GPH Real Stories: Grace's Story

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July 02, 2020

Grace web

Grace was referred to the Connecting Care program through the Illawarra Shoalhaven Local Health District, Asthma Clinical Nurse Consultant (CNC) from Wollongong Hospital, after it was identified that Grace had a few chronic diseases that could be better managed at home. Grace suffers from Chronic obstructive pulmonary disease (COPD) and Diabetes, she also experiences pseudo seizures and has an intellectual disability.

Grace was living with her foster father in their home south of Wollongong when GPH Connecting Care Coordinator Annie reached out. Grace has no contact with her mother due to a history of abuse.

Initial assessments revealed that Grace had presented to the Emergency Department 34 times in 12 months. She did not have the recommended diabetic strips at home to use her glucometer and test her blood glucose level (BGL), she had a poor diet and her COPD was being exacerbated by her foster dad smoking inside the home. Grace was also reluctant to speak to a Psychologist as she didn’t want her past trauma being brought up and she was not attending her GP appointments due to fear of having pseudo seizures.

Through health coaching techniques Grace identified several goals to improve her health and wellbeing and subsequently consented for referrals to be made to relevant health professionals.

Annie assisted Grace with a GP visit to discuss Psychologist options and get a Mental Health Care Plan put into place. Annie also referred her to the NSW Health funded program ‘Get Healthy’ for telephone health coaching to assist Grace with improving her diet and increasing her exercise regime.

 Annie was able to assist Grace with medication management, she also requested a review of Grace’s Asthma Action Plan with her GP and provided education to Graces foster father about the effect his cigarette smoke is having on Grace’s condition – encouraging him to smoke outside.

Annie connected Grace with a private psychologist who utilises NDIS funding for psychological support, which Grace had been approved for. The clinical Psychologist explained they would work with Grace on Dialectical Behaviour Therapy and not start with bringing up past trauma.

More recently, Grace has moved to the Hunter New England region. Annie was able to get in touch with the hospital and local health service providers to assist Grace to transition to similar supportive services close to her new home.  

 “A recent report has noted that Grace has not had any seizure activity since her last admission to hospital in February and since moving to the Hunter New England region, so I’m really happy with that result,” said Annie.



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