Maree Twomey

2 Lindsay Place

Richmond

NSW 2756

03.09.2024

Re: Maree Twomey (DOB: 17.04.1955) NDIS review September, 2024

Dear Maree,

I write to provide you with a review, a summary of your goals for the next year, and a budget for your NDIS plan review for the 5th of September, 2024. A copy will be emailed to Michelle Loasby (Area Coordinator, Uniting NDIS) and Natasha Barlow, your NDIS Service Coordinator, prior to the meeting.

For the purpose of this review, I would like to inform your team that due to a major health challenge in June, 2024, your goal priorities have changed considerably and will need ongoing support, as explained in the report.

Yours sincerely,

Michelle Hookham

The current report for Maree Twomey includes the following:

Table of Contents

Maree Twomey, NDIS Plan Review, September, 2024	3

1.	Review of care	3

1.1 Referral	3

1.2 Prognosis – Chronic and lifelong mental illness	3

1.3 Weekly psychological support required	3

1.3.1 Rationale for weekly psychological support	3

1.3.2 Impact of psychosocial stressors and justification for weekly sessions	4

2. Life stage outcomes and long-term benefits	5

3. Plan	6

4. Maree’s Goals:	6

5. 2024 NDIS plan for Michelle Hookham	8

Maree Twomey, NDIS Plan Review, September, 2024

Review of care

1.1 Referral

Maree was initially referred to me in April, 2019 by her GP, Dr Nagwa Morris. I have been providing mental health/therapeutic support services for her since that time, covered by her NDIS plan since January 2020. Maree consistently states that she finds my services invaluable and that it contributes significantly to her mental health recovery, stability and her being able to continue to live an independent life.

1.2 Prognosis – Chronic and lifelong mental illness

Maree will need ongoing psychological support, since her condition is chronic and lifelong. This helps her to navigate the challenges associated with her deterioration in health in a way that reduces the impact to her psychological and emotional wellbeing. Without this support, her mental health deteriorates and can lead to long-term inpatient admissions to mental health facilities, and a reduction in her capacity to manage independently.

Psychological support does not reduce the need for other supports. Maree has both physical disabilities that are deteriorating, and chronic and lifelong mental illness that needs continued support to maintain equilibrium. Other supports are simultaneously required to help Maree with managing physical aspects of her disability so that she can continue to live independently and access the community.

1.3 Weekly psychological support required

Over the past year, Maree’s psychological support needs have increased. Weekly consultations were approved in December, 2023 following her NDIS review, commencing in January 2024.

1.3.1 Rationale for weekly psychological support

Maree’s support needs have increased because of a combination of factors, including:

Increased physical health challenges associated with:

Impinged nerves in cervical vertebrae, requiring major reconstructive surgery and inpatient rehabilitation throughout July and August, 2024

Peripheral neuropathy (lack of feeling in her feet and fingers), resulting in increased falls risk and associated injuries

Deterioration in vision, leading to loss of driving licence and loss of independence

Deterioration in colostomy requiring additional bowel surgery in 2023, with complications

Mental/emotional wellbeing challenges including:

Relapse and mood instability associated with bipolar disorder, causing significant increase in mood changes, including severe low mood with suicidal ideation, to elevated mood, with associated irritability, anger management issues, lack of sleep and low-level mania

Bereavement and loss associated with loss of independence, loss of proximity to her surrogate family (who moved to Victoria)

Physical health issues have caused significant emotional distress

Irregularity of medication use at times of mental health relapses

Triggering life events that have caused extreme anxiety and distress and contributed to a relapse in mental health, including:

Severe back pain in June/July, requiring emergency trip to Hawkesbury Hospital in June, 2024

Traumatic fall (caused by impinged cervical nerves impairing mobility), requiring ambulance transfer to Hawkesbury Hospital, then Nepean Hospital for surgical intervention

Uncertainty about her future regarding mobility

Fear of loss of independence

Emotional triggers whilst an inpatient at Nepean Hospital

Ongoing grief re breakdown in relationship with ‘surrogate’ family

Unresolved issues with builder, appointed by NDIS to renovate bathroom

1.3.2 Impact of psychosocial stressors and justification for weekly sessions

When Maree experiences distress, she needs available supports to prevent a full escalation and relapse of her mental illness. This frequently involves phone calls to help her reassess distressing situations, make sense of triggers and to calm down. When she has scheduled weekly appointments, these frequent crisis calls reduce, as she is more stable. Without weekly sessions, crisis calls increase, often requiring out of hours phone support.

Weekly sessions and support help to detect early warning signs of relapse and provide early intervention. In the past, when these supports were removed, Maree had increased mental health hospital admissions, much to her frustration and disappointment, and less access to the community. Her cats had to go into long-term care, removing another source of comfort for Maree.

Weekly sessions also keep check on medication compliance, which further helps to maintain stability of mental/emotional health.

2. Life stage outcomes and long-term benefits

Weekly psychology would substantially improve the life stage outcomes for Maree, and be of long-term benefit.

Maree has a chronic and life-long mental illness. Bipolar disorder is not something that gets better or goes away over time, (in most cases). However, with the right supports and management, Maree could maintain stability of her mental health condition, so that she can live a life that is meaningful to her. This includes living independently in her own home, being able to access the supports that she needs to be an active part of the community, and having access to mobility devices (scooter) so that she can travel to the shops to collect medication, groceries etc.

