Evaluation of Sources of Support Service

5. Working on the Front-line: The Emerging Themes

Analysis of the SOS 100 cases highlighted a number of themes that illustrated the reality for the link workers in working with patients with complex factors affecting their well-being, and the positive and negative factors affecting progress.

5.1 Patient Typologies

At the heart of the SOS service was the patient. From the case analysis, six broad patient profiles can be suggested: the 'resistant', the 'challenging', the 'vacillator', the ‘dependent’, the 'focused', and the 'determined and motivated'. Taking each in turn:

5.1.1 The 'Resistant': within this group, 'resistance' manifests itself in different ways. For some patients, no matter what was organised by way of external help, they did not turn up at the external service/activity and, more often than not, disengaged from the SOS service itself. Other patients declined services/activities as not meeting their expectations, whilst a subset of this category could not accept external help. This 'resistant' patient created a dilemma for the Link Workers in deciding how far to persist, both in their own efforts to get the patient the necessary help, and being mindful of the impact on external services of patients not turning up or eventually turning down help. Initially the Link Workers tried to persist with such patients, setting new service appointments, but over time they came to realise that there were limits on the value of that strategy and had latterly taken a more pragmatic stand based on their accumulating experience with such patients. If the patient came with a known history of missing appointments with the GP and previous services, this could perhaps be considered a 'warning bell' in the future as to their potential behaviour with the service. At this moment the Link Workers do not have access to this information and it might be worth considering whether to flag this issue up in the referral from GP to Link Worker. Similarly, patients habitually missing/postponing their initial consultations with the Link Worker could be seen as a red flag in terms of willingness to engage with external services.

5.1.2 The 'Challenging': while it could be argued that all SOS patients were challenging to some degree or other, there were instances of patients whose behaviour and/or underlying clinical issues created particular challenges in terms of their ability to work with the SOS service. Patients with an underlying addiction issue (be that drugs or alcohol) could prove somewhat unreliable at keeping appointments, not out of any overt resistance to the SOS service and any external help offered, but through chaotic lifestyles impacting on ability to remember and take action. Difficulties in keeping appointments sometimes also applied to patients with memory issues. Both types of patient required ongoing prompting to get them to appointments or to be picked up and taken to appointments. External services trying to work with such patients faced the same difficulties, often resulting in such patients being discharged from the service for failing to turn up to appointments, or not being at home when staff called. That was not to say the external service did not make efforts to engage with the patient, but there were limits to this. Another type of challenging patient was those whose behaviour gave cause for concern in terms of their ability to interact with others in what could be deemed a reasonable manner - for example, patients whose levels of anger dominated their behaviour making it necessary to address that issue before trying to address others. Services raising this with the patient sometimes created a reality check that, in some cases, allowed them to accept specialist help. The opposite challenge was that of patients whose over-enthusiasm, and lack of social and negotiating skills, left a trail of failed attempts to get help and a reputation for being 'difficult'. In these instances, the Link Workers were left with a delicate task of reconnecting patients to services, whilst reassuring these services that the patient did now understand the need to listen to what was being suggested.

5.1.3 The 'Vacillator': on the surface these patients engaged with the service, but once the process reached a point where they had to act the tendency was to use what could be defined as delaying tactics - for example, cancelling or rescheduling appointments, making themselves unavailable or not turning up. This group understood they needed help but for a variety of reasons could not make the next step, even if the Link Workers offered to accompany them to a service/activity. What distinguished this group from the 'resistant' group was their reaction to the possibility of being discharged from the service. The 'vacillators' would ask to stay with the service and promise that the next time they would act on the advice or attend the external service/activity. On occasion, a family member would intervene and ask the Link Workers to give the patient another chance. In many ways this 'vacillator' group was more difficult to deal with than the 'resistant' group, as the underlying pressure was to give them that second or third chance in recognition that some patients required time to come to terms with what they themselves needed to do to improve their situation and to take responsibility. Initially, this type of vacillating behaviour left the Link Workers on the cusp of discharging patients then reversing the decision and more often than not finding themselves in a similar position a few weeks down the line. Latterly the Link Workers had, on identifying such patterns of behaviour, taken a stronger line and discharged such patients after two/three vacillating events, while at the same time pointing out the service would welcome the patient back in the future. It should be noted that for some patients the suggestion of being discharged from the service was enough to galvanise them into taking the advice/action they had previously agreed.

