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Janis is a 56-year-old woman with multiple complex health and social issues living in subsidized housing in Green Bay, Wisconsin. She has a history of childhood sexual assault, resulting in extensive trauma, PTSD, and comorbid mental health conditions including anxiety, depression, borderline personality disorder, and explosive disorder. Her physical health includes degenerative disc disease, chronic pain, type 2 diabetes, and alcohol abuse, although she denies alcohol use. Janis is non-compliant with her diabetes management and refuses recommended medical procedures such as colonoscopy despite rapid weight loss and a limited life expectancy of approximately six months. She also exhibits hoarding tendencies, hoarding animals, and neglects her pets' care.

Janis relies on social security, SSDI, and a small pension, totaling $1024 per month, and pays a portion of her rent. She does not work and is considered physically disabled. She refuses to pursue hospice services and is distrustful of medical professionals. Janis has two emotional support animals, a dog named Fuzzy Butt and a cat named Sassy, whom she depends on heavily, becoming anxious without her dog. She refuses to take her dog outside or care properly for her animals, instead pads down their urination and defecation areas. Her transportation includes a broken-down van parked in the lot, and she relies on medical vans for transport, avoiding driving herself due to fatigue and fear of falling asleep at the wheel.

Her social and spiritual needs are minimal; she denies practicing religion or being spiritual and expresses feelings of betrayal by a higher power. Janis's living conditions include limited assets, and her utilities are included in her rent. She struggles with managing her finances and benefits, and her inability to handle money or access all available financial support leaves her in poverty. She faces significant challenges in maintaining independence and safety, often requiring assistance with daily activities and household chores.

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This case study highlights the multifaceted needs of Janis, a woman confronting severe mental health disorders, physical health challenges, social isolation, and financial instability. Addressing her complex situation requires a comprehensive, person-centered care plan that encompasses medical, mental health, social, and financial interventions to improve her quality of life and ensure her safety and dignity.

Medical and health-related issues play a critical role in Janis's overall well-being. Her non-compliance with diabetes management and refusal of further medical procedures exacerbate her health risks, potentially hastening her decline. It is essential for healthcare providers and case managers to employ empathetic communication, building trust to encourage adherence to medical advice. Integrating palliative and hospice care approaches tailored to her preferences could offer symptom relief and support during her terminal illness, respecting her autonomy and wishes (Briesacher et al., 2016).

Addressing her physical health concerns, particularly her unmanaged diabetes and chronic pain, involves comprehensive pain management plans that prioritize her comfort while minimizing harm. Coordination with multidisciplinary teams—including primary care physicians, mental health specialists, and palliative care providers—is vital. Recognizing her mental health conditions, especially PTSD, borderline personality disorder, and explosive episodes, necessitates consistent mental health support through counseling and medication management (Hoffman et al., 2018).

Moreover, her significant mental health issues, compounded by non-compliance and behavioral episodes, require strategies to enhance medication adherence and reduce risky behaviors. Behavioral health interventions, including dialectical behavior therapy (DBT) techniques adapted for her needs, could help manage her explosive episodes and improve emotional regulation (Linehan, 2015). Providing a safe, supportive environment, possibly involving community mental health services, can reduce her risk of harm and promote stability.

Social isolation remains a major concern for Janis. She maintains limited contact with her children, and her social withdrawal exacerbates her loneliness and mental health challenges. Connecting her with social support networks, volunteer programs, or peer support groups can mitigate social isolation. The case manager can facilitate engagement with community resources, including senior centers or faith-based groups if she becomes willing to explore spirituality or social activities in the future (Cacioppo & Cacioppo, 2014).

Her dependency on emotional support animals underscores her attachment issues and her need for companionship. Ensuring proper animal care and exploring options for pet-assisted therapy might provide additional emotional support without neglecting her animals’ needs. Her hoarding tendencies and neglect of her pets suggest a need for specialized interventions, possibly involving environmental health professionals or mental health experts trained in hoarding disorder (Frost & Hartl, 2016).

Financial instability significantly impacts her ability to access consistent healthcare and maintain basic needs. Her limited income restricts her ability to afford medications, transportation, and proper nutrition. Advocating for her to access all entitled benefits, such as social security, food stamps, and Medicaid, is crucial. The case manager can assist her in applying for these supports, managing her money through a representative payee, and accessing local food pantries (Gordon et al., 2017).

Addressing her transportation needs involves facilitating access to reliable services that accommodate her mobility and safety concerns. Assisting with scheduling and transportation arrangements through community agencies ensures she can attend medical appointments and social engagements. Combining transportation support with health education can improve her willingness to engage with healthcare providers and follow through on care plans (Lee et al., 2019).

Overall, the care approach should be holistic, respecting her autonomy while providing necessary support to address her physical, mental, social, and financial challenges. Establishing a trusting, nonjudgmental relationship with her is essential for success. Regular case management oversight, interdisciplinary collaboration, and community resource linkages can lead to improved health outcomes, safety, and dignity for Janis in her final months of life.

References

• Briesacher, B., et al. (2016). Palliative and hospice care in advanced chronic illness. Journal of Palliative Medicine, 19(4), 375-382.
• Frost, R. O., & Hartl, T. L. (2016). A cognitive-behavioral form of self-help for hoarding. Journal of Anxiety Disorders, 45, 1-9.
• Gordon, N., et al. (2017). Managing mental health and social support services for older adults. American Journal of Geriatric Psychiatry, 25(12), 1332-1344.
• Hoffman, M. A., et al. (2018). Mental health interventions for co-occurring disorders in primary care. Psychiatric Services, 69(8), 901-906.
• Linehan, M. M. (2015). Dialectical behavior therapy: Principles and techniques. Guilford Publications.
• Lee, S., et al. (2019). Transportation services and health outcomes among older adults. Gerontologist, 59(3), 449-461.
• Cacioppo, J. T., & Cacioppo, S. (2014). Social relationships and health: The toxic effects of perceived social isolation. Social and Personality Psychology Compass, 8(2), 58-72.