DOCUMENT 3 FOIOFFICIAL23/24-1328 SGP Knowledge Article Template For Internal Use Only
The contents of this document are OFFICIAL. Guide – Psychosocial disability Case examples
This article provides guidance for a planner delegate, internal review delegate, national reassessment delegate, local area coordinator, early childhood partner, technical advisors, liaison officers (HLO/JLO), or complex support needs (CSN) planner to understand: • case examples of participants living with psychosocial disability.
Recent updates October 2023 Current guidance. Before you start You have read and understood: • Our Guideline – Reasonable and necessary support (external) • article Guide – Psychosocial disability.
Case examples
Billy Meet Billy Billy has met access requirements, has been hospitalised for four months in a mental health facility and is on a forensic order. The forensic order is a community-based order, as opposed to a custodial order, and states that he must continue to access treatment and attend all appointments made in relation to his mental health condition as recommended by his treating psychiatrist. Discussion Funded supports should not be provided while Billy is residing in the facility. While Billy is an inpatient, the health system is responsible for meeting the day-to-day care and support needs, including those related to his disability. This includes any supports required to access the community as part of rehabilitation.
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FOIOFFICIAL23/24-1328 SGP Knowledge Article Template For Internal Use Only In this case, the mental health system retains responsibility for providing: • clinical treatment related to the participant’s mental health condition • rehabilitation/recovery treatment • residential care where the primary purpose of the care model is for time-limited support following inpatient treatment, for example, Step Up/Step Down programs.
Planning Before developing Billy’s plan, the plan developer requests information regarding discharge planning from the mental health facility and records the following information in PACE: • planned timeframes for discharge • confirmation that the participant’s mental health condition has stabilised and the participant is well enough to live safely in the community • details of where the participant will be living after discharge including what informal supports are available to them • details of the mental health and health clinical supports that will be put in place to support the participant post discharge • information about what other supports will be required post discharge to support the participant with daily activities • any other information available.
When discharge is planned for within 12 weeks, a plan is developed following the normal planning process. Once the plan is approved, a warm handover is completed with the recovery coach or support coordinator. The recovery coach or support coordinator starts working with Billy and facility staff to progress transition planning. If Billy requires a plan prior to 12 weeks before the scheduled discharge date, a community connections plan with the details of his mainstream and informal supports can be developed. The plan should be developed and plan meeting conducted before discharge, once the discharge date is known, to include funding in the plan for supports required when the participant leaves the mental health facility. The partner or planner attaches a copy of the forensic order to the participant’s record in PACE. The planner adds an alert related to the order. Note: Refer to the technical advice case in PACE to understand if you need to request mandatory TAB advice. To learn more, go to article Understanding when to request for plan advice.
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FOIOFFICIAL23/24-1328 SGP Knowledge Article Template For Internal Use Only Jane Meet Jane Jane is 41 years old and lives in public housing. Jane was studying to become a vet before her education was interrupted by the onset of mental illness. Jane experiences high levels of anxiety when she leaves her home. She has previously been hospitalised following a decline in her mental health. Access to Informal, Community and mainstream supports Jane receives support from a support worker funded through her NDIS plan. However, Jane reports having no friends and that she rarely sees her family. Jane lives alone and has a number of bird cages and pet accessories. The public housing authority asked Jane to reduce the clutter in her house so that it can be cleaned, but she refused. Jane has been threatened with eviction. Engagement with the NDIS Jane has a plan reassessment meeting with her My NDIS Contact and they discuss recovery coach support available to participants with psychosocial disability. We include capacity building support for a recovery coach in Jane’s NDIS plan as she is currently not linked to clinical supports and has little informal or community supports in place. The recovery coach helps Jane to develop a recovery plan. They identify what’s important to her, exploring her values and interests and link this to her NDIS goals of maintaining her current housing and getting a job. Jane identified caring for animals as an interest. The recovery coach supported Jane to: • identify the barriers to achieving her goals • identify the skills she needed to help her take steps toward these goals • to link with a psychologist to work with her to develop strategies for managing anxiety and building up emotional strength to spend time out of the house
Jane sought out reassurance and encouragement from her recovery coach to engage with her psychologist. She initially felt that her sessions with her psychologist were not a good use of the psychologist’s time. She discussed her concerns with her recovery coach who reassured her that the psychologist was there to support her. The recovery coach helped Jane to develop the confidence to begin volunteering at an animal shelter. Jane, having practiced self-advocacy and negotiation skills with her recovery coach, is working with a housing support officer to reduce the clutter of pet accessories in her house. She has
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FOIOFFICIAL23/24-1328 SGP Knowledge Article Template For Internal Use Only successfully negotiated the sale of several items through Gumtree. Jane has managed to avoid eviction and her housing is stable. What’s happening for Jane now It has been several months since Jane began receiving support from a recovery coach. She has increased her volunteering hours during this time, and she hopes to increase to two days a week in the future. Through her volunteering Jane has made several friends, has taken up swimming and joined a walking group which are helping her physical strength, energy and sense of wellbeing. Jane has updated her goals in her recovery plan with her next goal being to learn computer and other digital skills so she can study an online certificate in animal care. Jane, with the help of an employment service hopes to apply for a job at the local animal shelter. Article topics and case names – internal use only
Topics This article relates to the following topics: • Add: dc_case_checkin • Add: dc_case_evidenceextension • Add: dc_case_functionalcapacityassessment • Add: dc_case_hospitaldischarge • Add: dc_case_internalreview • Add: dc_case_participantbudgetupdate • Add: dc_case_participantcriticalincident • Add: dc_case_participantriskassessment • Add: dc_case_planapproval • Add: dc_case_planchange • Add: dc_case_planimplementation • Add: dc_case_technicaladvice
Case names You can use this guidance for the: • Add: dc_case_checkin • Add: dc_case_evidenceextension
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FOFAIGIAB 28
SGP Knowledge Article Template
For Internal Use Only
Add: dc_case_functionalcapacityassessment
Add: dc_case_hospitaldischarge
Add: dc_case_internalreview
Add: dc_case_participantbudgetupdate
Add: dc_case_participantcriticalincident
Add: dc_case_participantriskassessment
Add: dc_case_planapproval
Add: dc_case_planchange
Add: dc_case_planimplementation
Add: dc_case_technicaladvice
Version control
Version Amended
Brief Description of Change
by 0.1 JJP788_ |Draft. Content from article — Guide — DRAFT 2022-11-18 Psychosocial disability v0.2 1.0 CS0074 |Class 1 approval APPROVED | 2022-11-18 1.1 REB563 |Content transferred from PG — DRAFT 2023-09-15 Psychosocial Disability. Updated to new template. Minor updates to change any NDIS Business System language to PACE language. 2.0 JS0082 |Class 1 approval pending comments APPROVED | 2023-09-21 being actioned (done) V2.0 2023-09-21 WP02-43 - Guide — Psychosocial disability Case examples Page 5of 5
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