Meet Michaela - a person with complex mental, physical health and social care needs

Michaela is 49-years-old, separated from her partner and living in a council house. She has no family nearby.

She has had a 'low mood', depression, ups and downs for many years and is no longer in touch with her elder son, who is in trouble with the law, while her younger son has a learning disability and lives in a community home.

Important to Michaela

  • Keeps and breeds pet rats
  • Seeing her younger son every week when she can
  • The possibility of him coming home to live
  • Exercising as much as I can - uses community gym 'when I don't feel down'

Daily living

  • 'When I'm depressed I only look after the rats and don't look after myself'
  • Mainly eats biscuits
  • 'My house and garden gets a bit messy'

Concerns and questions


  • Worried about weight ; intermittently 'binge' exercises and eats little
  • Neighbours complaining about mess in the garden
  • Ex partner harassing her: - 'calling me names'


  • Concerned she doesn't get enough support,
  • Needs to complete annual health checks (part of GP contract)
  • Knows Michaela finds it difficult to organise her day to day life and make plans
  • Picks up prescriptions erratically
  • Doesn't keep in contact with the community mental health team
  • Her T-shirt is stained and bra falling apart and unwashed

Personal Assets

  • Has lived in the area her whole life - 'people say hello'
  • Knows some people in the day centre gym
  • Tries to sort things out - uses Wii at home

Health concerns and provision

  • Depression
  • High blood pressure
  • COPD
  • Smoker
  • Over weight and fluxuations in weight
  • Used to see CPN - 'just asks the same questions' - organised a bath for 6 weeks
  • Medication includes: antidepressants / BP tablets 'I don't take them'/ 2 inhalers
  • Annual 'health' tests
  • Tests to check her chest - peak flow and spirometry
  • Blood pressure and kidney tests
  • Weight
  • Depression screening scale