ADLs

 

57. Member will decrease the number of prompts required to get him to do his laundry, from a baseline of 3-4 prompts over a 7-day period to a goal of 1 prompt, and sustain this change for 3 consecutive months, as measured by report of member's mother.

Rehab: CM will help member modify his behavior by teaching him to use a calendar, post-it notes, dry-erase board, smart phone alerts, and other reminders to do his laundry and clean up his living area.

Collateral: CM will educate member’s mother on strategies she can use to promote desired behaviors, such as avoiding arguments, using non-judgmental language, and providing reinforcement when tasks are successfully completed.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of anger, mood lability, and depression. Nurse will assist with medication management to help member overcome impairments related to inconsistent adherence to med regimen.

Medication: Nurse will conduct annual nursing assessments to assist physician with ruling-out organic causes of mental health symptoms and to identify physical conditions neglected as a result of mental illness that may warrant referral.

Group: Group facilitator will conduct Moving Forward group to help member identify and overcome common barriers to progress.

Member will attend group and practice using the mnemonic techniques he learns from his CM.

58. Member will increase the number of times he performs ADLs with 1 prompt from his R&B manager, from a baseline of 0 times per month to a goal of at least 2 times per month, and sustain this change for 6 months, as measured by report of R&B manager.

Rehab: CM will help member modify his behavior by teaching him to use a calendar, post-it notes, dry-erase board, smart phone alerts, and other reminders to perform his basic ADLs (e.g., showering, changing into clean clothes, making his bed, doing his daily chores, and taking his medication.).

Collateral: CM will educate member’s R&B manager on strategies he can use to promote desired behaviors, such as avoiding arguments, using non-judgmental language, and providing reinforcement when tasks are successfully completed.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence (see CFS 8).

Group: Group facilitator will conduct Moving Forward group to help member identify and overcome common barriers to progress.

Member will attend Moving Forward group, implement the reminders suggested by his CM, and discuss the results with his CM during their weekly meetings.

59. Member will improve management of ADLs as evidenced by showering, brushing teeth, and changing into clean clothes at least 2x/week, from a baseline of 0-1x/week, and maintaining this change for at least 6 consecutive months.

Rehab: CM will use modeling and prompts to help member acquire basic hygiene skills; will provide psychoeducation to raise awareness of the value of consistent self-care; will reinforce regular performance of basic hygiene tasks (e.g., showering on the same days of the week); will help member develop a plan for self-monitoring (e.g., a calendar to provide reminders, a trusted person to check in with, etc.).

CMS: CM will facilitate linkage to sources of basic supplies (such as deodorant, toothpaste, nail clippers, etc.) and hygiene-related services (such as laundromats and barber shops).

Medication: Nurse will facilitate linkage to PCP to rule out/identify/obtain treatment for medical conditions that could be contributing to poor hygiene (e.g., gastrointestinal conditions, infections, urinary incontinence, etc.).

Member will practice new skills and inform team of any barriers encountered (e.g., inadequate clothing, lack of access to washing machines, etc.).

60. Member will increase the number of nutritionally-balanced meals he eats, from a baseline of 0 per day to a goal of at least one per day, and sustain this change for 6 months as measured by collateral, CM observation, and member self-report.

Rehab: CM will accompany member shopping and teach him how to purchase a healthy balance of nutritious foods without exceeding his budget. Will assist member with learning to plan and prepare meals for himself.

CMS: CM and TAO Nurse will provide member with educational materials about healthy food choices and the effect of diet on physical and mental well-being. Will facilitate linkage to medical, dental, and other healthcare providers.

Medication: Nurse will conduct annual nursing assessments to assist physician with ruling-out organic causes of mental health symptoms and to identify physical conditions neglected as a result of mental illness that may warrant referral.

Member will follow meal plans to the best of his ability and discuss the results with his CM during their weekly meetings.

61. Member will increase the number of times he showers and changes into clean clothes, from a baseline of once every 2 weeks to a goal of twice a week, and sustain this change for at least 3 consecutive months, as measured by collateral, member self-report, and CM observation.

Rehab: CM will use modeling and prompts to help member acquire basic hygiene skills; will provide psychoeducation to raise awareness of the value of consistent self-care; will reinforce regular performance of basic hygiene tasks (e.g., showering and doing laundry on the same days each week); will help member develop a plan for self-monitoring (e.g., a calendar to provide reminders, a trusted person to check in with regarding personal hygiene, etc.).

CMS: CM will facilitate linkage to sources of basic supplies (e.g. bath soap, laundry detergent, etc.).

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder. Nurse will assist with medication management to help member overcome impairments related to lack of med adherence.

Medication: Nurse will conduct annual nursing assessments to assist physician with ruling-out organic causes of mental health symptoms and to identify physical conditions neglected as a result of mental illness that may warrant referral.

Member will practice new skills and inform team of any barriers encountered (e.g., lack of hygiene supplies, appropriate clothing, etc.).

62. Member will increase the number of times she can leave her apartment and go to the store by herself, from a baseline of 0 times in the last 6 months (due to fear of having a panic attack), to a goal of once every 3 months, and sustain this change for 6 months as measured by member self-report.

Rehab: CM will teach member mindfulness techniques to help her manage distressing thoughts and feelings she has, and train her to use positive self-talk that reassures her of her ability to endure anxiety symptoms without serious consequences. Will accompany member to the store initially, then gradually fade support as member develops greater self-confidence.

CMS: CM will provide educational materials about panic attacks to help member understand that she is not "going crazy" or having a heart attack when symptoms occur. Will show member how to use the Common Ground library to find more information about panic attacks and stories of people who have successfully overcome them.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence (see CFS 8).

Member will practice the mindfulness techniques she learns, then engage in them while imagining herself in feared situations.

63. Member will increase the number of IADLs he can perform without assistance, from a baseline of 1 (communicating with people on the phone) to a goal of 3 or more, and sustain this change for the remainder of the cycle, as measured by collateral, CM observation, and member's demonstration of skills.

Rehab: CM will help member acquire independent living skills by modeling and rehearsing; will teach member to use a calendar, post-it notes, day planner and other mnemonic techniques to help him remember when to perform recurring tasks. Will provide feedback and reinforce desirable behavior, then gradually fade support as member acquires new skills.

CMS: CM will check-in with client on a regular basis to monitor progress towards goals and facilitate coordination of care.

Collateral: CM will educate member’s significant support persons on his mental illness, how they can support him in achieving his goals (e.g., praise, non-judgmental language, positive reinforcement), and how they can facilitate his access to mental health services.

Member will implement the skills and techniques he learns and discuss the results with his CM during their weekly meetings.

64. Member will increase the number of times he uses public transportation instead of requesting a ride from his CM, from a baseline of 0 times per month to a goal of at least once a month, and sustain this change for the remainder of the cycle, as measured by collateral, member self-report, and CM report.

Rehab: CM will use assessments, journaling activities, educational handouts, and skill-building exercises from the "Practical Life Skills" Workbook to help member reduce his dependence on others. Will accompany member during the early stages of treatment, then gradually fade support as he develops greater self-confidence.

CMS: CM will facilitate linkage to transportation by providing information from OCTA about bus routes, schedules, and ACCESS.

Group: Group Facilitator(s) will conduct Moving Forward group to help participants identify and overcome common barriers to progress (in both real-world settings and within TAO, where moving from higher to lower acuity teams is based on successful application of skills outside the program).

Member will attend Moving Forward group and practice the skills he learns with his CM.

 

All PHI has been de-identified per HIPAA Privacy Rule