Management of Mental Illness

 

97. Member will demonstrate the ability to accurately and consistently self-administer prescribed medications without assistance, as measured by report of MD/NP, TAO nurse, and CM.  Baseline:  Unable to self-administer medications on a consistent basis.

Rehab: CM and Nurse will help member develop a system for remembering what medications should be taken and when they have been taken (e.g., calendar, checklist, dry-erase board, use of blister packs, etc.); will use SOAR (Supportive Choice Making) to help member resolve ambivalence over meeting with his psychiatrist and taking the medications that are prescribed or recommended to him.

Collateral: CM will familiarize member’s R&B manager with the system he will be using and provide advice on how she can help him become more self-sufficient.

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

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence.

Member will keep treatment team informed of any unforeseen challenges or barriers encountered that could interfere with the ability to manage medications successfully.

98. Member will be able to demonstrate 3 techniques that allow her to experience feelings of frustration and anger without hurting herself.  Baseline:  Cutting is the only way member knows of to relieve emotional turmoil.

Rehab: CM will teach member alternative coping skills for managing feelings of frustration and anger, such as deep breathing, progressive relaxation, positive mental imagery, physical exercise, venting to a trusted friend, and journaling.

CMS: CM will facilitate linkage to support groups and provide information about the risks and potential consequences of cutting, such as scarring, infection, loss of function, and uncontrolled bleeding.

Therapy: Clinician will use CBT to help member identify, challenge, and replace inaccurate thoughts that are most closely linked to her fears of abandonment and episodes of anger.

Member will start a journal and write at least one "positive affirmation statement" per day regarding herself, her strengths, and her abilities; and reach out to a member of her team or a trusted friend if she feels she may engage in cutting.

99. Member will decrease incidents of self-harm, from a baseline of 2 major incidents in the last 6 months to a goal of 0 major incidents, and sustain this change for 6 months, as measured by collateral, member self-report, observations by treatment team.

Rehab: CM will use RCCS skill-building exercise "Choice Making" to help member recognize the connection between extreme emotions and decisions she later regrets. Will teach alternative coping skills for managing intense emotions, such as deep breathing, progressive relaxation, physical exercise, venting to a trusted friend, participating in groups, and journaling.

CMS: CM will facilitate linkage to support groups and provide information about the risks and potential consequences of self-injury, such as scarring, infection, loss of function, and uncontrolled bleeding.

Collateral: CM will educate member's significant support persons on her mental illness, how they can improve her access to services, and how they can help her achieve her goals.

Group: Group facilitator will conduct RCCS group to help participants improve their ability to manage strong emotions such as anxiety without the use of substances.

Member will participate in RCCS group and practice using the alternative coping skills she learns.

100. Member will reduce suicidal ideations and gestures (as described in CFS 8) from 7 times per week to a goal of 0 times per week and sustain this change for 6 months, as measured by self-report and provider observation.

Rehab: CM will help member explore self-defeating patterns in her behavior and work to increase her awareness of the consequences of choices she makes. Will teach member more effective ways of coping with depression, such as staying busy, creating a schedule of daily/weekly activities, spending time with friends, attending groups, sharing her feelings with others, and engaging in physical exercise.

Collateral: CM will educate, train, and counsel member’s significant support persons on her mental illness and accessing mental health services to help member accomplish her goals.

Group: Group Facilitator(s) will conduct Coping Skills and DBSA (Depression and Bipolar Support Alliance) Groups to help participants form connections with peers, recognize they are not alone, share experiences, and celebrate accomplishments.

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

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence.

Member will practice using the coping skills she learns and use the Common Ground library to learn more about people like herself who have recovered from severe depression.

101. Member will decrease instances in which she stops taking her medication due to emotional distress, from a baseline of twice in the last 6 months to a goal of 0 times, and sustain this change for at least 6 months, as measured by member self-report and report of psychiatrist/NP.

Rehab: CM will help member identify self-defeating patterns in her behavior that have led to problems in the past and help her develop a plan for change going forward. Will teach alternative coping skills for managing emotional distress, such as deep breathing, progressive relaxation, physical exercise, venting to a trusted friend, and journaling.

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

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence.

Member will practice using the coping skills she learns and consult with her psychiatrist before making any changes in her med regimen.

102. Member will decrease non-emergency ER visits, from a baseline of 6 visits in 6 months to a goal of no more than 2 visits in 6 months, and sustain this change for 6 consecutive months, as measured by collateral and member self-report.

