQ+ workers
- Indigenous health workers
- Vocational therapists
- Family violence workers

Where possible and relevant to particular client, these staff should also be invited to whole-of-team meetings also.

Secondary consultation with the AOD sector and/or Area Centres is likely to be necessary for access to addiction physicians (FAChAMs) and addiction psychiatrists.

The purpose of designated ‘teams’ is to ensure a whole-of-person approach to care, and to put in place every necessary condition for team-work. It is essential that members of the team:

- Have the right mix of disciplines
- Are committed to the principles of teamwork including sharing risk
- Have weekly whole-of-team meetings
- Conduct case conferences with GPs and other staff as needed
- Know each other well enough to seek support, having scheduled but also ad hoc discussions as needed
- Contribute to the formation and implementation of Care Plans
- Are committed to a culture of learning and teaching across disciplines.

A multi-disciplinary team can increase the likelihood that gains made in one area (eg. AOD treatment) can be consolidated across other areas (eg. Social inclusion, mental health, housing), so that the client experiences incremental whole-of-life improvements over time.

Note: A new complex client does not necessarily get a large support team, but rather the disciplines are brought into the team as they are required, understanding that there is no hand-off, but rather an augmentation of the team. It is understood by all staff that people recover in the context of relationships (with the human beings who are providing professional support), and they commit to care for the client for as long as it is required, and as long as the Centre remains the appropriate venue for care.

Note also: Staff members who are part of a multi-disciplinary team may also support clients who are not deemed complex and have only one person in their Centre support team. Caseloads for individual practitioners are balanced for numbers, complexity of clients and level of involvement in care.
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BACK TO THE CASE STUDY

DAY 2:

Damien does not show up for his second appointment. Although he now has an assigned care coordinator (Kym) that Fatima has discussed him with, Fatima does the follow-up in this instance because Damien hasn’t met Kym yet. After two days of leaving messages, Damien finally answers the phone. After the initial assessment Damien was a bit overwhelmed by thinking about issues that he had been suppressing for a long time. Fatima engages Damien in a bit of Motivational Interviewing and psycho-education. She tells him that his reaction is totally normal; in fact it’s so normal that they even talked about it a little when he visited last time. “Didn’t make it any easier though,” says Damien and he and Fatima have a wry laugh. Fatima tells him that recovery (“That’s our fancy word for getting healthier and happier”) is non-linear (“That’s our fancy word to say that you’re going to have your ups and downs”). Fatima reminds Damien that he took the first, brave step to enter the Centre, explains in some detail what a consultation with the GP might entail and asks him if that is still what he wants. She waits through a long pause before Damien says yes, that is definitely still what he wants. Can he maybe come in today? Fatima is very familiar with the ways of working of the GP she had lined up and is certain he’ll squeeze Damien in for an opportunistic drop in. “How soon can you get here, she asks?”

Fatima makes a note in Damien’s file that she thinks he will benefit from some peer support and emails one of the peers to check his availability that afternoon.

LATER THAT DAY:

Damien attends and the Centre, checks in with reception. “Good to see you again Damien”, says the reception worker who Fatima had worded up to give Damien a little extra attention (that’s actually Damien’s first friendly word from someone since he left the Centre days ago; his smile is genuine). “Fatima will be right out.”

Fatima takes Damien to see Dr Anh Nguyen, makes the introductions and tells Damien she’ll catch up with him after the session. ‘Dr Anh’ is a General Practitioner with advanced skills training in medically assisted treatment of opioid dependence and other AOD training. A nurse pops into the room to do basic observations while Damien and Dr Anh chat (this is a drop in and things are a little hectic). It’s obvious to Damien that Dr Anh already knows quite a lot about him, and there is no backtracking or re-telling of his story. Fatima and Dr Anh complete a Mental Health Care plan for Damien including the need to access (onsite) clinical mental health supports in the form of a mental health nurse.

NOTE: General Practitioners are central to the delivery of AOD treatment in primary care.

WHAT’S NEXT:

Over the next couple of months Damien sees Dr Anh, Fatima and his mental health nurse Joe several times. His appointments (reminders, check-ins) are made and followed up by Kym (care coordinator) and he gets a support call about once a week from Bruce, a mental health peer who is also gay (it has emerged gradually that Damien is gay and that this is a cause of considerable stress with his family, and something that he largely keeps secret).