As stated above, weekly sessions and support help to detect early warning signs of relapse and provide early intervention to prevent full deterioration. Her NDIS history validates this. During 2022 when she had her NDIS supports in place, Maree had no admissions to hospital, despite managing significant life stressors. When the supports were withdrawn in February 2023, she had to be readmitted to hospital as she wasn’t coping. Maree has provided feedback on many occasions of how services have helped. There have been several times over the past two years where Maree’s health deteriorated to her being acutely suicidal. I have been able to talk her through these times, either by an emergency phone call or home visit, helping to mitigate risk. I have been able to conduct mental health/risk assessments as needed and discuss care options as needed. Because of these supports, Maree has been able to access help, which has prevented other inpatient admissions to SJOG.

Maree is at the life stage of older adult. She has lost her ability to drive, due to a deterioration in mobility and vision. Whilst other supports help Maree with managing physical aspects of her disability so that she can continue to live independently and access the community, psychological support helps her manage the mental/emotional challenges associated with her mental illness and deteriorating health. My service provides both psychological and social support. This helps Maree to manage her mood, which helps her to maintain her relationships with people in her life. When unwell and without support, her bipolar disorder can deteriorate, characterised by labile mood. She can become irritable, angry and lash out at people she loves, which impacts these important relationships.

Maree also has the long-term goal to publish her autobiography, which is in the final stages of production. Psychological support helps Maree maintain compliance with medication, which helps her to think clearly, to organise her thoughts well, so that she can write from a grounded place.

Maree had her financial management order with the NSW Trustee and Guardian revoked on the 31st of May, 2023. This is a significant achievement for Maree as she steps into another of her life stage goals – to manage her finances independently. I am a key part of her team helping and guiding her to establish good financial management of her affairs

3. Plan

There is direct link with Maree’s physical health challenges impacting on her emotional wellbeing. Because of the complexity and ‘co-morbidity’ of these experiences, Maree needs a team approach to care.

Maree would like to continue to access therapeutic support with myself on a weekly basis. I am happy to provide this support, as approved by the NDIS, and to continue to help Maree achieve her goals outlined below:

4. Maree’s Goals:

Core area	Maree’s goals/words	Challenge	Action/how I’m helping achieve this
Independent living	I want to be in control of my life and live independently.	Due to mobility and vision impairment, Maree is no longer able to drive and is unsteady on her feet.	Education re using mobility aids; counselling during transition periods; encourage access to community events and facilitate as needed.
Safe and inclusive housing	I want to find a new place to live in the Hawkesbury in a quiet area, where I feel safe, where I can meet new people, and have people around me	Maree’s mobility has deteriorated in the last year, caused by an impinged nerve in her neck. She had major surgery in 2024 to resolve the issue, but will require a long period of physiotherapy to get her physical strength back. She has become aware that living alone is no longer ideal for her physical and mental health.	Help Maree to explore options for over 55’s housing and support her with the practical and emotional preparations for moving house.
Occupation	I want to publish my book this year.	Maree has completed her autobiography and has a publisher in mind. Making an informed decision with how to move forward is a priority.	Assist Maree to consider the options and support her to make her own choices.
Safety	Deep down, I don’t want to die.	Maree’s physical health problems lead to periods of low mood and suicidality, with self-harming behaviours and episodes of high risk.	Monitor mental health Risk assessment as needed Identify early warning signs of relapse and apply early intervention strategies.
Trauma	I want to recover from the trauma of the fall and the traumatic flashbacks of the events before ambulance arrived. I want to find peace with my childhood trauma.	Maree’s recent fall was traumatic; she was I pain and unable to move to call for help. Returning home after hospital has been triggering for her. Maree has a history of significant childhood trauma. This underpins her mental health and an array of negative core beliefs which make it hard for her to develop trust in relationships and belief in herself.	Trauma informed care. Psychodynamic work. Somatic psychotherapy and psychoeducation as needed. Solution focused therapy.
Mood	I want to be stable; I want to write from a stable place – not with my mind all over the place.	Bipolar disorder leads to mood swings – mostly depressive, but with occasional elevated mood – which manifests also with irritability, anger outbursts and impulsivity.	Psychoeducation. Strategies for managing mood. Diversional therapy. Relaxation practice.
Social interaction/ accessing the community.	I want to be able to go out whenever I want and enjoy meals with my friends. I need to be more assertive in friendships so I don’t feel taken advantage of. And to give constructive feedback respectfully.	Maree has lost confidence socialising because of the unpredictability of her bowel stoma. Maree is by nature very social, so this directly affects her mood. Mobility has also limited her freedom to socialise outside of the home.	Support Maree to engage with others and connect with community. Maree would like to increase her NDIS supports to enable some recreational outings in addition to her basic functional support needs (shopping appointments etc) Liaison with health team.
Health and wellbeing	I want to have a year without major medical issues and appointments	Maree has complex physical and mental health conditions that continue to deteriorate over time.	Life-style coaching; support to manage medication, nutrition and health maintenance.

5. 2024 NDIS plan for Michelle Hookham

Maree is a person with complex and lifelong mental illness and comorbidity of complex physical health conditions, impacting her functioning. Maree requests that my services be continued as part of her NDIS plan.

Maree is concerned that because of her prolonged time in hospital over the past year, due to neck and back surgery and rehabilitation (two months) and subsequent admission to SJOG for mental health recovery following this, that her NDIS funding will be decreased. I urge the NDIS not to use the current years’ expenditure as typical, since it is not. In Maree’s words “Please do not take away my funding or supports that have been on hold, because I was in hospital this year for a lengthy time.”

Weekly psychological support sessions are recommended for Maree.

One-hour Weekly appointments, with a total of 50 appointments in 12 months.

Location: 6 Christie St, Windsor OR home visits.

Since Maree no longer has a driver’s license, I have included provider travel for 24 visits.

Yours sincerely,

Michelle Hookham