Introduction:
This paper is a Service Review for Mr Jo Smith, who has been reluctant to engage with his support network agency. Due to his reluctances i.e. resistance, engagement was crucial in initiating a review of the support Mr Smith was currently receiving. Recently, Mr Smith agreed to meet with the two support workers, Rae Mondi & Ena Shebelle, to begin the process of reviewing his support plan. Herein, is the report of that meeting.

Initial Engagement for a Revised Service Plan Ena Shebelle and I, Rae Mondi, visited Mr Smith at his home. The realisation that Mr Smith had afforded us this opportunity moved us to inform him that, as part of his support network, the agency would like to review his current Service Plan in order to make improvements. We informed Mr Smith that although we have initiated this process we are required to seek and gain his permission to conduct this process. Mr Smith was hesitant, at first, but asked us to explain what the process involved. We explained the planning process, with special emphasis on his central role in the authorship of the contents and the methods deployed to implement the new plan. With his agreement secured we planned for our next meeting to reassess the current service plan as far his needs are concerned and how we can better support him. The meeting ended with Mr Smith informing us that he will try his best to be at the meeting, a week from today, at our Southport office.

Reassessment of Service Plan
The meeting was held at our Southport Mall facility. After a few preliminaries, such as the agency’s confidentiality clause, legal-ethical-cultural-human rights obligations, we moved on to explaining the reassessment process to Mr Smith. We explained that the agency sought to always ensure that our commitment to our obligations underpinned all of our practices, procedures & policies. We informed Mr Smith that, although the planning and implementation of the Revised Service Plan may include his current support team members, it is he who will ultimately decide the what-who-where-when-why of the new plan. We checked with Mr Smith if he understood the suggested process he assured us that he had.
Reassessment began with asking Mr Smith to explain what parts of the current plan did he like and why did he like it? This was followed up with, asking Mr Smith to tell us which part of the current plan he did not like and why he did not like it? The third phase included using the ‘HEADS’ model of psychosocial interviewing to revisit Jo’s world again to clarify where he felt he was and to identify, with his input, how he wanted to manage his life from here on. This enabled Jo to identify what was important to him to support his recovery and sense of autonomy. The fourth aspect of the reassessment, we asked Jo to structure a new revised plan with the concerns he had identified in the previous three steps. Jo asked for guidance over some of his choices, for which we provided.
Based upon our conversation with Jo, the following reasons may have contributed to his resistant and reluctant behaviour: 1. Jo receives his Newstart payment, from Centrelink, on Friday mornings. He thought that by shopping 3-4 days later wasn’t helping him budget his money. Jo did not like being transported by various drivers. One of his previous drivers had a habit of speeding. 2. Jo’s experience with the activities at the ‘drop in’ centre caused him to become nervous and anxious. He did not know which room to go to and what activities were available. The driver would drop him off and drive away leaving Jo to walk into a place full of strange people, he feared crowds. 3. Forgetfulness and fearful of doctors caused Jo to miss appointments. 4. Jo admitted that he resented the fact that every time support workers from the agency would call around they would go on about his medications, in particular, he is not taking them regularly.

As a result of identifying the areas that Jo was not happy with, Jo, then gave us what he wanted to happen in the new plan: 1. The challenge of sticking to the budget, after 4 days, has led Jo asking for shopping to be on Friday afternoons instead of Tuesday. He also requested if he could use the same driver and that we call him to remind him the day before. He hoped, in time, to learn how to catch the bus and shop himself. 2. Writing was an interest that Jo wants to pursue. He, with our guidance, has decided to join the ‘Writer’s Club’ at the ‘drop in’ centre. Jo would like to write about his experiences as one with a mental illness. The class of seven is something that Jo is confident that he can manage without being anxious. The agency agrees with Jo that someone needs to go with him to assist him in settling in. Jo also identified a bus which stopped outside the centre and wondered if the same support worker would teach him how to catch this bus to and fro the centre. Jo is happy with the present time and day, i.e. Thurs, 9.30-11.30am. Rae Mondi, current support worker, is now Jo’s designated driver, advocate and mentor. 3. After informing Jo of our bulk billing medical services and of our offering waiting patients coffee and finger foods, Jo asked that he come under the care of ‘The Holistic Centre for Excellence’ (THCFE), immediately. Jo also asked for a ‘reminder’ phone call the day before appointments. We made Jo an appointment with Dr Josephine Heinz, GP, for Monday 12th, June. Rae, will call him the day before, pick him up, show him around the facility, introduce him to Dr Heinz, wait for him and return him home. Jo stated that he would probably try and keep future appointments knowing he wouldn’t feel out of place and he felt like we cared and valued him. Jo thought that eventually he would like to use the bus that he had seen go by the agency. 4. To support Jo with his medications, he suggested that we have the Pharmacist, here at the centre, review his medications and for someone, to remind him by phoning him at least twice a week. He felt that after 3 months he may form the habit with his medications. SERVICE PLAN Mr Jo SmithSupport Need | D.O.B.14.10.82Support provided | Details of implementation | Key Performance Indicators ( after 3 months ) | Help Jo to budget his money. | i)Move shopping day.ii)Same driver.iii)Reminder phone call.iv)Teach how to access bus. | i) Shopping day now Friday.ii)Rae Mondi is designated driver.iii)Rae will call Jo, late afternoon, the day before. Rae will also remind him when Rae takes him to the ‘drop in’ centre on Thurs mornings.iv)Rae will teach Jo, by showing Jo the total process of purchasing bus ‘go cards’, locations of ‘stops’ and how to catch and exit buses. | i)Monitor Jo’s attendances and ability to purchase groceries, record it. If Jo engages in two of the planned four shopping organized, per month, that would be a marked improvement when compared with last plan.ii & iii)Jo will respond favourable to the phone calls.iv)Rae, when calling the day before, will, on occasions, ask Jo if he is interested in making tomorrow’s shopping day a ‘bus’ shopping day. | Help Jo join a weekly activity | i) Jo wants to join the ‘Writer’s Club’ at the ‘drop in’ centre. ii)Jo wants a designated driver and mentor. iii)Jo wants to learn how to catch the bus to the ‘drop in’ centre. | i)Jo is joined by Rae for 3 weeks at the ‘Writer’s Club’. ii)Jo is informed that Rae Mondi is his designated driver and mentor.iii)Jo is to learn how to catch the bus. | i)Jo is attending the ‘Writer’s Club, without Rae in class, and is something in his week, he looks forward to.ii & iii )Jo is catching the bus by himself after 3 months. | Assist Jo to attend important meetings and commitments | i)Jo asked to be transferred under the care of THCFEii)A reminder call for all appointments is agreed to.iii)Designated driver/mentor to pick up Jo.iv)Jo would like to eventually use public transport(bus). | i)Jo is transferred under the care of THCFE, immediately.ii & iii)Rae will call Jo, day before appointment and pick him up the day of appointment.iv)Rae will, as part of the ‘bus program’, continue training Jo. | i)Jo indicates that he is settled with being under THCFE.ii & iii) The growth of Jo’s confidence is causing him to make his appointments. iv)Jo may be confident enough to catch bus to appointments after 3 months. | Support Jo with his medications | i)Jo wanted his medication reviewed.ii)A phone reminder | i)A pharmacist was obtained to review Jo’s medicationsii)Rae, took responsibility for the phone calls. | i)Jo’s meds would be reviewed every 3 months.ii)Jo informs his GP, support workers & others that he has been compliant with the taking of his meds, and the various checks by his medical team confirms this. | | | | |

THCFE = The Holistic Centre For Excellence.