Rehab: CM will help member identify patterns in his behavior that have led to problems in the past, increase awareness of the consequences of choices he makes, and help him develop a plan for change going forward. Will teach alternative coping skills for managing emotional distress, such as deep breathing, progressive relaxation, physical exercise, venting to a trusted friend, and journaling.

Collateral: CM will educate R&B manager on member’s mental illness and provide training on how she can support member in accessing mental health services and accomplishing his goals.

Group: Group facilitator will conduct COEG (Co-Occurring Education Group) to increase participants’ awareness of the relationship between substance dependence and recovery from mental illness.

Member will attend COEG group and use the Common Ground library to learn more about people like himself who have made a successful recovery from mental illness.

103. Member will make effective use of her support network as evidenced by having no more than one psychiatric hospitalization in the next 12 months.  Baseline:  4 hospitalizations in the past year with 0 instances of reaching out to support system as symptoms increased.

Rehab: CM will help member identify self-defeating patterns in her behavior, teach alternative coping skills for managing her symptoms (e.g., deep breathing, physical exercise, venting to a trusted friend, participating/sharing in groups, and journaling), and stress the importance of staying engaged with her treatment team and taking medications as prescribed.

Collateral: CM will educate member’s significant support persons on her mental illness, how they can improve her access to services, and how they can help her achieve her goals.

Group: Group Facilitator(s) will conduct Coping Skills and DBSA (Depression and Bipolar Support Alliance) Groups to help participants form connections with peers, recognize they are not alone, share experiences, and celebrate accomplishments.

Member will attend groups, practice using the coping skills she learns, consult with her prescriber before making any changes in her med regimen, and use the Common Ground library to learn more about her illness and how others have recovered from it.

104. Member will decrease instances of summoning emergency responders (i.e., police, fire department, paramedics) for non-emergency reasons, from a baseline of 3x/6 months to a goal of 1x/6 months, and sustain this change for 6 months, as measured by collateral and member self-report.

Rehab: CM will help member identify self-defeating patterns in her behavior, teach alternative coping skills for managing symptoms (e.g., deep breathing, exercising, using distraction techniques, reducing exposure to stress), and reinforce the importance of taking medications consistently.

Collateral: CM will educate member’s significant support persons on her mental illness, how they can improve her access to services, and how they can help her achieve her goals.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to control positive symptoms of schizophrenia.  Nurse will assist with medication management to help member overcome impairments related to inconsistent adherence to med regimen.

Group: Group facilitator will conduct COEG (Co-Occurring Education Group) to increase participants’ awareness of the relationship between substance abuse and recovery from mental illness.

Member will attend COEG group and use the Common Ground library to learn more about people like herself who have made a successful recovery from mental illness.

105. Member will improve her ability to manage future manic episodes, from a baseline of having no plan for what to do to a goal of having a well-developed plan in place, and sustain this change for the remainder of the cycle, as measured by member's description of plan.

Rehab: CM will help member learn to recognize the early warning signs of mania (unable to sleep, calls friends in the middle of the night, talks more than usual, begins planning elaborate projects) and assist her with developing a plan for what to do when she observes them (alerting significant support persons, using physical exercise and other techniques to discharge excess energy, etc.).

Collateral: CM will educate member’s significant support persons on her mental illness, how they can improve her access to services, and how they can help her achieve her goals.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to stabilize mood. Nurse will assist with medication management to help member overcome impairments related to inconsistent adherence to med regimen.

Group: Group Facilitator(s) will conduct Coping Skills and DBSA (Depression and Bipolar Support Alliance) Groups to help participants form connections with peers, recognize they are not alone, share experiences and solutions, and celebrate accomplishments.

Member will practice using the coping skills she learns, implement the agreed-up safety plan if she recognizes signs of mania, and consult with her prescriber before making any changes in her med regimen.

106. Member will identify, challenge, and replace negative self-talk with positive and more accurate self-talk, from a baseline of 0x/wk to a goal of 3/wk, as measured by statements she makes to members of her treatment team.

Rehab: CM will use skill-building exercises from the "Building Resiliency" workbook to increase member’s awareness of her strengths, abilities, and accomplishments; improve her self-confidence; increase her motivation to work towards treatment goals; and help her envision positive outcomes.

Therapy: Clinician will use therapeutic interventions such as CBT to help member identify and correct self-defeating thoughts that may be contributing to feelings of guilt, shame, and hopelessness.

Group: Group Facilitator will conduct DBSA group (Depression and Bipolar Support Alliance) to help participants form connections with similarly-diagnosed peers, recognize they are not alone, share experiences and solutions, and celebrate accomplishments.

