Case Study With a Full Service Partnership Framework:

A Social Work Perspective

None of the faculty, planners, speakers, providers, nor CME committee members have any

relevant financial relationships with commercial interests.

There is no commercial support for this CME activity.

S.M.A.R.T.Specialized Multidisciplinary Aggressive Response Treatment Team Is a Full Service Partnership (FSP) program. Consists of:◦ Two Behavior Health Specialists (Case Managers )◦ One Clinical Therapists◦ A Psychologist◦ A Substance Abuse Counselor◦ A Registered Nurse◦ A Family Advocate ◦ Two Peer Support Specialist

This means that we will offer and provide all or some of an array of services to our consumers , i.e. case management, help with entitlements, help with housing, group and or individual therapy, family support, psychiatric evaluation, medication management, crisis intervention, etc.

S.M.A.R.T.Specialized Multidisciplinary Aggressive Response Treatment Team

Initial contact and or outreach is primarily in the field.

Therapeutic services are primarily provided in the office.

S.M.A.R.T.Specialized Multidisciplinary Aggressive Response Treatment Team

The Bridge Program is a step down program for S.M.A.R.T.

This team is a secondary team consisting of:◦ A clinical therapist and a Peer Support

Specialist Provides case management and therapy

for consumers who are stable but still in need of ongoing support (monthly contact).

Target Population There are three criteria to qualify to S.M.A.R.T.:◦ Riverside (Western Region) resident◦ 59 ½ or older◦ In need of services but have functional capabilities and

are unable to access services in the community◦ Considered “high risk” for: Homelessness (or homelessness already) Institutionalization Incarceration due to behaviors that are symptomatic of mental

illness

Referrals come from a verity of sources including:◦ ITF, APS, RPD, Code Enforcement, Shelters, and the

Safe Haven (The Place) Welcome Center

Services Provided Primarily field-based to meet consumer’s needs Include:◦ Mental Health Assessment and Evaluation◦ Extensive Case Management Services◦ Application for entitlements (SSA benefits, health

insurance, food stamps)◦ Emergency housing (motel) with stable/permanent

housing as a goal◦ Therapy (group and/or individual)◦ Linkage with other social service agencies◦ Linkage with medical and dental appointments◦ Recommendation for psychiatric appointments and

medication evaluation.

Case Study Ms Jones is a 65 y.o, Caucasian female. Married and divorced one time,

with no children . She reported being homeless for the last three years.◦ However we suspect she had been homeless much longer.

Ms. Jones had several contacts with mental health prior to being referred to us; including several visits to ETS, two hospitalizations at ITF( lasting a week or more). It is believed that she had been placed on conservatorship twice in the distant past and had one stay at Metro State hospital.

Ms. Jones had several contacts with police, some resulting in trips to ETS and two resulting in brief stays in jail.

She was Initially referred to SMART 6/2015 by the Welcome center at The Place. ◦ Welcome Center serves as a drop-in for adults of all ages to come and get connected

to MH services.

Ms. Jones would present there for help with food. She had no apparent income, was easily agitated, and was observed talking with her auditory hallucinations.

Initially Ms. Jones did agree to services and intake paper work was signed. How ever, she was not amenable to help with benefits, housing, doctor, or psychiatric appointments.

Case Study When initially assessed she presented with:◦ Disheveled appearance. Dirty/Torn clothing, strong body odor, overall poor hygiene. Her long curly hair was matted (stiff with dirt) and riddled with live bugs

◦ Auditory hallucinations-ongoing conversations with voices throughout the interview, pausing to tell the voices to be quiet.

◦ Rambling, tangential speech with references to being a renowned artist, an art school director as well as having conversations with God.

◦ Speech was pressured and disorganized with evidence of flight of ideas and loose associations.

◦ Motor activity was restless and gesticulating.

She remained homeless and would disappear for weeks at a time. In June, having been unable to locate her and provide services , we

closed the case.

Case Study Over the next few months several referrals from community

programs were received and responded to in regards to Ms. Jones. ◦ Ms. Jones continued to decline services.

In September 2016, a referral was received from The Welcome Center at The Place. ◦ S.M.A.R.T. staff responded and Ms. Jones still refused services. ◦ Further more, her vision was significantly impaired. ◦ She was holding the wall to guide her and help her with balance. ◦ There was a report that she had slept in the street in front of the

Welcome Center,. This was due to her being unable to find the sidewalk or make it to the line for the shelter located next door.

◦ She continued to refuse services ◦ She was placed on a hold, with an administrative request that AMR

transport her to a medical hospital prior to ETS, for medical hospital prior to ETS, for medical clearance.

