Community Description

Case Scenario: YAMAMOTO FAMILY

Agency Information and Background

You are employed as a generalist social worker in a primary care community health agency that serves a large metropolitan area of a major capital city, Durum. The service area includes a low socio-economic area as well as sections of middle to high socio-economic areas.

Your team consists of a social worker (you), a psychologist whose role is to provide cognitive/intellectual assessments and other test instruments for mental health issues; three nurses who provide in home assessments of physical health issues and prescribe home aide assistance for housework and shopping; an Occupational Therapist (OT) who provides assessments of daily living skills and provides reports to order aids to daily living. A Medical Director has overall management of team and final decision in the acceptance of cases to the service, treatment planning and discharge planning.

Your role is to undertake psycho-social assessments of clients and/or their families who are referred by general practitioners, or other health and medical agencies for various health related issues; you provide referral to appropriate agencies for problems such as emergency relief, emergency accommodation, child care and other community supports. You link clients to relevant agencies in the area based on your assessments and you provide supportive counselling to assist clients to reach their goals – which are related to supporting and increasing their health and wellbeing. Your agency allows a maximum of ten visits following case presentation to the team and case acceptance before review at the case review meetings. A further ten sessions may be negotiated based on your ongoing assessment and review of progress toward the goals of intervention.

You do not provide specialist services in regard to mental health, infant and child health or child safety. Your case load is primarily providing psycho-social support to adults with health related problems and their family members who are impacted by the situation, as well as appropriate referral.

There is a large metropolitan hospital which refers to the community health centre on discharge of clients into the community, and to which you refer for specialist health intervention across the range of sub-specialities found at most major hospitals inclusive of but not limited to mental health, oncology (cancer), paediatrics, surgery, gerontology, maternity and endocrinology.

Presenting Problem

Mrs. Yamamoto is a 52 year old woman diagnosed with breast cancer which has metastasized to her lungs. The diagnosis of her illness was three months ago, she had a course of chemotherapy to manage the effects of the cancer but due to the extent of the cancer the prognosis is poor with little likelihood of remission. She was admitted to hospital for two days due to an adverse reaction to her last chemotherapy treatment and has been discharged home 3 days ago with no further active treatment planned. Her current prognosis is approximately 6 months. The nurse and OT have visited to assess the home environment and put in place aids to daily living to assist with bathing and mobility. She is not eligible for home help assistance as she lives with her teen-aged son and daughter, and has an independent income.

Mrs. Yamamoto expressed concerns to the nurse and occupational therapist about the welfare of her three children and elderly mother, all of whom have depended upon her for support over the past ten years. She is worried about how they will cope following her death and requested help from a social worker to sort out her problems.

At the team case review meeting where Mrs. Yamamoto’s case was presented by the community health nurse who conducted the initial visit, a cross referral was made to you to assess and intervene in Mrs. Yamamoto’s situation. At this review, the discharge report from the hospital was discussed and you are aware that as Mrs. Yamamoto’s disease progresses she will experience considerable respiratory distress and pain in the last weeks of her life, and it is likely that she will need palliative care to manage this. Mrs. Yamamoto is aware of the likelihood that she will need palliative care but has asked that this information not be shared with her family until she is closer to needing it. She wishes to have as much time with her family as possible and to remain in her own home for as long as possible.

The community health nurse in your team (who conducted the initial home visit with the OT) is a strong advocate for out of home palliative care and during the team meeting, she has strongly presented her view that Mrs. Yamamoto should be transferred to palliative care as soon as possible to reduce the burden on her family. She feels that Mrs. Yamamoto is being selfish in imposing her needs on her family and she asks you to convince Mrs. Yamamoto that palliative care is best option for all concerned. The OT comments that with aids to daily living and other community supports to help Mrs. Yamamoto with bathing, shopping and monitoring her medication and health status she is able to manage at home for some time yet. The Medical Director is non-committal during the meeting but asks you to complete a thorough assessment and present your treatment intervention plan at the next fortnightly review.

Since this initial review meeting you have contacted Mrs. Yamamoto and have home visited on two occasions to assess the situation. From your interviews you have gained the following information and observations, as well as the collateral information from the clinic files and hospital report.

Background

Mrs. Yamamoto lives at 21 Ferguson Street, Lime View, in a low maintenance three bedroom brick bungalow which she bought 10 years previously following her divorce from her husband. She has a landline 5476 0942 and a mobile phone, 004002 4567 which she keeps close to her to enable her to be easily contacted.