5.1.4 The 'Dependent': the key strength of the Link Workers in creating strong working relationships with the patients could also work against the service if patients became too comfortable and/or did not have the confidence to let go. For many patients the Link Worker (as evidenced by the patient feedback comments) represented the first person who gave them time, listened, and worked across their needs to create a coherent achievable plan. The temptation for some patients was to try and cling to the service even if their initial needs were met, perhaps as much for the psychological and therapeutic benefits as the practical benefits. In other patients the dependency behaviour could become an excuse to do nothing -for example, unless the Link Worker went with them/took them to a service/activity they would not go. Weaning people off the service took as much skill as engaging the patient with the service.

5.1.5 'The Focused': this group of patients had a strong notion of what they would like to get from the service In addition, some of these patients had a strong focus within their lives that pushed them into taking action (e.g. children and partners or a life event that highlighted the need for change). Some patients were focused on improving/strengthening relationships within their lives, re-engaging with family and friends, and putting their lives on a more positive track. Others were focused on very specific practical issues such as moving house, getting employment/more suitable employment, reconnecting with past interests and/or getting involved with new interests. For these patients, the SOS service was a way of accessing information and help to achieve their goals.

5.1.6 'The Determined and Motivated': these patients came into the process with or without a clear agenda to address but with an underlying 'can do' attitude that the Link Workers could harness to achieve progress. These patients might still require support to initially interact with services/activities but the support was limited and, in general, once pointed in the right direction these patients acted independently and were often difficult to follow-up because they were so busy and out all the time. In other instances patients began to use the ideas they picked up from the SOS service (e.g. setting up a creative room within the family home to improve the quality of interaction with the children). Even patients who initially appeared anxious and lacking in confidence could find reserves of determination when they felt they had support, and could achieve major changes in their lives through their own actions - for example, being assertive with employers and negotiating better working conditions and/or moves into less stressful work and even changing careers. That type of success could reinforce motivation and determination in dealing with other aspects of their lives. Drawing out and supporting these reserves was critical to the degree of progress within a case.

5.2. The Impact of and on Family and Friends

In one fifth (20) of the cases, family and friends played a role. They acted as facilitators or impediments to progress and were the focus of the goals the patient set.

5.2.1 Family/Friends as a Facilitator: one of the key ways in which family/friends assisted progress was in going along to activities/courses with the patient. Not only did this ensure the patient attended, it provided a familiar supportive presence when walking into a new place for the first time. Within relationships opportunities were being created to share interests, old and new, and through that encouraging families and friends to do more together. For example, in one case the husband of a patient did the groundwork for them both to attend a college course that he was equally interested in. In another case the patient and daughter attended a counselling course together: although it was meant for the patient, the daughter felt they too would benefit, particularly in understanding the issues their parent was facing and the strategies that might help them cope. There was one instance of an economic exchange within a family whereby the patient was paid to undertake some childcare to allow another family member to go out to work. Given that the patient had been looking for something to occupy her time it was a 'win-win' situation for the family as a whole. The importance of the family/friends role was not only that of emotional support and verbal encouragement, but practical support of 'going and doing' with the patient.

5.2.2 Families as an Impediment: not all family relationships worked in the patient's favour. In some cases over-protective parents could have a negative effect. Breaking the dependency cycle was not easy and working with the SOS service provided one way of opening these issues and exploring options. In one case the patient was supported to get rehoused in their own tenancy. Living independently encouraged a less dependent relationship with the parent such that the patient was now doing things of their own accord. As noted earlier, families going with the patient to services/activities could be very positive, but in other instances it could have unfortunate consequences. For example, when the parents of one patient attended an external service meeting the effect was to discourage the patient from speaking and the impression was left that the patient had their housing needs covered and therefore there was no role for the external service. In that particular case the housing issues were eventually sorted without any further intervention from the patient's parents.

