Health

 

129. Member will make progress in overcoming his symptoms of depression as evidenced by choosing to meet with his PCP at least once, as measured by report of PCP and member self-report.  Baseline:  No PCP visits in over 5 years.

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 help him 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 work towards treatment goals.

CMS: CM and TAO Nurse will facilitate linkage to PCP and provide information about health and wellness to help member make more informed decisions about healthcare.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of depression and anxiety. 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 implement decision-making skills he learns and begin applying them to real-life situations.

130. Member will make progress in overcoming his anxiety and irrational fears, as evidenced by choosing to meet with his PCP at least once to discuss his health issues.  Baseline:  Member has several health issues but has not seen a doctor in the last 3 years.

Rehab: CM will teach member to use SOAR (Supportive Choice Making) to help him make better decisions regarding self-care, and relaxation techniques such as deep breathing, positive mental imagery, and positive self-statements to help him manage the anxiety he feels when going to the doctor’s office.

CMS: CM and TAO nurse will facilitate linkage to PCP and provide information about health and wellness to help member make more informed decisions about healthcare.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder (A/H, paranoia, delusional thinking). Nurse will assist with medication management to help member overcome impairments related to lack of med adherence (see 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 implement decision-making skills he learns and begin applying them to real-life situations.

131. Member will increase the number of recommendations by his PCP that he follows up on, from a baseline of 0/4 to a goal of at least 2/4, and sustain this change for at least 6 months, as measured by report of PCP and/or evidence provided by member.

Rehab: CM will use skill-building exercises from the "Wellness Lifestyle" and "Practical Life Skills" workbooks to increase member’s awareness of the importance of following his PCP’s recommendations regarding maintaining proper weight, participating in regular exercise, getting enough sleep, engaging in physical activity, avoiding risky behavior, and restricting his intake of harmful substances.

CMS: CM and TAO Nurse will facilitate linkage to PCP, referrals to specialty services, and information about member’s health conditions.

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 a notepad, day planner, smart phone notes, or other method of tracking/recalling PCP recommendations.  

132. Member will take the medications his doctor prescribes for diabetes on a consistent basis and obtain refills before he runs out, as measured by member self-report and report of nurse.  Baseline: Member was out of meds for nearly 4 months last year.

Rehab: CM will work to increase awareness of patterns in member’s behavior and decision-making that have contributed to problems in the past, and assist him with developing a system for remembering what medications should be taken, when he has taken them, and when he needs to call for a refill (e.g., blister packs, calendar, dry-erase board, smart phone alerts, etc.).

CMS: CM and TAO Nurse will facilitate linkage to PCP, pharmacy, and information about diabetes.

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

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of depression, anxiety, and mood lability. Nurse will assist with medication management to help member overcome impairments related to poor 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 system for managing medications and contact his PCP and treatment team immediately if he is unable to get his meds.

133. Member will schedule her own appointments as directed by her doctor and attend them without the assistance of her CM, as measured by report of MD and CM.  Baseline: Member scheduled 1 out of 4 required appointments in the last 12 months and needed a ride from her CM to get to 3 of them.

Rehab: CM will work to raise awareness of the value of consistent self-care; will use coaching, supervised practice, and positive reinforcement to help member gain proficiency with scheduling; will help member develop a plan for self-monitoring (e.g., using a calendar to provide reminders, establishing a contact person at her doctor’s office to touch bases with, etc.).

CMS: CM and TAO Nurse will facilitate linkage to healthcare services as directed by PCP.

Collateral: CM and TAO Nurse will educate member’s significant support persons on her mental illness and access to mental and physical healthcare services to help member accomplish her treatment goals.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of depression, anxiety, and mood lability. Nurse will assist with medication management to help member overcome impairments related to poor 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 plan for tracking appointments and practice scheduling them on her own (initially with CM, then without).

 

All PHI has been de-identified per HIPAA Privacy Rule