Member will think about strengths she has that have allowed her to survive in the face of adversity and write them down in a composition book.

107. Member will increase the number of anxiety-reduction techniques she is able to use, from a baseline of 1 to a goal of 4, and sustain this change for the remainder of the cycle, as measured by member's ongoing description of the techniques and how she has used them.

Rehab: CM will teach member coping skills such as deep breathing, progressive relaxation, positive mental imagery, physical exercise, venting to a trusted friend, and journaling to manage feelings of anxiety.

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

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

108. Member will advance to the Contemplation stage of change as evidenced by her admission that she might have a mental illness, her ability to verbalize the pros and cons of participating in treatment, and her willingness to meet with a member of her treatment team at least once every 2 weeks.  Baseline:  Denies having a mental illness and meets with a member of her team less than 1x/month.

Rehab: CM will work to establish rapport and trust; use supportive, non-judgmental language; assess willingness to change; and gently work to raise doubts about member’s belief that she does not have a mental illness and has nothing to gain from treatment. Goal is to increase member’s participation in treatment and ability to accomplish treatment goals.

CMS: If member is receptive, CM will provide basic information about member’s diagnosis and show her how to use the Common Ground library at TAO to read stories by similarly-diagnosed peers.

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

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder and anxiety.  Nurse will assist with medication management to help member overcome impairments related to inconsistent med adherence (see CFS 8).

Member will identify a time and place she is willing to meet with her CM each week.

109. Member will be able to identify each of his medications, when he is supposed to take them, and the condition(s) they were prescribed to treat.  Baseline:  Doesn't know what his medications are, when he is supposed to take them, or why they were prescribed.

Medication: TAO Nurse will assist member with learning the names of all medications he uses, the healthcare provider who prescribed them, the purpose of each medication or the symptoms the medication is supposed to treat, how often and at what dose (amount) he is supposed to take, and when refills are needed. Goal is to improve member’s ability to self-manage his medications so he can move to a lower level of care.

Collateral: CM and TAO nurse will educate member’s signficant support persons on how they can help member improve his ability to manage his medications and accomplish his treatment goals.

Member will implement strategies recommended by TAO Nurse for improving his ability to manage his medications (e.g., using pill cassette, blister packs, labels, etc.).

110. Member will increase the number of hours of restful sleep she gets per night, from a baseline of 2 or less to a goal of at least 5, and sustain this change for at least 3 months, as measured by member self-report.

Rehab: CM will teach member relaxation skills such as deep breathing, progressive relaxation, positive mental imagery, physical exercise, venting to a trusted friend, and journaling to discharge excess energy; and strategies to promote sleep such as avoiding late-day consumption of caffeinated beverages and other stimulants, reducing daytime naps, and adhering to a set schedule for bedtime and wake-up.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to stabilize mood, improve sleep, and reduce symptoms of thought disorder (primarily A/H).

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence.

Member will establish a set bedtime-uptime schedule and stick to it even on weekends.

111. Member will increase the number of days he gets out of bed, showers, and gets dressed by 10 AM, from a baseline of 0x/week to a goal of 4x/week, and sustain this change for 6 months, as measured by member self-report, report of R&B manager, and CM observation.

Rehab: CM will use skill-building exercises from the "Building Resiliency" workbook to increase member’s awareness of his strengths, abilities, and accomplishments; improve his self-confidence; increase his motivation to work towards treatment goals; and help him envision positive outcomes.

Therapy: Clinician will use therapeutic interventions such as CBT to help member identify and correct self-defeating thoughts that may be contributing to feelings of depression.

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

Group: Group Facilitator will conduct DBSA group (Depression and Bipolar Support Alliance) to help participants form connections with similarly-diagnosed peers, recognize they are not alone, share experiences and solutions, and celebrate accomplishments.

Member will attend group and follow agreed-up schedule for going to bed and getting up.

112. Member will increase the number of times he meets with his psychiatrist at the clinic as opposed to in his home, from a baseline of 0 to a goal of at least 1 out of every 3 meetings, and sustain this change for 6 months, as measured by report of psychiatrist or NP.

Rehab: CM will use skill-building exercises from the "Building Resiliency" workbook to help member envision positive outcomes, such as reduced dependency on others and increased self-esteem, to strengthen his motivation to work towards treatment goals. Will teach member relaxation techniques to manage anxiety he feels around strangers, and use modeling and role-play to improve social/interpersonal skills. Will provide praise and positive reinforcement when member engages in desired behaviors.

