| SSN: 123-45-67 |
Tx Plan Date: 1/0/21/99
|
Review Date: 4/21/00 |
Primary Treatment Team:
Sally Shue, MA (IS)
Fred Fowler (Substance Abuse Specialist)
Jane Johnston (Employment Specialist)
Nancy Norton, RN
Mike Mathews, MD |
Discharge Criterion:
1. No significant major psychotic or affective symptoms for two years, and
2. No major role dysfunction in areas of work, socialization, and self-care
for one year under conditions of minimal treatment. |
| DSM IV Diagnoses |
Axis I
295.30 Schizophrenia, Paranoid Type
304.80 Polysubstance Dependence
|
Axis I Axis IV
Psychosocial
Stressors:
Rejection by family
Inadequate social support
Unemployed
Inadequate housing/unsafe neighborhood
Multiple arrests/convictions
Hostile relationships w/others
Severity:
3 - Moderate |
Axis II
301.7 Anitisocial Personality Disorder w/Borderline Features |
Axis III
History of exposure to Hepatitis A, B, & C as validated by
laboratory studies;
Esophageal refulx
Non-tuberculosis mycobacterium
|
Axis V
Current GAF:
30
Highest GAF past year: 30 |
Strengths
1. Survival skills developed while living on the streets
2. High school diploma
3. Desire for more stability in his life
4. Engaging personality |
| Focus Area #1 Jones experiences:
(1) persistent delusional thoughts of a religious, satanic, and paranoid
theme (i.e., “The Smithville Co. Sheriff’s Department injected
me with germ warfare.” “The devil is trying to kill me”)
(2) persistent auditory hallucinations (Satan or the Holy Spirit are talking
to him) which, at times, command him to harm others or himself - Mr. Jones
has a history of suicide attempts and two felony arrests for murder;
(3) periods of unpredictable agitation, leading to cursing with loud shouting
speech and implicit threats to others;
(4) when acute, hallucinations and delusions increase with an increase
in impulsive acts (often leading to misdemeanor arrests);
(5) symptoms become worse with the use of alcohol and illegal substances.
|
Goal Trial of new generation medication (Risperdal)
to better control psychiatric symptoms while minimizing side-effect.s, Mr.
Jones will take medications consistently as prescribed to allow for an adequate
trial or communicate a need for a change 90% of the time through 10/00 as
measured by staff observation and document in progress notes. |
| Goal - Through 4/00, Mr. Jones will have
no incidents of unplanned hospitalization as measured by staff, community,
and crisis report. |
Plan
(1) Mike Mathews, M.D. to see q 4-6 weeks for medication prescriptions,
Sx assessment, and supportive therapies.
(2) Daily 1:1 with Integration Specialist (IS) for symptom assessment, medication
education
(3) Weekly 1:1 with IS, for psychoeducation, Sx assessment, and development
of coping strategies (e.g., anger management, environmental issues)
(3) ACT team to be available 24/7 for crisis response and support services..
|
|
Focus Area #2
History of involvement with the criminal justice system including three
felony convictions, multiple arrests, and hospitalizations
|
Goal - Through 10/00, Mr. Jones will have
no arrests or physical altercations as measured by self, staff, community
and police reports. |
Plan
(1) IS, to meet monthly with Mr. Jones for 1:1 on the relationship between
his mental health and behaviors and involvement in the criminal justice
system and develop coping strategies.
(2) IS, and Substance Abuse specialist to interact with law enforcement
officials to provide education about MI and function as liaison, PRN
|
Goal - Through 10/00, Mr. Jones will revisit
his timeline on a monthly basis during1:1 to identify pattern and develop
pre-crisi copin strategies as monitored by staff report. |
Focus Area #3
Extensive history of substance abuse which contributes to an increase in
psychotic symptoms and possible suicidal/homicidal risk (see Need Area #1).
History of burglaries to obtain money to purchase substances (see Need Area
#2). Predominantly ETOH and “crack” cocaine use, but inclusive
of LSD, PCP, MDMA, marijuana, amphetamines, tranquilizers, and sedatives.
Most recent use was ETOH and “crack” cocaine. Substances are
often used to “drown out the voices so I don’t have to hurt
anyone. |
Goal - Mr. Jones will understand the connection
between substance use, increase in psychiatric symptoms, and arrest.as evidenced
by being able to verbalize the relationship to staff on three of more different
occasions prior to 4/00. |
| Goal - Mr. Jones will understand the dangers
of combining alcohol and other illegal substances with his prescribed psychiatric
medications as evidenced by being able to verbalize the dangers on three
or more different occasions prior to 4/00. |
Plan
(1) 1:1 motivational interview 3 x week - Substance Abuse Specialist
(2) Weekly dual-diagnosis group at ACT program office – Substance
Abuse Specialist |
Goal - By 1/00, Mr. Jones will identify one
or more factors he personally views as benefits from reducing or eliminating
the use of alcohol or other substances. |
Focus Area #4
Inability to conduct activities of daily living without consistent prompts
and assists (i.e., living arrangements, money management, nutrition, housekeeping
and grooming/hygiene) as directly related to Focus Area #1 symtomatology
including paranoia, impulsive agitation, and poor interpersonal social skills
|
Goal - Mr. Jones will maintain his residence
in a safe environment for three consecutive months by 10/00 as monitored
by self, staff, and apartment manager. |
Plan
(1) IS and Substance abuse specialist to work with Mr. Jones on locating
affordable safe housing.
(2) Weekly 1:1 with IS for apartment maintenance monitoring. Based on need,
interaction by staff will be titrated from side-by-side assistance to verbal
prompts)
(3) IS to meet monthly with Mr. Jones to review budget and to liaison with
his payee on PRN basis.
(4) Weekly monitoring of food supply/trips to grocery store and education
about nutrition.
|
Goal - Mr. Jones will complete and adhere
to a monthly budget to ensure that his basic needs are met for 6 months
without need for supplementation as monitored by self, staff report, and
payee report by 10/00. |
Focus Area #5
Care and management of medical and dental needs is complicated by Mr. Jones’
difficulties to recognize the need for intervention and to follow through
with medical recommendations due to Focus Area #1. |
Goal - F/U re: esophageal reflux, non-TB
mycobacterium, and sores on head/face |
| Goal - dental appointment |
Plan
(1) Nurse to schedule dental appointment and accompany Mr. Jones.
(2) Nurse to schedule appointment with MFP to address medical needs. |
Goal - ongoing monitoring |
