Lars’ Patient Pathway

Lars is a 33-year-old young man with health issues that require assistance from both specialist and municipal health services. Throughout his childhood, he was mistreated by those close to him and lived with these experiences in solitude until adulthood. Additionally, his childhood home was marked by significant alcohol use and mental illness among his caretakers.

Currently, challenges arise in transitioning between different levels of service, as he is seen as unwilling to accept help from municipal services and too sick to be treated by the specialist health service.

Lars has frequently sought help from the ambulance and hospital for back pain, which, along with his social anxiety, prompts his referral to PACT. .

In his interactions with PACT, where physical activity and a trust-based approach are emphasized, Lars gradually opens up about his childhood traumas. Lars aspires to lead a normal life, have a job, and be social.

Lars's first referral to PACT occurred during his hospitalization on a surgical ward for back pain. The referral also mentioned a previous back surgery and persistent pain before and after the procedure. After several hospital stays, the medical staff concludes they cannot alleviate Lars's pain and refer him to PACT. At our first meeting with Lars, he exhibits severe social anxiety symptoms, with his entire body shaking and excessive sweating.

Upon his discharge to a staffed municipal residence for individuals with substance abuse and mental health challenges, we meet him again. Given his back pain, the focus shifts to physical exercise. This proves difficult as Lars often faints from pain he associates with his back, leading to a cautious approach. Additionally, an MRI is conducted to confirm or refute the presence of new physical conditions in his back. No connection is found between his back and the pain.

Adaptation and care in challenging life situations

In the staffed residence, it becomes clear that many residents abuse drugs and there is often considerable noise. PACT gradually recognizes the negative impact this has on Lars. He expresses feeling unsafe in his own home. Only later, once we understand the traumas Lars carries, do we comprehend his adverse reactions to his neighbours’ behaviour (afterwards, it turned out that the stay in the staffed residence has re-traumatised Lars).

Working with the residence staff and Lars, a plan is developed for counselling and follow-up aimed at ensuring Lars's safety. He is also assigned a primary contact for closer supervision.

PACT also assists Lars in applying for a private market apartment, recognizing that living in a communal drug-use environment is not beneficial for his psychological well-being. Furthermore, he is referred to municipal physical therapy. After this, PACT concludes its supervision of Lars, believing he is well cared for by municipal services.

About 6 months later, Lars is referred back to PACT, this time by the ambulance service, which mentions a particularly challenging situation for both Lars and the ambulance crew.

After discussing with Lars and confirming his willingness to have PACT re-enter his life, we contact the ambulance crew for more detailed information about the incident. It emerges that due to a lack of information about Lars's challenges (the ambulance service does not share medical records with either the hospital or the municipality), the crew struggled to manage the situation. In the ensuing conversation, PACT referred to a model (the Tolerance Window) to explain Lars's difficulties. Now, the ambulance crew shares this model with their colleagues, a model that is also used in internal training.

Lars has had extensive contact with the ambulance service. Before PACT's initial involvement, he was taken to the hospital by ambulance seven times in emergencies. He also frequently contacted the ambulance service for pain relief, allowing the crew to leave without hospitalizing him. After PACT's first intervention, ambulance hospitalizations drop to three. After the second referral to PACT in 2023, there have only been two scheduled ambulance trips to the hospital for outpatient exams and follow-ups.

Step by step: Lars' journey to recovery

During the second referral, we visit Lars at his own home. He still suffers from back pain but appears calmer. He receives home care service multiple times a day. Initially, only the PACT social worker engages in weekly discussions with Lars, focusing on his future aspirations and how PACT can assist him in achieving them. Through these conversations, Lars becomes more relaxed and starts sharing bits about his early childhood.

The municipal substance abuse and psychiatry service is in weekly contact with Lars (by phone) but stops as they feel unable to contribute to his improvement. PACT maintains close contact with Lars' GP, and together they decide to refer Lars to the Adult Psychiatric Outpatient Clinic for assessment and potential treatment of childhood trauma. However, this referral is rejected because Lars is deemed too physically ill for trauma treatment.

After interdisciplinary meetings with PACT, discussions with Lars, his GP, and home nursing, it is decided to invite Lars to a collaborative meeting with municipal substance abuse and psychiatric services and the specialist health service. This meeting aims to provide a comprehensive view of Lars and the challenges hindering his treatment access in both the municipal and hospital settings. Lars is perceived as unresponsive to municipal assistance and too sick for trauma treatment in the specialist health service, falling through the system's cracks.

During the collaborative meeting, PACT outlines the complexity of Lars's situation, leading to a consensus on the current situation. Together, they devise a strategy wherein the municipal services offer weekly counselling to enhance Lars's mental health and self-reliance.

This plan also involves consultation with the specialist health service, which will offer trauma treatment once Lars is prepared. The home care service continues its daily support, with PACT ensuring continuity through weekly home visits.

Presently, Lars's daily life has improved, PACT notes better physical health and a new engagement level in conversations. The home nursing service also observes progress. Although Lars is not yet ready for trauma treatment, he is in a significantly better place in his life.

PACT's experience with patients facing mental health challenges indicates that organizations often withdraw support too soon when improvements are noted. This experience suggests that, especially in cases of denied referrals and mental health issues, prolonged involvement can lead to positive outcomes. Vulnerable individuals may require more time to stabilize.

Building trust takes time, and some may need a longer treatment duration than the current healthcare system provides.