Lime View is a middle class suburb within the health district. Mrs. Yamamoto worked in a mid-management administration position in the Commonwealth Government until she took sick leave from her job. She is currently using her long service leave which will cease in 5 weeks time, after which she is able to draw upon her superannuation.  She has not yet contacted her superannuation company to investigate her entitlements but believes that her superannuation includes life insurance as well as work cover.

Mrs. Yamamoto, is an Australian citizen of European descent, she is an only child and since her father died 4 years ago she has provided support – shopping, cooking, cleaning and laundry for her elderly widowed mother who lives close by in a small self-contained unit

She married Mr. Yamamoto 24 years ago at the age of 28 years. They separated 14 years ago shortly after the birth of their youngest child when Mr. Yamamoto returned to Japan, his homeland. They formalized their separation by divorce 10 years ago. All of the children are Australian citizens. Their separation was amicable and there is no history of domestic violence or abuse. Mrs. Yamamoto says the marriage failed due to the stress of caring for May, and their disagreement on how best to manage her needs. Mr. Yamamoto is fluent in the English language; no other family member is fluent in Japanese language.

Mrs. Yamamoto has three children, two of whom reside with her. Her eldest child, Amaya, suffers from an intellectual disability and lives in a group home. Until her she commenced chemotherapy 3 months previously, Mrs. Yamamoto visited her daughter regularly and every 4 weeks had an “at home day” where she picked up her daughter and brought her home to stay overnight for a visit. Since she became ill Mrs. Yamamoto has found that the demands on her have been too much and she ceased the overnight visits, although she has maintained contact with her daughter.

Family Members and Extended Family

Mrs. Janice Yamamoto – mother, 52 years

Amaya (May) – eldest daughter, 22 years

Kenji (Ken) – son, 20 years

Emiko (Emi) – daughter 14 years

Mrs. Ivy Robertson, maternal grandmother 78 years – lives close by

Mr. Ryoma Yamamoto – father 54 years (divorced) resides in Kanazawa, Japan.

On your first visit Mrs. Yamamoto was at home, as was Emiko her 14 year old daughter who complained of illness – headache and stomach ache which prevented her from attending school. Mrs. Yamamoto asked Emiko to go to her room and leave you to talk together. However at various times during the interview Emiko interrupted to ask if you wanted tea or coffee and lingered in at the doorway before withdrawing to her room. You noted that despite claiming to be unwell Emiko does not appear to have any signs of illness.

Mrs. Yamamoto tells you that her eldest daughter, May, suffers from intellectual disability and lives in a group home with others, supported by Disability Services. May has a low/dull I.Q. (<70), and receives a Disability Pension which provides for most of her needs, but Mrs. Yamamoto provides some extra support to buy clothes or attend outings. She worries that May will not have this extra support and she feels that May might react badly to her death even though she has not lived at home for 6 years. Although May knows that her mother is unwell she does not know about her mother’s diagnosis and Mrs. Yamamoto is not sure how to go about explaining this to May.

She is currently able to pay the mortgage on the house and there is sufficient money from her superannuation to pay out the mortgage upon her death, but she is not sure how the transfer will be managed – if she needs to transfer the mortgage to her son and daughter to ensure that they are able to stay in the home after she dies. Nor has she yet discussed the future arrangements with her children or what can be done to continue providing extra support for May without putting her disability pension in jeopardy. Mrs. Yamamoto says she thinks that there should be enough money to provide a small allowance for May and to support Ken and Emi to finish their education. Ken is currently enrolled in an Engineering Degree with 2 years to completion and Emi is in Grade 9 at a private girl’s school. She hopes to go to university.

You ask Mrs. Yamamoto if Ken and Emi are aware of her prognosis. Mrs. Yamamoto tells you that they attended a family meeting at the hospital where the oncologist explained her condition to Ken and Emi and they are aware that she has maybe another 6 months with them. Both were very distressed following the interview but there was no further discussion – following delivering the information the oncologist left. Emi and Ken had to leave the hospital soon after as it was the end of visiting hours and there has been no further direct discussion of her prognosis and the progression of her illness. Her mother Mrs. Robertson is aware of the prognosis and is also very worried about the children.

You notice that Mrs. Yamamoto is looking carefully down the hallway to Emi’s room to check where she is before she begins to tell you that her ex-husband had recently been in contact. He wants to help out in the situation and is coming to visit in 2 weeks. He has proposed that he take custody of Emi and take her to Japan to live with him. Mrs. Yamamoto says that Emi is very distressed by this plan as she has not seen her father for some time and he has not been very present in her life, she does not speak Japanese and is afraid of fitting into the education system in Japan. She is worried that meeting with her father will increase Emi’s distress as she is already constantly ill and missing school. Mrs. Yamamoto received a letter from the school informing her that as Emi had been absent for more than half of the term the school administration board was considering requesting Emi leave because she would be unable to achieve favourably in the State examinations which would bring down the school’s overall standing in the State.