Collateral: CM will educate member’s significant support persons on his mental illness, how they can support him in achieving his goals (e.g., avoiding arguments, using non-judgmental language, providing reminders, assisting with transportation, offering praise, etc.).

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

Group: Group Facilitator 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.

113. Member will increase instances of sleeping throughout the night without disturbing/awakening others, from a baseline of 1x/week to a goal of 5x/week, and sustain this change for 6 months, as evidenced by report of R&B manager.

Rehab: CM will teach member strategies for falling asleep and staying asleep, such as avoiding caffeine and energy drinks, reducing late-day stimulation (e.g., video games, TV, loud music), taking medications as prescribed, and adhering to a set bedtime schedule. Will help member create a plan for what to do if he cannot sleep, such as listening to music on his headphones or identifying a quiet place where he can pace and walk-off excess energy without disturbing others.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to stabilize mood, improve sleep, and reduce symptoms of thought disorder (primarily A/H). 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 implement the strategies recommended by his team and discuss the results with his CM and prescriber.

114. Member will increase the number of times he successfully manages intense emotions by using DBT techniques, from a baseline of 0x/month to a goal of at least 2x/month, and sustain this change for the remainder of the cycle, as measured by clinician’s observations and member self-report.

Therapy: Clinician will teach member core DBT skills such as mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation to manage painful emotions and decrease conflict in relationships.

Group: Group facilitator will conduct RCCS group to help participants improve their ability to manage strong emotions such as anger and anxiety.

Member will attend RCCS group and practice using the DBT skills he learns in therapy.

115. Member will increase instances of early help-seeking when symptoms appear to be getting worse, from a baseline of 0x/event to a goal of 1x/2 events, and sustain this change for the remainder of the cycle, as measured by collateral, member self-report, and CM observation.

Rehab: CM will help member learn to recognize when her symptoms are getting worse and help her create a plan of action for those situations (i.e., what to do, who to call, in what order, etc.). Will teach member skills for reducing/controlling her symptoms, such as remembering to take her medications in the right amounts, at the right times; identifying and eliminating unnecessary sources of stress, and learning self-calming techniques.

Therapy: Clinician will use CBT to help member identify negative patterns of thinking that are interfering with her recovery (e.g., the need for substances, cultural stigma, etc.) and replace them with more accurate ones.

Group: Group facilitator will conduct COEG (Co-Occurring Education Group) to help participants gain a better understanding of the relationship between substance abuse and recovery from mental illness.

Member will work with her CM to identify early warning signs and recurring patterns associated with relapses that, if observed, indicate the need to reach out to others for assistance. Member will attend at least one series of COEG group.

116. Member will seek assistance and notify a member of his treatment team whenever he starts hearing voices telling him to harm others.  Baseline:  Member does not seek assistance and only informs his treatment team after symptoms have subsided.

Rehab: CM will help member learn to recognize when his symptoms are getting worse and help him create a plan of action for those situations (i.e., what to do, who to call, in what order, etc.). Will teach member skills for reducing/controlling his symptoms, such as remembering to take his medications in the right amounts, at the right times; identifying and eliminating unnecessary sources of stress, and learning self-calming techniques.

Therapy: Clinician will use CBT to help member identify negative patterns of thinking that are interfering with his recovery (e.g., that his illness is shameful, that he is being punished, etc.) and replace them with more positive and accurate ones.

Group: Group facilitator will conduct COEG (Co-Occurring Education Group) to help participants gain a better understanding of the relationship between substance abuse and recovery from mental illness.

Member will work with his CM to identify early warning signs and recurring patterns associated with relapses that, if observed, indicate the need to reach out to others for assistance. Member will attend at least one series of COEG group.

117. Member will be able to demonstrate 3 techniques that allow him to manage the voices he hears without disturbing others.   Baseline:  Unable to demonstrate any techniques that work for him.

Rehab: CM will assist member with developing skills for managing his A/H, such as remembering to take his medications in the right amounts, at the right times; identifying and eliminating unnecessary sources of stress; engaging in physical exercise; using distraction techniques such as listening to music on his headphones; and reaching out to his treatment team and/or supportive others if his voices are becoming more prominent.  

Collateral: CM will educate member’s significant support persons on the value of maintaining a low-stress environment, keeping volume levels down, using active/reflective listening, using non-judgmental language, and having only one person speaking at a time.

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.

Member will practice using the skills he learns from his treatment team and consult with his psychiatrist before making any changes in his med regimen. 