5.2.3 Families as the Focus: it was notable that some patients used the SOS service to get help/open up opportunities for family members. For example, one patient suspected their child had specific behavioural difficulties but the service professionals they dealt with disagreed leaving the patient frustrated and not knowing where to go for help. The Link Worker made the appropriate clinical service connections; the child was diagnosed as having specific behavioural difficulties, and help and advice was provided to the patient and their child. Through the Link Workers other patients got help for family members in relation to mental illness, dyslexia and weight issues. In other examples the family help being sought was linked more directly to lowering the levels of stress in the patient's life (e.g. helping a partner find activities to do on their own and lowering the dependency on the patient to go and do things with them; linking a daughter to a service to give the patient some 'me time' and the daughter something positive to do with her time. Indeed, the latter linkage was so successful, the daughter ended up with a job at the service). Patients were also looking for activities that could be done as a family unit by way of strengthening that relationship or, where families were separated, reconnecting in a positive way. For example, linking one patient to the Active Families service resulted in an overweight family getting active together and trying new things; they now cycle and swim - activities they had never done before. However, this focus on the family could also work against dealing with the patient’s own issues (e.g. the grandmother who decided not to continue with the SOS service at the time in order to give her grandson her full attention as he had just moved in with her and had yet to settle).

5.3 Working with External Services

In large part the ability of the SOS service to fulfill its brief was dependent on the range of, and access to, external services and the ability of these services to respond to the needs of the SOS patients.

5.3.1 Flexible Service Response: the degree of flexibility of external services impacted on what could be achieved for SOS patients. Some patients’ levels of anxiety were such that they would not travel to a service even with the support of the Link Worker. Other patients were unwilling or anxious about leaving their local area. Those with family commitments could find it difficult to agree to meetings outwith their local area, particularly if they had no access to a car and were reliant on public transport. Having access to relevant services that could make home visits and/or meet with patients in their own locality got round what could have been an insurmountable barrier to getting help. Services such as Making Money Work would do home visits, while others such as the Listening Service and Penumbra would come to a local community setting to meet the patient. In addition, seeing the patient in their own environment could give valuable insight into their needs and the impact of the 'home'/'local' environment as a facilitator or impediment to addressing these needs. Those patients who worked shifts found it difficult to fit in with services - that is, the time they were available might not be the time the service could give, so any flexibility in time/location/venue was crucial to engagement.

5.3.2 The Service Cascade: the 'cascade' operates at formal and informal levels. An example of the former was a referral to a money service that led to a referral to an energy saving service. In other instances referrals to 'umbrella' organisations with multiple sub-divisions led to an internal cascade (e.g. some mental health support organisations offer drop-in services that can then lead to clients moving onto activity groups). In general the Link Workers noted how helpful some external services could be in this respect (i.e. redirecting the original SOS referral to a more appropriate service/'group'). Not only did it mean the patient getting the right help, it built on the Link Worker's knowledge and refined their use of the services. The Link Workers refer in the knowledge that, if appropriate, a suitable 'cascade' for their patient will happen within multi-provision services. An example of the informal 'cascade' was a patient attending an adult literacy class who got talking to the worker running the class and learned about a local walking group; the patient subsequently joined the walking group.

5.3.3 The One-Stop Shop: many of the external services might look as though they are single issue services but this was far from the case. Within their remit they were capable of dealing with a broad range of issues and creating a pathway that moved the patient through the service to a positive outcome. In the following example one external service (DCC Youth Literacy Team) working with the Link Worker successfully addressed a patient's multiple goals. The patient was socially isolated with mental health and literacy issues, little family support, and was generally struggling with life, but they knew what they wanted in this case to get a place in college and/or a job. They set goals with the Link Worker of structuring their day, improving their literacy, engaging in activities to improve their social skills, and getting a place in college and/or a job. Attending the Youth Literacy Team brought structure to the week; the patient was given 1:1 support to address literacy issues; they got involved in group activities provided by the Youth Literacy Team, including a bus ticket to facilitate travelling to venues; they were helped to make applications to college and for a job in the care sector, which the patient subsequently got. The Link Worker worked in tandem, prepared the ground with therapeutic support to the patient, negotiated with the Youth Literacy team, provided support visits to ease the patient into the Team, researched courses and helped with references. One external service with multiple relevant roles, one Link Worker, a focused, determined patient and four goals successfully achieved.