In week three Kym has lined up an appointment at the Centre with an intake worker from the AOD inpatient detox service (intake workers visit frequently as required; the care coordinators group appointments to make the most of the intake workers time). Kym is present throughout the appointment and has, ahead of time, negotiated and documented which aspects of Damien’s history he is happy to share with the AOD service. Nothing extraneous, just issue relating to risk, readiness and medical wellbeing. NB. Kym didn’t make the appointment until she was confident that Damien would pass the assessment (she knows the system inside out).

AFTER THAT:

Damien stays heavily involved in the Centre for 7 months. During this time Damien:

- Undertakes a week-long inpatient detox (external to the Centre), with Bruce checking in on him a couple of times over the phone.
- becomes a devoted group attendee (a LGBTQ+ AOD group through NA, Bruce took him to his first couple of sessions)
- commences buprenorphine treatment for opioid addiction (he and Dr Anh are planning to continue this for several months while he strengthens his community networks, improves his family relationships, and improves his daily exercise routine – the Centre has used brokerage funding to pay for 6-months’ membership of a local gym)

After a good chat with Damien weighing up pros and cons, Dr Anh slates Damien for discussion at the weekly whole-of-team meeting. He explains that they are shortly going to stop the buprenorphine treatment and monitor Damien’s progress. Some team members are nervous about this and Anh explains that he’s already scheduled an online secondary consultation with an Addiction Specialist (FAChAM) he knows well at the Statewide AOD service (with whom he does regular training). Anh won’t proceed without further advice and once again discussing Damien’s readiness with Damien himself. Bruce offers to step up his contacts if and when the treatment regime changes (and he’ll call him after this meeting for a quick check in).

Gemechu is Damien’s family support worker. Damien’s mum & dad have been attending a fortnightly online support group for families/loved ones organised through the Centre and Gemechu has established a high level of trust with them. Gemechu says he’ll get in touch with Damien and see if he wants Gemechu to help explain this transition to his family.

Fatima has been in the background of Damien’s care lately, but speaks up here. Does Anh think that, if this transition goes well, Damien might be in a good position to start psychotherapy to address underlying traumas. “I’ve got capacity”, chimes in Jan, the senior clinical psychologist in the team. The three schedule a time to do a case conference outside of the meeting. Jan goes on to engage Damien in a variety of modalities including CBT and DBT in processing issues of childhood trauma.

There are ups and downs, and in the end Damien needs to detox again and the plan to end buprenorphine is postponed a number of times All through that time Damien knows where to go, who to call, what to do and how to look after himself. He is always ashamed when he slides backwards, but there is no doubt in his mind that the Centre will always be there for him and he keeps coming back. Some historical legal issues surface from previous property crimes related to paying for drugs when he was unemployed. These are dealt with through the onsite Health Justice Partnership, for whom a non-custodial sentence is relatively easily achieved with reports from several members of Damien’s support team, and commitment to ongoing treatment (psychological counselling monthly suffices to meet that requirement).

IN SUMMARY

At a time when things were going downhill for Damien, when things could have descended into incarceration, alienation from family, worsening mental health, social isolation and self-harm, the downward slide was arrested by a highly skilled, multi-disciplinary approach to stabilisation. The support team around Damien grew and changed strategically as Damien’s needs and the team’s understanding of those needs changed. Damien was continually at the heart of the decision-making process, personally attending several case conferences and always informed of their outcome.

From the moment he set foot in the Centre Damien began to experience incremental, whole-of-life improvements. This commenced with improvements in social inclusion from the warm welcome provided by Lenny, Fatima and the reception staff, and continued through medical, psychological therapy and psycho-social/wellbeing interventions. Much of this support was provided wholly within the Centre where the ability to manage complex comorbidity was essential, as well as maintaining a broad clinical and non-clinical (whole person) perspective. Where specialist support was required from the AOD sector (inpatient detox, AOD support groups and secondary consultation) this was provided with little disruption or inconvenience to Damien. That's integration.

Feedback on this hypothetical case study is warmly welcomed. Please make comments and suggestions however brief or lengthy.

Patrick Lawrence
Chief Executive Officer