integrated chronic care empowers clients to find their voice

Integrated Chronic Care (ICC) assists people with complex, chronic and often dual diagnoses to navigate the health system and care for their mental, social and physical wellbeing.

Lucy Bassett works as cohealth’s ICC Care Coordinator and she says one of the most rewarding things about her job is empowering people to find their voice.

“Seeing [the client] now and seeing the pride that he feels and the trust he’s put in me is a big thing,” says Lucy, speaking about a client she has spent the last year working with. “That’s the thing that makes me want to get out of bed in the morning and keep working with this cohort of people.”

ICC is guided by clients and places a big emphasis on what they want their care to look like and what they want to focus on. The care clients receive is not prescriptive and they are always asked what’s important to them and what health and social outcomes matter to them the most. Often by supporting a client with one issue, Lucy discovers that there is something else they want support with.

“I’ll get a referral and it will ask that I touch base with a person around smoking cessation or weight gain associated with medication,” says Lucy.

“Then I actually talk to the client and that’s not always the thing that’s most important to them and that they want support with. It’s about helping clients feel empowered to talk about their needs, so they can say ‘this is what I want in order to feel better’.”

Lucy recalls supporting a client called Cassie* who, although she was referred to ICC because of her diabetes, wanted support to connect with her community and find strategies for managing her mental health.

After getting to know Cassie, Lucy was able to refer her to the women’s health nurse, a counsellor, the diabetes nurse educator, and a dietician. Lucy supported Cassie to establish goals around self-care, including cooking food she enjoyed, breathing exercises, and practicing gratitude.

It is so important that trust is built between clients and cohealth staff, so that our clients feel safe and heard. Once Cassie felt comfortable with Lucy and the care and support she was getting, she felt safe enough to try connecting to a new GP. Cassie had attempted suicide at the beginning of the year and had not been able to talk to her GP about it. She is now connected to a new GP who has helped her to change medications and is supporting her with a mental health care plan and to find a long-term trauma counsellor.

Cassie mentioned to Lucy that she would love to eat a steak, and while chatting about this Lucy found out that Cassie had had several teeth removed and had trouble chewing meat and crunchy fresh foods. Cassie told Lucy she was ashamed of this and had not told the dietitian. Lucy was able to refer Cassie to cohealth’s dental services to have a check-up and a denture made. When trust is built, clients feel comfortable and they know they will not be judged. Lucy was able to use the trust she built with Cassie to support her to regain her confidence and ability to eat more widely.

Lucy learned that Cassie had survived family violence and experienced anxiety about leaving her home. However, during lockdown Cassie agreed to share some walks with Lucy over the phone. During these walks Lucy took Cassie through guided meditation, and they would both share a gratitude at the end. One day Cassie said “I am glad I am alive. I have found freedom in the park today, I am not frightened here”. This was an incredible achievement, as Cassie had built up the confidence to be physically by herself during these walks and to see value in her life and her surroundings.

Stories like Cassie’s show us the importance of listening to our clients and letting them guide their own health outcomes.