Case Study Ms. Jones was cleared by the hospital and diverted from

ETS to Aurora Charter Oaks in Covina. ◦ The following day contact was made with Aurora Charter Oaks

nursing and social work staff to update records to include recent severely impaired vision.

◦ The supervising nurse agreed to request a referral to an ophthalmologist.

◦ Ms. Jones declined all services while in the hospital. ◦ She was not placed on medication and an attempt for a

temporary conservatorship was turned down. After four weeks in the hospital, she was discharged and

transported to The Place Welcome Center. ◦ We were notified late in the day on Friday. ◦ Arrangements were made for emergency housing in a motel. ◦ She was provided with food for the weekend

Case Study The following Monday, staff went to visit with Ms. Jones. Her room

was in disarray, there was food scattered all around the room and there were burn marks on her clothing and in the bedding, presumably from smoking in bed.

Ms. Jones was agitated, continuing to respond to voices, waving her arms as if trying to strike the clinician, and was not agreeable to, nor appropriate for supervised placement

A second hold was written, again with request for medical clearance, with a note to please address the cause of sudden blindness◦ She was cleared medically and hospitalized for two weeks at ITF. ◦ Once again was released when a temporary conservatorship was

turned down by the courts. ◦ Still unknown was the cause for her loss of vision or whether or not it

was treatable ◦ After four weeks in the hospital, she was discharged and transported to

The Place Welcome Center.

Case Study Upon discharge, Ms. Jones agreed to sign paperwork for placement, benefits, and

payee. She was placed in a unlicensed room and board◦ The plan was to place her on Life Support, a program that will pay for placement

when benefits are pending. When she arrived at the Room and Board she changed her mind and refused to

sign paperwork necessary to maintain her placement.◦ She continued to decline treatment of any kind and continued to exhibit

psychotic symptoms. ◦ She was however, amenable to bathing, washing her hair and brushing her teeth.

Her behavior appeared to be calmer and less aggressive. ◦ The Room and Board operator agreed to work with her to obtain necessary

signatures Two staff were assigned to visit separately each week, in order to further engage

Ms. Jones. Though the Room and Board operator was not receiving payment the operator

was hesitant to give notice. Unable to navigate the streets due to visual impairment, Ms Jones did not leave. She

did ask to contact her brother in Florida. She only granted verbal authorization for staff to talk with her brother as she is paranoid of signing anything.

Case Study March 15th, three and a half month post hospitalization, Ms. Jones agreed to sign

paperwork for placement, benefits, and payee. She also requested we contact her brother and signed a release to talk with him.

We learned from her brother that Ms. Jones did have a Masters Degree in Art. She had also studied Art abroad in Italy and France . She had returned to the states in her late 20’s, resided in Florida, where she established herself as an artist.

Ms. Jones moved in with a boyfriend and both became heavily involved in drugs. He overdosed in the apartment and died. ◦ She stayed with the body for a week before contacting the authorities.

According to her brother, in this same time frame, she underwent surgery for thyroid cancer and a benign tumor in her uterus. Her brother also reported that there were problems with the anesthesia and that he had been informed by the doctor that there was brain damage, possible permanent. It is unknown how severe

Her brother reported that Ms. Jones began experiencing symptoms of mental illness following these events. She was granted Social Security Disability, but eventually became homeless and monies were suspended when they were unable to locate her.

According to her brother, Ms. Jones has had: multiple crisis episodes with chronic symptoms, multiple involuntary hospitalizations, has been in Metro State Hospital, and several petitions for conservatorship were made without success.

What We Have Accomplished

On 3/15/17, after three months in placement and active involvement with S.M.A.R.T., Ms. Jones did sign paperwork to re-establish her Social Security Disability, payee paper work, and a rental agreement. This will allow for Life Support, which will secure her housing. Though she continues to experience paranoia and auditory hallucinations, her demeanor is much calmer and her personal hygiene is much improved. This has resulted in no contacts with police and no hospitalizations for the past three months.

Next Steps

Medical appointments - complete physical Ophthalmologist appointment Psychiatric appointment Involvement in therapy, either group or

individual Once stabilized, permanent housing

FSP Model vs. Medical Model Services are provided in the field as well as in the

office Emphasis is on engaging the high-risk consumer Treatment is based on client’s goals◦ Developed with client and CT input

Treatment often begins with basic needs (shelter, food, medical care)◦ Emphasis on housing stabilization first.

Visits with psychiatrist and medication treatment is encouraged but not required

Therapy, either group or individual, is available but not required

Please feel free to contact Priscilla with any questions you may have.

Priscilla BrunyProgram Coordinator

Geriatric Medicine Division P.Bruny@ruhealth.org

(951) 486-5623