118. Member will improve ability to manage delusions as evidenced by no longer reporting that he feels unsafe in his apartment, and sustain this change for 6 consecutive months.  Baseline:  Due to delusional beliefs member continuously reports feeling unsafe.

Rehab: CM will work to establish trust with member, teach him strategies for testing his beliefs, and provide positive reinforcement for his willingness to consider alternative explanations for the distressing thoughts and feelings he has.  Will teach member skills for managing his symptoms, such as remembering to take his medications in the right amounts, at the right times; and identifying and eliminating unnecessary sources of stress, as this is known to make his symptoms worse.

Collateral: CM will educate member’s significant support persons on the value of maintaining a low-stress environment, keeping volume levels down, using active/reflective listening, using non-judgmental language, having only one person speaking at a time, avoiding arguments, and acknowledging that member’s beliefs are real without supporting the actual delusions.

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

Group: Group facilitator will conduct COEG (Co-Occurring Education Group) to help participants gain a better understanding of the relationship between substance use and recovery from mental illness.

Member will attend COEG group and implement the strategies and techniques recommended by his treatment team.

119. Member will increase the number of clinic visits in which she shows no visible or behavioral signs of responding to internal stimuli, from a baseline of 1x/4 visits to a goal of 3x/4 visits, and sustain this change for 6 months, as measured by observation of treatment team.

Rehab: CM will assist member with developing skills for managing her symptoms, such as remembering to take her medications in the right amounts, at the right times; reaching out to her treatment team and/or supportive others if her voices are getting louder or more frequent; and identifying and eliminating unnecessary sources of stress, as this is known to make her symptoms worse.

Collateral: CM will educate member’s significant support persons on the value of maintaining a low-stress environment, keeping volume levels down, using active/reflective listening, using non-judgmental language, and having only one person speaking at a time.

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

Member will use the skills she learns from her treatment team and consult with her prescriber before making any changes in her med regimen.

120. Member will be able to demonstrate 3 techniques, such as thought-stopping and deep breathing, that help her control the anxiety she feels in situations that remind her of past trauma.  Baseline:  Unable to demonstrate any techniques.

Rehab: CM will help member identify triggering situations and explore ways of avoiding and/or limiting her exposure to them; will teach relaxation techniques such as thought-stopping and deep breathing to help her cope with anxiety and feelings of panic; will use skill-building exercises from the "Building Resiliency" workbook to increase member’s awareness of her strengths and abilities, and improve her self-confidence.

Therapy: Clinician will use therapeutic interventions such as CBT to help member identify and correct self-defeating thoughts that may be contributing to feelings of guilt, fear, and hopelessness.

Member will practice using the anxiety-reduction skills she learns, discuss the results with members of her treatment team, and complete homework assignments as directed by her therapist.

121. Member will be able to spend 7 consecutive nights alone in her apartment and get at least 5 hours of restful sleep each night, as measured by member self-report.  Baseline:  Spends 2-3 nights alone per week; unable to sleep some of those nights due to symptoms of PTSD.

Rehab:  CM will use skill-building exercises from the "Building Resiliency" workbook to increase member’s awareness of her strengths, abilities, and accomplishments; improve her self-confidence; and increase her motivation to work towards treatment goals. Will help member identify triggers to panic, explore ways of avoiding and/or limiting her exposure to them, and teach coping skills for managing anxiety.

CMS: CM will provide member with educational materials on the causes of PTSD and how it can result in intrusive recollections, flashbacks, nightmares, anxiety, being more easily startled, and having difficulty sleeping.

Therapy: Clinician will use therapeutic interventions such as CBT to help member identify and correct self-defeating thoughts that may be contributing to feelings of guilt and anxiety.

Member will maintain an awareness of triggers, use the coping skills she learns, and complete homework assignments as directed by her therapist.

122. Member will increase the number of psychiatrist appointments he attends without CM assistance, from a baseline of 0 to a goal of at least 1 every 3 months, and sustain this change for 6 months, as measured by chart notes and report of CM.

Rehab: CM will work to raise awareness of the value of consistent engagement; will provide coaching to help member gain proficiency with scheduling appointments and using public transportation; will help member develop a system for remembering important dates and times (e.g., using a day planner, wall calendar, or smart phone alerts; having a close friend or family member assist by sending reminder texts; calling in at regular intervals to confirm upcoming appointments, etc.).

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

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

Member will implement plan for tracking appointments and attending them on his own.

123. Member will remain open to the possibility that medications might be beneficial to him, as evidenced by meeting with his psychiatrist once a month to discuss this subject.  Baseline:  Has not met with psychiatrist in over 9 months.

