IntensivePreventive Case Management

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Intensive-Preventive Case Management

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Introduction

• History
• Innovation by Necessity
• A Team Model
• Holistic Approach
• Committed to Hard Data and Case Study in
  Development
• Case Management Model (chart)
• Roles
• Measuring Reliability
• Outcomes
• Intensity
• Prevention

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Agenda

• Overview 15 minutes
• Data Review 10 minutes
• Intensive-Preventive Case
• Management in Action 35 minutes
• Question Answer 10 minutes

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Overview

• Client Population Demographics
• Social Worker Role
• Public Health Nurse Role
• Results
• Other Roles

Med
Psy
CS
Self
PHN
SW
Jobs
HC
OC
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Data Review

• History
• Data Tool
• Results to date
• Trends

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The Role of the Social Worker

• Assessment
• Service Access
• On-going case management

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SW - Assessment

• Assessment for service eligibility
• Assessment of need
• - ecological systems model
• - strength-based
• - solution-focused

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SW - Service Access

• Least restrictive setting
• Financial and medical assistance
• Mental health Collateral services
• Community resources
• Social Support Networks

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SW Ongoing Case Management

• Crisis intervention
• Advocacy
• Service Brokerage
• Individual monthly contact
• Medication management review

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The Role of the Public Health Nurse

• Prevention
• Promote
• Protect

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PHN - Prevention

• Screening clients for risk factors or disease
  conditions
• Communicate
• Interpersonal relationship
• Assist individuals to identify and access
  resources

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PHN - Promote

• Optimize self-care capabilities of the client and
  coordinate services to promote optimal health

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PHN - Protect

• Plead the clients cause or act on the clients
  behalf, with a focus on developing the clients
  capacity to plead his/her own cause or act on
  his/her own behalf

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Case StudY 1

• Mary Lou is a 66 year old woman who was living in
  her own home. Her toilet had broken over the
  winter and neighbors reported her to St. Louis
  County after seeing her pour buckets of human
  waste out the front door. When inspectors
  arrived they found Mary Lou living in an
  unlivable situation with buckets and piles of
  feces all over the house. Mary Lou was admitted
  to the psychiatric unit and was diagnosed with
  Major Depressive Disorder and was placed under a
  civil commitment. She was assigned to the IP
  Team. She entered an assisted living facility
  after her discharge from the hospital where her
  mental health stabilized. She was able to get
  her home repaired with the assistance of AEOA and
  is now living independently again.

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Case Study 2

• Julie is a 67 year old woman who was referred to
  the IP Team by her primary medical doctor while
  Julie was on the psychiatric inpatient unit.
  Julie suffered from Major Depressive Disorder and
  Severe Agoraphobia. She had gotten to the point
  of not being able to leave her apartment and she
  let her medical health fail to a near death
  situation. Julie spent 2 weeks in an inpatient
  rehabilitative unit and received PT/OT and
  Diabetes adjustments. With continued case
  management from the IP team and adjunct services
  in her home, Julies health improved and she no
  longer suffers from Agoraphobia symptoms. She
  continues to live independently in her apartment
  and is once again driving herself to appointments
  and social events.

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Case Study 3

• Pamela is a 56 year old woman who was referred to
  the IP Team after being reported to St. Louis
  County for hoarding and making her apartment
  unlivable. She had garbage stock piled and many
  other items piled up so that she no longer had
  anywhere to sit, lie down and barely walk in the
  apartment. After working with Pamela for a few
  months, it was discovered that she was also
  doctor shopping, using polypharmacy, and self
  medicating for her many medical issues and her
  Major Depressive Disorder. Pamela is now living
  in an assisted living center where she has 3
  meals a day, her meds given to her on a regular
  schedule and she is now only seeing one primary
  medical doctor. Her health has improved 10 fold
  and her mental health is now stable.

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Case Study 4

• Duane is a 55 year old man who was referred to
  the IP Team when he was placed under commitment
  in the inpatient psychiatric unit. Duane had
  been in and out of state hospitals for sever
  Paranoid Schizophrenia most of his life. The IP
  Team struggled with several inpatient stays on
  the unit for months and different placement
  issues. The IP Team found an all male Corporate
  Foster Home that specializes in Mental Health
  approximately 1 year ago and Duane still resides
  in that home today. He has only had one brief
  hospital stay in that year and after a medication
  adjustment went right back to the home and is
  doing great.

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Case Study 5

• Katherine is a 32 year old woman with Bipolar
  Disorder and Borderline Personality Disorder.
  She was referred to the IP Team from the
  inpatient psychiatric unit. She was living in an
  assisted living facility and was struggling with
  several inpatient stays on the unit for
  depression and suicidal thoughts and attempts.
  She wanted to go out on her own and get an
  apartment so bad, that she finally made the move.
  This put her right over the edge again and she
  ended right back up on the unit. During this
  hospital stay, the IP team was meeting with
  Katherine and started talking about alcohol and
  chemical use. It was discovered that each of the
  hospital stays were preceded with a drinking
  binge. Even though the client stated she didnt
  drink a lot, she revealed that she had black outs
  each time she did drink. We immediately asked
  for a Rule 25 assessment and Katherine went to an
  IRTS facility following this discharge and
  entered into a 90 day outpatient alcohol
  treatment program. Katherine is now sober and is
  back in her apartment and has had no
  hospitalizations on the unit in over 4 months.

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Summary

• Review model
• Question Answer

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Where to Get More Information

• St. Louis County Public Health and Human Services
• Adult Disabilities Unit
• PO Box 1148
• Virginia, MN 55792
• kearneyi_at_co.st-louis.mn.us
• pritchardp_at_co.st-louis.mn.us
• hannaym_at_co.st-louis.mn.us
• perkoj_at_co.st-louis.mn.us
• Social Worker Ilona Kearney 218-262-6042
• Public Health Nurse Patti Pritchard
  218-262-6035
• Supervisor Michael Hannay 218-749-0657
• Senior Manager Judd Perko 218-749-7179
  218-726-2709