5.3.4 Access Issues: from the case analysis, five issues emerged:

• First, even when the Link Worker found a service or course for a patient, there was no guarantee these would go ahead, would complete, or would exist by the time the patient got a place or was ready to take up an offer. In eight cases one of these issues occurred: in three cases the service folded either just before or shortly after the patient was due to attend. In the remaining five cases, the course was either cancelled at the outset or cancelled midway through due to a lack of people attending.
• Second, not every service was free to every patient: some services were required to charge for their services or access was means tested. This could create problems, particularly if the patient had started working with the service before a decision had been made regarding charges. In one such case it had been hoped that due to the patient's circumstances the charges would be waived, but this did not happen and the patient had to temporarily leave the service with a debt for the use of the service to date. Liaison between the Link Worker, the service, and the department concerned resolved the matter and the accumulated debt was waived. In another case a patient was unable to attend a course as there was a charge and no obvious source of funding assistance. Some patients do not have the money to travel to services/activities and in one case the Link Worker raised the travel funds from another source. It should be noted that some patients were actively asking for low cost or no cost activities as they did not have the ability to pay.
• Third, attendance at one type of service/course blocked access to other services. For example, patients on methadone programmes were excluded from accessing some services. Being on a Benefits related course could make it difficult to access other job support because of the tight rules surrounding its implementation. Indeed, and as one case illustrated, trying to step back from such courses to take advantage of other employment advice/opportunities was extremely difficult and, in that instance, required the help of the local MP to open a way forward.
• Fourth, and unsurprisingly, there were waiting lists for some services, particularly those related to counselling and befriending, and not only as a result of lack of staff, but also as a result of 1:1 matching systems (no matter how appropriate), and therefore who was available when. In one instance the delay was due to trying to get a group of volunteers together that could work with a particular group of people and their needs.
• Last, the Link Workers highlighted what appeared to be actual service gaps during the time period of the case study (2013/2014). One related to help for families of offenders: there was a telephone helpline but, at the time of need, no local support group could be found. Similarly, at the time, there appeared to be a lack of 'open access' support groups for patients with post-traumatic stress syndrome.

5.3.5 First Impressions: how services presented and communicated with patients could have an impact on the patient's mood and willingness to co-operate. For example, letters related to benefits issues caused much angst leading to some patients withdrawing from all services, one patient contemplating suicide, and another refusing to take up a volunteer role for fear of losing their existing benefits. The Link Workers were able to address these issues by reconnecting the patient to services; advising GPs of the 'suicidal thoughts' of another patient (where there was a risk to life); and getting advice to the patient who feared their benefits would be cut. Patients could be fragile in terms of their dealings with external services, thus a service not returning a call meant one patient stated he did not want to deal with them despite the potential help on offer. Another patient found the telephone manner of a worker so off-putting they would not consider going to the service. The lack of in-depth knowledge of a patient's circumstances occasionally resulted in services making erroneous assumptions about the patient's willingness to accept help. In some cases the Link Worker was able to provide background information that resulted in a more understanding attitude, but in other cases the background reasons were so delicate and personal that it presented a real dilemma as to whether the information should be shared. Lastly, first impressions can be so positive that if a worker leaves a service/group the patient may decide not to continue, as happened in another case.

5.4 The Role of the Link Worker

As noted earlier in the report, the Link Workers had a wide variety of roles within cases, and rarely did a case require one role. Underlying the common roles was the ongoing encouragement and prompting to ensure patients attended the service/activity on offer. The case analysis also highlighted seven broad roles that underpinned the achievement of patient goals and created a strong and positive link worker presence within the City's service environment.

5.4.1 The 'Tailored' Approach: the cases highlight the efforts the Link Workers make to ensure that the patients got to the right service for them. This was not simplistic matching of needs to a service, but a carefully considered plan emerging from the consultation process. For example, there were different 'issue-based' counselling services available and differing styles of befriending services. The Link Workers were not only looking at service availability and patient needs, but who the patient was in terms of personality, their past experiences, and their present state of functioning (mental and physical). The Link Workers were using their accumulated knowledge of the various services and how they operated to make the best match for the patient. For example, in one case understanding the nature of the patient's social isolation was critical in deciding between one organisation, which promotes recovery focused support with individuals to improve their mental health and well-being, including integrating people back into the community by taking them out to activities, and another, which provides a listening ear. The patient might have been perceived by professionals as socially isolated but was quite content with that state and not looking to interact more widely with people. What the patient wanted was someone on whom they could unburden their worries and the Link Worker referral was made with this in mind. In another case the behaviour of the patient determined which service could be accessed: one service may have had difficulties with the patient’s behaviour whereas the other service option was well versed in challenging behaviour. The Link Workers would use the past experience of patients to ensure the right fit. However, a challenging past experience with a service did not necessarily mean the service could not be accessed - it depended on the nature of the experience and the extent to which the Link Workers could inform, advocate and negotiate to ensure the right conditions for that patient on this occasion. Where issues of trust were a key feature in a case, the Link Workers were careful to ensure the receiving service understood this and acted accordingly.

