Children’s Mental Health Targeted Case Management – Page 4

PH-F17-3791

5/20/24: Patient discharged from inpatient and admitted to PCR.

5/8 update: Patient scheduled for admission to PrairieCare Residential on 5/20/24 at 10:00am.
5/6 update: Patient is currently awaiting an RTC bed through PrairieCare Residential in Maple Grove. Patient has been approved for 3rd pathway funding through Hennepin County. Due to patient behaviors seeming to increase, other options are being explored for aftercare as denials are a possibility. Parents do not feel safe with the patient coming home.

Discharge Plan:
Residential Treatment:
-PrairieCare Residential; intake 5/20/24 at 1000

Other RTC Referrals:
-Nexus Gerard; referral made
-North Homes; referral made, declined due to FAS and IQ
-Avanti Center for Girls; referral made, declined due to aggression and peer conflict

Outpatient Providers:
Establish CMHCM; opened with Soreya Jama through Hennepin County, 3rd pathway funding approved

Establish/Continue CTSS with Samira through Nexus FACTS
Continue Therapy with Mary Midler at Great Lakes Neurobehavioral Center in Edina (weekly)
Continue PCP with Dr. Megan Reilly at Partners in Pediatrics in Plymouth
Continue Psychiatry with Gerard Balan at Plymouth Psych Group
Continue IEP Case Management with Yvette Zeese at Wayzata High School
Continue Neurological Services with Dr. Catalfamo at Noral Neurological Clinic in Bloomington

ADMISSION NOTE: Patient was admitted due to acute safety concern and was unable to contract for safety at home. Pt was in PHP in the past and family was monitoring her 24/7 at home as instructed. Pt became irritated that she is constantly being watched and ended up having altercation with her mother because she was instructed by her mother to change outside of her bedroom because the mother was unable to see her. Pt ended up leaving and went to her grandmother’s house which is next door while mom followed her, pt went straight to the kitchen grabbed a knife and start threatening to stab herself. Mother was able to wrestle the knife out of her hands and called EMS. Pt has a history of depression, anxiety, epilepsy, and fetal alcohol syndrome.

PH-F16-3692

Update 5/09/24: Patient discharged from inpatient to home with outpatient supports in place while awaiting admission to RTC. Admission to Avanti RTC tentative 6/4/24

Update 5/08/24: Patient is accepted to Avanti Center for Girls RTC. Tentative admission date is 6/04/24.
Update 5/01/24: Patient is accepted to Avanti Center for Girls RTC. Estimated opening early-mid May. County funding approved for placement.
Update 4/24/24: Patient is accepted to Avanti Center for Girls RTC. Estimated opening early-mid May.

Patient is a 16-year-old female who presented to inpatient from ED due to increase in SI and suicide attempt. She has had 6+ psychiatric inpatient hospitalizations. She has had two residential 35/45-day evaluations as well as a history of participating in outpatient mental health services.

Discharge Plans:
RTC:
-Gerard (Referral sent & received, wait list out until September or later)
-North Homes (declined due to previous programming experience)
-Avanti Center for Girls (Accepted, opening early-mid May)

CMHCM: Carlton County

PH-F12-3437

Update 5/14/24: Patient discharged home to the care of her guardian with outpatient supports to bridge Day Treatment.

Update 5/10/24: Patient tentatively scheduled to discharge home on 5/14/24, with outpatient supports to bridge PHP at Amberwing.

Update 5/6/24: Douglas County CPS is navigating PHP and Day Treatment with the guardian for aftercare. PHP waitlist is approximately 3 weeks and guardian still needs to obtain insurance coverage. Douglas County CPS will be closing out their case on 5/10/24 due to a lack of immediate safety concerns as evidenced by the guardian willing to take the patient home.

Update 4/30/24: Guardian is making statements of wanting the patient to return home. Patient was declined from foster placements in Wisconsin, and family placement is not an option either. Douglas County, WI, CPS, working with the guardian on a transition plan home, including Day Treatment and Outpatient Therapy. Patient remains at the hospital.

Update 4/24/24: Parent still not willing/able to take pt home. County involved and navigating alternative living arrangement/placement. DC rec is PHP.

Update 4/17/24: Parent still not willing/able to take pt home. County involved and navigating alternative living arrangement/placement. DC rec is PHP.

Update 4/3/24: Parent still not willing/able to take pt home. County involved. DC rec is PHP, openings available at PC PHP when patient is able.

Patient was admitted from Essentia Health in Duluth after attempting to run away from home. Pt has conflict w/ dad & has made HI statements toward him (burning him, switching meds out so he will OD). Pt also has a Hx of inappropriate sexual behavior with older men & on the internet.

Historically, patient lived with extended relatives for the first 11 years of her life due to mitigating circumstances that did not allow biological parents to meet her needs. Patient then went to live with her biological mom and was then sent to live with her dad, as mom was unable to meet patient needs. Patient has been with dad for about 1 month now, and he has indicated that he cannot meet her needs either, and declines for the patient to return home.

Discharge Plan:
PrairieCare Recommends:
Establish PHP; county coordinating with Amberwing, estimated 3-week waitlist

Establish Individual and Family Therapy:
-Insight Counseling in Duluth; referral made
-SOAR Services in Superior, WI; referral made
-Nystrom and Associates in Duluth; referral made

Establish PCP
Establish CMHCM (Open with Kalley Rustad at Douglas County CPS for long-term supports, closing case 5/10)
Establish CLTS (Referral made to Douglas County, CPS also coordinating)

Estimated length of stay:
Seven to ten treatment days; patient is medically ready for discharge; pending Douglas County, WI, establishing aftercare with the guardian. Guardian is now willing to take the patient home.