Mrs. Yamamoto also tells you that she does not want to spend too much of her money on home help or other supports as she wants to have as much money available to her children as possible following her death. She is worried about the funeral costs and wants the arrangements to be organized prior to her death so that the children do not have the burden. She says that her son Ken became very upset when she said she wanted the “cheapest funeral possible” because she did not want the money spent on the coffin or service. Ken strongly feels that this would not honour his mother. She also worried because it was getting harder for her to manage her personal care.  Ken at times had to help her to manage toileting and showering and she felt it was inappropriate for a young man of his age to do this, although he said he wanted to help her, and she did not want Emi to have to manage this burden as she was too young and already very easily upset.

Mrs. Yamamoto also asks you if you can help to sort out services for her mother. Up until her recent admission to hospital she still managed to see her mother regularly and on days when she felt well she was able to do some cleaning and laundry. Ken has helped with shopping for his grandmother, and her neighbours also look in on her to check if she needs any help. Mrs. Yamamoto is very, very worried about the burden placed on Ken even though he has willingly helped she knows that he has to keep up his study and will also have to work in placement as part of his degree which will also put demands on his time. Ken has not talked much about his future placement of late when a few months ago before her diagnosis he was keen and enthusiastic about exploring his placement possibilities. She thinks he has to go to placement interview in the next few weeks but she has not talked with him about this since she was discharged from hospital.

Mrs. Yamamoto is often tearful throughout the interview but says she is not crying for herself but because she is so worried about what will become of her children and her mother. She says she cannot relax and feels stressed and agitated all of the time. She is unable to get out and do things for herself and she feels overwhelmed that there are so many things to do and to organize but she is so tired at times that it is hard to concentrate and get the energy. She says she does not want support from a palliative care team to die at home because she worries that that will be too much to place on her children but she is not yet ready to go a palliative care unit. She does not know very much about palliative care and how to arrange it or if it can be arranged that she is admitted when she feels that time is right.

She refused any further involvement of the nurse in your team as she felt that she did not understand her desire to be with her family, did not listen to her and she felt she was being pressured to accept admission to out-of-home care. Mrs. Yamamoto begins to weep and this brings Emi quickly into the room. She looks at you and says angrily “Why are you making my mother cry?” You say “It is a very sad time for everyone in this family and there seems to be a lot to cry about.” Emi bursts into tears and sits down close to her mother, who hugs her close. Mrs. Yamamoto comforts Emi, and says “It’s all right darling, I am just very sad about leaving you too soon, and this social worker is helping me to sort out things so it won’t be so hard for you.”

Emi says to you “I’m sorry…”. You are able to engage her in a conversation about worrying about her mother. You wonder whether it is hard for Emi to go to school at the moment when she is so worried about her mother. Emi is able to say that she feels worried about her mother all the time and does not want to go to school because she wants to be with her mother as much as she can, she says “I do not want to be at school and not be here if she needs me .. What if she dies when I am not here?” You notice that Emi is very tearful, has difficulty maintaining eye contact and seems to be much younger than her 14 years. She remains clinging to her mother until you leave.

On your next visit, Ken is at home with his mother and sister, and he has brought his grandmother to visit Mrs. Yamamoto. You note that Mrs. Robertson (grandmother) although elderly is not frail and is very mentally acute and aware of the situation. After introductions to Ken and Mrs. Robertson, Mrs. Robertson turns to you and says that Ken is lovely boy and she likes to see him often but she thinks that looking after her is too much for a boy his age. Ken responds “No grandma I can manage, I can look after everyone it’s okay.” You note the tension in Ken’s voice when he insists it is okay. Emi says “I can help too, Ken and I want to stay together … I don’t want to live with dad.” Ken says very fiercely to you as if challenging you to disagree, “Emi can stay with me I can look after her ‘til she finishes uni. We want to stay together. Dad hasn’t been around for years and he can’t just walk in and take over. Don’t we get a say in our own lives?” Emi nods in agreement.

Mrs. Robertson becomes tearful and says it’s wrong; it is not fair that this has happened to Janice, she is too young and children shouldn’t die before their parents.