5.4.2 'Joint Working/Team Working': analysis of the cases highlighted four types of working:

• First, where the referring service does preparatory work using their own knowledge of, and access to, services before handing over to the Link Worker. For example, in one case a GP organised the Health and Homeless Outreach Team to address an immediate crisis in a patient's life, before then referring on to the SOS service. By stabilising the patient's accommodation the GP was able to focus the referral and facilitate the Link Worker's role. A variation on this type of working was where the Link Worker referred patients back to the GP as the gatekeeper to mental health services (e.g. accessing the Health Psychologist) and/or to have their medication reviewed.
• Second, where the Link Worker and the external service work in tandem to address an issue (e.g. the external service (Connect) helped the patient complete the Attendance Allowance form and the Link Worker provided the supporting statement).
• Third, where the Link Worker facilitates another service's ability to do home visits and that, in turn, enables the SOS patient to have their specific needs assessed. For example, where the service visit required two people but only one staff member was available at the time of the appointment the Link Worker might attend in their absence. The Link Worker would also attend (as appropriate) just to introduce and facilitate the first meeting between the patient and receiving service as a way of strengthening the chances of engagement.
• Last, by working closely together it was possible to discharge patients that might otherwise have been held by the SOS service. For example, in cases where the level of support being provided by the external service was sufficient to allow an agreed discharge from the SOS service.

5.4.3 Making Connections: on occasion the Link Worker acted as an 'advocate' between a service and a family where communication had not been properly established or had broken down. In one such case the Link Worker (with the patient's permission) reassured the parent and created a link to the patient's befriender where none had existed. A similar role was making connections between services in a case: for example connecting social work and the health visitor so that each party knew what was happening and both could update the Link Worker on the key aspects of the case from their service's point of view. Last, making connections to ensure there was clarity regarding the Link Worker role and no duplication of effort between the Link Worker and other services in a case. This was particularly important where there might be lengthy waiting times for an external service and the Link Worker continued to offer practical and therapeutic support to ensure that the patient stayed engaged until the receiving service had an opening.

5.4.4 Breaking the Impasse: there were examples of cases where the role of the Link Worker focused on finding out what had happened to applications for different types of Benefits. In one such case a benefits appeal had not been actioned with seemingly no-one assigned to addressing the matter. The patient's levels of distress were such that their ability to cope and function were severely impaired. With the withdrawal date of the benefit drawing close and all other avenues of help exhausted, the Link Worker (in concert with another service supporting the patient) got the local MSP involved and the issue was resolved within two weeks. In another case the Link Worker accompanied a patient with severe mental health issues to a meeting with an employment lawyer to try and find out what was happening to resolve work issues that had led to the patient going 'off sick' and living under the threat of dismissal from the company. The Link Worker's presence not only addressed the impasse, but crucially ensured that the patient understood what was being said and took necessary action. The Link Worker then involved Remploy and they provided support to the patient to look for alternative employment. The Link Worker managed to find a volunteer post for the patient and Remploy continue to support the patient to find a more permanent post.

5.4.5 Plugging Gaps and Holding the Fort: as previously mentioned, it was not always possible to get the required service at the required time, and in some cases the Link Workers supported the patient until the service became available. The alternative was to risk losing the patient and/or the progress they had made. For example, Link Workers offered therapeutic support while patients waited for counselling services. Where community cars were unavailable, at times, Link Workers took older patients to community activities until alternative arrangements could be made. In another case, the Link Worker stayed involved until an advocacy worker could be appointed. External services were very appreciative of the Link Workers support and joint working but on occasion that could spill over into trying to keep the SOS service involved when it was unrealistic to do so.

