Peter is a forty-five year old man. He is diagnosed as having autism but no learning disability, he is articulate and literate. He lives alone without support. For many years Peter was employed as a hospital porter. This was Peter’s main contact with people. However, three years ago he was made redundant and this dramatic change in circumstance affected him greatly. He has become increasingly depressed and de-skilled. Currently his case involves his G.P., social worker, support worker, psychiatrist and occupational therapist. To date these different agencies have had very little contact with each other. He forgets appointment times, which means he has not been attending appointments with his psychiatrist and often does not answer the door to the occupational therapist. His support worker reports that he has not been taking his prescribed medication and is neglecting himself and staying in bed all day.

Strategies

• Remember that Peter’s good verbal skills are likely to mask other difficulties, such as difficulty in organising himself and getting to appointments. 
• Agree one person who can act as Case Co-ordinator.
• Arrange a multi-disciplinary meeting, if possible to be attended by Peter and his parents if they are available.
• Agree a plan of action to ensure that everyone involved has key information, e.g. the best way to communicate with Peter and his priority needs.
• Agree specific roles and responsibilities to ensure that Peter’s mental health, physical health and general wellbeing are effectively monitored.
• Agree a means of exchanging relevant information (with Peter’s permission) to ensure that everyone involved is well informed of current issues and how these are being individually and jointly managed.