Getting unstuck along the clinical pathway: an integrated multi-agency approach

Abstract

Purpose – The purpose of this paper is to highlight how the management of an adult with intellectual disabilities and complex medical conditions by a multi-disciplinary and multi-agency team approach across a clinical pathway (primary, secondary and tertiary care, health, social and third sector agencies) can be used to improve the person's physical and mental health outcome. Design/methodology/approach – Literature review and case report in which the paper describes the presentation of the patient with multiple complex physical health conditions, mild intellectual disability and challenging behaviour and description of the management process and the observed outcome. Findings – The patient required input from the multi-disciplinary community intellectual disabilities team and multi-agency team including social services and community support team, admission to a specialist intellectual disabilities ward to optimise her management. She improved relatively well and was discharged to the community. On discharge she continued to receive ongoing psychiatric, psychological and community psychiatric nurse input and maintains the sustained improvement in her mental health. She no longer displays risky or challenging behaviour, her mood has improved and there is no self-harm ideation. She remains anxious at times, however, her symptoms are much improved and do not affect her daily functioning. Originality/value – This case highlights the profound and enduring psychiatric and behavioural sequelae following brain malignancy and treatment and how essential a multi-disciplinary and multi-agency approach is in the successful management of complex issues. Her symptoms appeared relatively treatment resistant until she had a specialist inpatient admission. This case study also demonstrates the strengths and advantages of having specialist care pathway for such complex presentations, allowing for integrated community, secondary and tertiary care, and for the care system to work together in a coordinated and managed way.