5.4.6 Keeping It Local: the Link Workers had not constructed a simplistic rote knowledge of the available services, but had built (and continue to build) a sophisticated understanding of what could be delivered where in relation to a patient's practical circumstances. The Link Workers used their liaison and negotiating skills to put together the best local response, as well as the best service fit. For some patients keeping it local was crucial to engaging with external services and activities. Some patients lacked confidence to leave their neighbourhood; in some cases it was fear for their personal safety if they were seen in other areas of the City; for other patients, family commitments (including childcare) constrained both the time and place of engagement. If the external service was flexible enough then local community centres provided a good option for engagement, as well as sources of local activities. As patients grew in confidence, some began to range beyond their comfort zone (e.g. one patient started going to art classes that required taking a local bus in another area of Dundee, something the patient would not have done on their own before working with the SOS service).

5.4.7 The Therapeutic Underpinning: the Link Worker role was not designed to be therapeutic in a clinical sense, but this aspect of the work has underpinned much of the case work, particularly through the initial consultation phase. All three Link Workers are qualified counsellors. The Link Workers used their therapeutic skills to support the clients to deal with strong emotional responses and find strategies to work with these emotions and any attached behaviours. Three basic uses emerged: first, getting patients to trust in the service, relax and open up to the Link Worker. The Link Workers did this by building a rapport and creating a safe environment in which the client could explore sensitive and emotive issues and concerns. Second, helping the patient address behavioural issues and other deep seated issues that might prevent them taking full advantage of the SOS service, and any external services/activities on offer. The Link Workers did this by working on issues such as creating routines, structure and purpose to the day, looking at self-care, sleeping and eating patterns, and use of medication. Third, applying therapeutic techniques on external service/activity visits to calm the patient and help them deal with new people and new situations. The Link Workers did this by working through the patient's symptoms of anxiety and helping them prevent/deal with panic and fear. Changes in the way that health inequalities organisations operate in Dundee provided an opportunity to appoint a therapeutic support link worker to the SOS service on a temporary basis. This was intended to provide a more structured approach to dealing with those patients whose levels of stress and anxiety and general behaviour required a more intensive intervention. To date 33 referrals have been made by the Link Workers and 22 patients have engaged at some level with the SOS Therapeutic Worker. The goals set by the SOS Therapeutic Worker link to the goals set by the Patient with the Link Worker.

5.5 A Reality Check

The analysis of the 100 cases suggests the Link Workers had a notable success rate in achieving patients goals provided the patients worked with the service and took on board the advice and help on offer. As noted earlier in the report, few patients who engaged with the service left without at least one positive intervention.

5.5.1 The Right Service, the Wrong Moment: not all patients were in a frame of mind that allowed them to work with the Link Workers. Some were so overwhelmed by the issues in their lives that levels of stress and anxiety had to be brought under control before a meaningful conversation could occur. In one such case the Link Worker made an immediate referral to the Therapeutic Worker to work on the patient's distress and provide them with strategies that would allow them to cope better and re-engage with the Link Worker. In another case a patient felt too anxious to attend a confidence building course at the time the course was starting and wanted to leave it for another time when they felt better. Patients with depression and low mood could experience a decline in their mental health which could act as a barrier to engaging with others just as opportunities opened up. Part of the Link Worker's skill lay in judging when to give patients time and space to decide if it was the right time to engage with a particular service/activity.

5.5.2 A Step Back to Go Forward: the Link Workers recognised that a clinical review of the patient's medication could be as helpful as matching the patient to another service, particularly patients with low mood, depression and anxiety. Counselling or other support services were not always the answer and a review of the patient's medication might be more appropriate, especially if it helped manage the patient's symptoms and allowed them to take advantage of the support on offer. In another case the Link Worker organised a bowel screening for a patient who was so fixated on the fear of bowel cancer that no progress could be made until that issue was addressed. Some patients had underlying literacy issues which prevented them accessing services unless helped by a family member/friend (i.e. reading and completing application forms). Going one step back and addressing a basic skills gap might be the only way forward to achieving their stated goals.

5.5.3 You Are Never Too Old: there were few patients aged 80yrs and over in the case study group (and the service in general). The issues those cases presented were indicative of the other age groups within the SOS service, and the services used and benefits gained similarly. One patient set three goals - two were met and one partially met. This included finding a service to listen to their side of the 'move to sheltered housing' the family was trying to achieve for the patient and work through their feelings. The patient's alcohol use had reduced due, in par,t to physical issues, but also due to resolving the issues surrounding the move to sheltered housing. Lastly, the patient's depression and low mood began to lift.