Journey to Greater
Independence
Community Health & Local Government
in Partnership 18 June 2014
Background
 Mira was 42yr old Malaysian lady
 CVA (Stroke) while visiting Malaysia 7 years ago & no rehab or
post stroke education provided
 Prior to her trip she was an active single lady working as a music
journalist and yoga teacher
 On return to Australia she had minimal supports from her only
family member
 She was living alone in a private rental unit, at risk of eviction
 Client was initially referred to Frankston Council for shopping
assistance due to mobility issues
Frankston Council’s Initial Broader
Needs Assessment
 Strained relationship with sister & wanted to be independent
from her
 Found to have extremely poor mobility (bottom shuffling).
Frequent falls.
 Sleeping on the floor with minimal basic household items
 Underweight, isolated & vulnerable
 Risk of Eviction
 Clear goals of what she wanted to do
Outcome
 Commenced Unescorted shopping
 Information provided on multi purpose taxi card, Open door
for Medical transport, disabled parking permit form
 Referrals to Community Health through the Active Service
Model OT
 Case discussion at ASM Partnership meeting
Occupational Therapy Assessment
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Unsteady gait, high falls risk, no gait aide
No rails or assistive equipment. Infrequent showers and meal prep.
5 front steps- bum shuffling up and down as a result of frequent falls
No reliable strategy for managing community access and finances
No social support (apart for fourtnightly visit by sister to “drop” her at
the shops)
Mild Dysphagia and underweight
Expressive language impairment
Cognitive issues-poor insight, memory, processing, judgement,
planning skills
Limited understanding of cause, impact and management of stroke
Client Goals
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To improve balance and increase confidence
Increased mobility with no falls, be able to climb steps
Get back to shopping & library at Seaford
To become independent from her sister
Cook Malaysian Meals
To feel safe
To return to driving or ride a bike
Interventions
 Joint Assessment with Physio for gait aids and home based exercise program.
 ASM equipment Funding Assistance.
 PADL’s and DADL’s- SWEP equipment and home mods undertaken by Frankston
Council Home Maintenance Service, education on alternate techniques
 Extensive travel training with Allied Health Assistance
 Speech Pathology referral - dysphagia, communication and cognition
 Community Health Counselling referral- grief and loss, assertiveness
 Advocacy – Support to change GP & become independent from sister
 PH Stroke Education package undertaken by OT & PT over several sessions
 Future planning - Assisted with options for housing (Office of Housing
Application), Enduring Power of Attorney, Support groups, Neighbourhood
House, and taxi application appeal
 Mira declined Vulnerable persons list
Collaborative Review
9 Months Post Referral:
 Mobility/physical capacity- using walker and pick up frame
 No recent falls, undertaking home exercise program and grading Monash gym circuit
independently
 PADL’s and DADL’s – Managing independently at home. Preparing preferred Malaysian
meals. Had gained some weight
 Community Access - Managing all bills and moved from unescorted to escorted
shopping
 Has ½ price taxi card
 Speech Pathology – education and compensatory strategies provided.
 Cognition has significantly improved with understanding of deficits.
 Medical – Mira is now seeing a GP who’s values mesh with her own alternate
philosophy.
 Safety and self management – Mira has separated from sister and has an alternate
Enduring Power of Attorney. Reports feeling more able to deal with difficult situations
threatening her safety and wellbeing
Outcomes of ASM Collaboration
Where is Mira today:
• Mobility – mostly mobilising with a walking stick. Progressing to the CH
Pilates group and investigating local yoga classes.
• Community Access – Further training by AHA in catching public
transport very successful. Visiting various shops, library and social
groups across the Peninsula.
• Frankston Council’s Community Transport/Bus – take’s Mira to the
shopping centre
• Specialist review provided clearer understanding of prognosis – follow
up education regarding preventing further strokes and cognitive
strategies undertaken by OT.
• Mira now proactively self managing all affairs to the point she has put a
pre paid funeral in place so she has “control over everything”.
• Mira planning a trip to Malaysia to visit her father.
• Mira now thinking of becoming a volunteer –perhaps at a CH exercise
group.
Agency Experience
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Highlighted extensive skills within both agencies
Required commitment of staff more than funding
Case conferencing was critical to the success
Client was motivated and had clear goals
Seemed time consuming initially but cost effective given
minimal intervention required now
 Rewarding to see Mira achieve most of her goals and improve
her quality of life and overall wellbeing
Thank you
Lisa Manser – Program Manager/Occupational Therapist
Community Health, Peninsula Health
(LManser@phcn.vic.gov.au)
Gretchen Strauss – Coordinator Community Care
Frankston City Council
(gretchen.strauss@frankston.vic.gov.au)
Amy Robertson – Assessment Officer
Frankston City Council
(amy.robertson@frankston.vic.gov.au)