Amanda’s story

Her last relationship was unhealthy and ended badly when Amanda, 24, fled with little possessions and nowhere to go. For six months, she’s been staying on friends’ couches and self-medicating to make it through the day. She fears she’s running out of people to lean on for support. She has no job and no desire to enjoy her life anymore. She used to love online gaming and going out for coffee, but even these activities hold no comfort for her now.

Referral

Amanda’s doctor is trying to look after her medical needs, but she needs more support. She invites a PCCS Plus Social nurse to meet Amanda during their appointment. A lot of Amanda’s needs are outside of her physical wellbeing, but are directly impacting on it.

Needs assessment and goals

The PCCS nurse learns some of Amanda’s story during their joint GP visit and speaks further with her following the appointment to discover more about her health needs and goals.
The nurse takes time to really listen to Amanda’s concerns and learns that:
• She wants a place to go that she can feel is hers because she’s tired of couch surfing and straining her friendships.
• She misses her online gaming because she left her computer behind when she left her relationship.
• She wants to sort out how she’s going after her last relationship, but it feels like every time someone starts to help she has to move somewhere new and start again.
• She wants to move past her pain and not feel so hurt when talking or thinking about the past.
• She wants to look after herself financially; to have enough money to go out for coffee and enjoy life.

Action Plan

After sharing her goals, Amanda and her PCCS nurse work together on an action plan to meet her goals.
In the short term, it includes:
• Finding Amanda emergency accommodation until she can find something more stable
• Providing her with more intensive social work and linking supports while she moves around a lot.

In the moderate term, it includes:
• Sourcing stable longer-term housing
• Becoming financially stable by looking for work and investigating benefits available
• Exploring local supports once she’s settled in a bit

The long-term goals include:
• Linking Amanda to local supports for her health care
• Looking at supports around her trauma, mood and substance abuse
• Finding the right people that work well with her
• Getting her friendships back on track so she can enjoy going out for coffee again
• Resuming her love of online gaming
• Feeling safe enough so she can allow herself to fall in love again.

How Plus Social helps Amanda achieve her goals

A combination of internal and external referrals helps Amanda on her journey to improving her mental health and her life.
The PCCS nurse introduces Amanda to a social worker on the team who helps her find emergency accommodation. They also go to Centrelink together to help her access benefits. Robina Housing Service Centre provides a housing support worker to help find more permanent accommodation options.
Amanda’s GP is happy her housing is more stable. She asks the PCCS nurse to help find a good counsellor who can work with Amanda on both her
trauma symptoms and substance abuse. The GP reviews Amanda’s Mental Health Care Plan and Amanda commences sessions with the psychologist she found with the help of her nurse. The nurse also links Amanda with a drug and alcohol worker from Lives Lived Well through the GCPHN’s Alcohol and Other Drugs (AoD) service.
Amanda starts visiting a local gaming café and says she feels a bit more hopeful. She meets some new people to have coffee with and is feeling enjoyment from her hobby again.

End goal: self management

Plus Social allows Amanda up to 26 weeks of assistance, used consistently
or in blocks as needed, and if she still needs more care coordination she can be re-referred. But the aim of the program is to get the right people in place to create sustainable supports so that Amanda can take back charge of her own life.
If something goes amiss again in the future, Plus Social is always there to step back in and offer a reassuring and supportive hand to get her through any adversity.