The personal care and support planning discussion/conversation with the mental health worker lead Michaela to make a number of decisions. Some of which she can review informally herself and with local support.
She meets regularly with the mental health worker, monthly to begin with in order to check that the whole plan is going well. After a couple of visits she agrees to go to the practice nurse herself to have her blood pressure checked and learn more about which tablets are which, because she wants to stay healthy for her son who she is now seeing monthly.
She is going to the local community project as well as the gym and is enjoying the company and the activity which is in turn helping with her weight
She has a person-centred review after six months and invites her son to this.