CMS: CM will work to facilitate ongoing linkage between member and his psychiatrist and nurse.

Medication: MD/NP will provide psychoeducation and keep member informed about options for treating his symptoms with medications, including a discussion of potential risks, benefits, and side-effects.

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 use the Common Ground library at TAO to learn more about his illness and read stories about similarly-diagnosed peers, including their thoughts, feelings, concerns, and experiences in treatment.

124. Member will choose to receive feedback from members of her treatment team in a non-defensive manner, as evidenced by observation and consensus of persons involved in her recovery.  Baseline:  Becomes guarded and defensive when constructive feedback is offered.

Rehab: CM will help member explore recurring patterns in her decision-making and the consequences of the resulting behaviors; will provide skill-building to help member manage feelings of anger and resist urges to act impulsively; will use skill-building exercises from the "Anger" workbook to improve problem-solving and choice-making skills.

Therapy: Clinician will use therapeutic interventions such as CBT and DBT to help member recognize links between symptoms, behaviors, and impairments; develop insight into her illness; improve life functioning; and overcome negative thoughts and feelings.

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

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence as described in CFS 8.

Member will start a journal and write at least one “positive affirmation statement” per week about her strengths, her past accomplishments, and things she is proud of, with the goal of creating a sense of self-respect that is not dependent on others’ opinions.

125. Member will make a list of specific concerns he has about psychotropic medications (e.g., the possibility of movement disorders or negative effects on his health) and process this list with his psychiatrist.  Baseline:  Declines meds but will not explain why.

Rehab: CM will help member explore patterns in his decision-making and the consequences of the resulting behaviors; will assist member in weighing the imagined risks and potential benefits of discussing his concerns with his doctor; will provide skill-building to help member develop positive alternatives to maladaptive behaviors (i.e., improved communication skills, more effective problem-solving skills, etc.).

Medication: MD/NP will provide psychoeducation to help correct misconceptions member may have, such as underestimating the potential benefits of medication therapy, overestimating the threat posed by side effects, beliefs that medications are not necessary, concerns that medication could change his personality or result in addiction, etc.

Member will use the Common Ground library at TAO to learn more about his illness and read stories about similarly-diagnosed peers, including their thoughts, feelings, concerns, and experiences in treatment.

126. Member will identify a place and a time each month that he is willing to meet with his CM in the community, and sustain this change for the remainder of the cycle.  Baseline:  Member's whereabouts are usually unknown which prevents his CM from providing services.

Rehab: CM will work to increase member’s awareness of patterns in his decision-making that have contributed to problems in the past, and teach him to use SOAR (Supportive Choice Making) to make better decisions going forward. Will use skill-building exercises from the "Building Resiliency" workbook to help member envision positive outcomes and increase his motivation to engage with his treatment team and work towards treatment goals.

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

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence as described in CFS 8.

Member will implement decision-making skills he learns and begin applying them to real-life situations.

127. Member will demonstrate the ability to accurately and consistently self-administer his medications without assistance, as measured by report of nurse and R&B manager.  Baseline:  Unable to self-administer medications without assistance.

Rehab: CM will help member develop a system for remembering what medications should be taken and when they have been taken (e.g., calendar, checklist, dry-erase board, request for blister packs, etc.); will use SOAR (Supportive Choice Making) to help member resolve ambivalence over meeting with psychiatrist and taking the medications that are prescribed or recommended to him.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder, mood lability, and depression. Nurse will assist with medication management to help member overcome impairments related to lack of med adherence as described in CFS 8.

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 keep treatment team informed of any unforeseen challenges or barriers encountered that could interfere with the ability to manage medications successfully.

128. Member will reduce instances of running out of medication, from a baseline of 3 times in the last 6 months to a goal of 0 times, and sustain this change for 6 months, as measured by collateral, nurse report, and member self-report.

Rehab: CM will work to increase awareness of patterns in member’s behavior and decision-making that may have contributed to health issues in the past, and assist him with developing a system for remembering what medications should be taken and when they have been taken (e.g., calendar, checklist, dry-erase board, blister packs, etc.).

CMS: CM will facilitate linkage to PCP, pharmacy, and information about member’s health conditions.

Collateral: CM will educate member’s significant support persons on his mental illness and how they can improve his adherence to med regimen, to help him achieve his treatment goals.

Member will begin using the recommended systems and discuss the results with his treatment team.

 

All PHI has been de-identified per HIPAA Privacy Rule