Ken repeats that it is okay, he can manage he will keep the family together. After a silence, Mrs. Yamamoto says “I know you will do your best Kenji but it would rest my mind if we sorted some things out and maybe worked out what will help to keep you together.” You see Ken does not make eye contact with his mother but he nods slowly in agreement. His grandmother reaches out and strokes his arm. You say “Maybe if we think together about what things need to be done to rest your mother’s mind it might support you in keeping the family together..”  You sit with the silence until Ken eventually looks up at his mother and shifts his gaze to grandmother before looking at you and saying “Alright… okay I’ll listen but I can still manage, I’ve been the man in this family for a long time.” (You note that he is teary and is struggling to not cry).

Mrs. Yamamoto also tells you that May’s support care worker brought her for a visit yesterday. You notice that both Ken and Emi look away and will not make eye contact with their mother or grandmother. Mrs. Yamamoto says that May at first did not seem to understand the situation but then began to ask many questions about what happens when you die and where her mother would be, and then became progressively distressed so that the visit was curtailed. Her support worker reported that May was refusing to come out of her room and had displayed some aggressive behaviours this morning. Ken did not want his older sister to visit until she settled down more because when she is upset her behaviour becomes very physically aggressive and he is afraid that she may hurt his mother. Emi also says she is afraid of her older sister when she is in these “moods”. Mrs. Yamamoto says she cannot physically deal with May anymore that is why she went to live in the group home, but still she feels that she must see May and spend some time with her before she dies.

You notice that Mrs. Robertson is still crying and wringing her hands. Emi has snuggled in close to her mother and Ken has stood up to look out the window with his back to everyone, he struggles to square his shoulders.

You bring the interview to a close by summarizing the main points that have been discussed, and you suggest that it would be beneficial to everyone to also start planning for the next few months so that the family can have the opportunity to discuss their options. You agree to return next week after team review to discuss the options for intervention with them. All of the family members want to be present, and Mrs. Yamamoto suggests that it may be better to make a separate time to meet with May and her support worker, as she will need to have more time to understand the issues.

Community Description:

Lime View is a middle class suburb within the Health District that is served by your organization. There is a mixture of houses and units with good access to transport – trains and buses that run to the university and into the city. There are predominantly white collar workers, academics and some shared student households resident in the area. There are also some more elderly residents who are gradually moving away to units and age care accommodation.

The infrastructure in Lime View is dense it includes two major shopping centres and small local shops that are accessible by bus and train. The local shops include a newsagent, bakery, butcher, fruit and vegetable shop, delicatessen, chemist, general practitioner, dentist and a general grocery store. The area is well served by government agencies including your Community Health Centre, Child Health Service, Child and Youth Mental Health Service, Aged Care Services inclusive of home help for cleaning and shopping, Domiciliary Nursing Care Services (visiting nurses who assist with daily living – bathing, medication, wound management) and Non-government welfare services – Lifeline, Salvation Army, Red Cross and St. Vincent de Paul. There are local sporting clubs including soccer, tennis and swimming, and cinemas in the shopping complexes. There is a local government funded Neighbourhood Centre which supports Meals-on-Wheels and actively supports other community programs such as play groups, after school care and holiday programs and a mobile library and day program for disabled and elderly residents. There is a Citizen’s Advice Bureau and Legal Service, which is funded by the Commonwealth Government’s Community Legal Services Program, and a local government grant program to provide free face-to-face information about legal matters and possible avenues of action. There is a palliative care unit in the local area which maintains 20 beds and has a community team that supports the management of terminal conditions for patients who remain at home and transfer into the unit at the end stage if necessary.

The university and a number of private and public secondary schools are located within the area or in adjacent suburbs. These institutions also have student counselling services (university), and school nurses and school guidance counsellors (schools).

The majority of the residents are Anglo-Australian, however there is a population of international residents who study or work at the university but tend to be transitory – leaving after contracts or courses have been completed.

• You are required to develop a Psycho-Social Assessment and Intervention Plan from a generalist social work perspective
• You are required to refer to the literature and reference to support your assessment and intervention plan where appropriate (this variation in report writing style is included as this is an asses sable academic learning exercise designed to increase your knowledge and skill
• You are required to develop a separate intervention plan although assessment and intervention can be entwined the focus of this task is on demonstrating your assessment skills and ability to translate the key issues into intervention goals. The Psycho-Social Report should conclude with a formulation paragraph which contains the key information/issues which will be the basis for developing the intervention plan. (Please note that social work practice is inclusive and intervention planning should be done collaboratively with your client to develop agreed upon goals of intervention – this will be assumed for this task).