PH-F17-3426

Update 4/26/24: Patient discharged from inpatient on 4/26/24 and admitted to VOA Bar None Shelter Plus.

Update 4/24/24: Patient has been accepted to VOA Bar None ShelterPlus Program with admission scheduled for Friday 4/26.

Update 4/17/24: Updated clinical/referral resubmitted to Anthony Lewis Center for acceptance consideration.

Update 4/4/24 – County is working towards referrals to group home settings at North Crow Group Home – Cokato and Annadale – Village Ranch while awaiting appropriate RTC placement. Anthony Lewis Center tentatively reconsidering the referral if patient does not need a medical setting.

16-year-old female presenting to PrairieCare Inpatient Hospital. Patient is diagnosed with RAD, depression, anxiety, ADHD, PTSD, polysubstance use emerging personality traits. Patient has had multiple hospitalizations, utilizes outpatient resources and completed DBT, one RTC placement, been in a group home, and is currently in foster placement. Patient’s current foster placement is unwilling to have patient return. Patient is currently under guardianship of Wright County.

Discharge Plan:
Dual Diagnosis RTC:
– MHealth Fairview-Maplewood (Referrals submitted: Update 3.13.24 – Cannot be approved until housing is confirmed)
– Wings (Referrals submitted Denied 3.15.24 due to mental health needs exceeded current program capabilities)

Current Providers:
– Individual Therapy
– Chemical Dependency Counseling
– Medication Management
– CMHCM with Wright County

PH-F14-3695

Update 4/23/24: Patient discharged from inpatient on 4/23/24. Patient scheduled to begin PrairieCare PHP on 4/24/24 while continuing to pursue Group Home placement as recommended by the county.

Patient is a 14-year-old female presenting to inpatient on 03/19/2024 from the ED due to running away from shelter placement. Patient has a history of participating in PHP two times, DBT, ongoing outpatient mental health services, and being in shelter placement.

Discharge Plan:
RTC:
-North Homes (on the wait list)

CD-RTC: Referrals submitted/considered for the following facilities:
-Hazelden (Pt’s insurance not accepted in Minnesota)
-Rogers (Declined due to elopement risk)
-M Health Fairview (Declined due to elopement risk)
-Anthony Louis Center (referral sent 03/27/24)

Group Home Placement (as recommended by JST/county):
-Little Sands (Referral submitted by CM; declined d/t LON)
-Village Ranch (Referral submitted by CM; reviewing 4/10; pending additional review on 4/17)
-North Homes (Pt is on the waitlist for RTC; pt is not eligible for their group home due to age)

Existing Outpatient Providers:
CHMCH: Hennepin County
Psychiatry: Nystrom & Associates

PH-F16-3669

Update 4/29/24: Patient discharged from Inpatient on 04/19/24 to wraparound outpatient mental health services while continuing to pursue RTC options.

Patient admitted to PrairieCare Inpatient Hospital 3/19/24 from the ED following increased thoughts of suicide with a plan. Pt has had previous IP stays at PrairieCare, Mayo Clinic, Riverside and Prairie St. John’s. Pt had a previous residential stay at Gerard. RTC has been pursued and funding has been approved through Dakota County although currently pt has been declined by viable in-state options. Level 6/PRTF programming is also being explored.

Referral is currently pending at Bar None Haven. Referral also made to Acadia to explore out of state options. Referral will be made to Nexus East Bethel PRTF as CMHCM is willing to help pt switch to straight MA if Nexus is able to accept. Patient is medically ready for discharge and is pursuing an interim plan of dcing home with wrap around services while awaiting placement.

RTC (CASII LEVEL 5) (funding approved, in QI process):
-Acadia (referral sent to explore out of state options)
-Avanti (declined)
-PCR (declined)
-North Homes (declined)
-Gerard (declined)
-Northwoods (waitlist 2+ years, so not a viable option)
-Newport (Insurance not accepted, so not a viable option)
-Nexus Mille Lacs (only accepts biologically male patients, so not a viable option)

PRTF/CASII LEVEL 6
-Bar None Haven (referral pending)
-Nexus East Bethel (referral to be sent, CMHCM able to help switch to straight MA if accepted)
-Grafton (requires ID dx)
-Leo Hoffman (only accepts biologically male patients)
-Northwoods (2+ year WL)

PH-M17-3533

4/10/24: Patient discharged from inpatient on 4/10/24 and admitted to Gerard RTC.

4/3/24 Update: Accepted at Gerard, parent and pt excited for Gerard RTC. However, pt’s parent not in agreement to VPA for the purpose of RTC funding, thus, missed admission. Parent working with county to make some edits on VPA and then pt will admit to Gerard RTC on 4/10/24.

Case Description: 17 y/o male w/ hx of MDD, GAD, ODD, PTSD, polysubstance abuse( in remission), multiple suicide attempts currently presenting due to SI w/ plan to hang self. Patient has been struggling w/ worsening symptoms of depression due to mothers upcoming death anniversary coming up.

Insurance is BCBS MN PMAP

Discharge Plan: RTC:
– Gerard (Referral submitted by IT, Tentative admit Weds 4/3 at 1300 pending county funding; 3.21.24 County funding approved but adoptive parent not in agreement to “sign custody to the county” for the purpose of RTC funding, thus, missed admission, next admission scheduled for 4/10/24)
– North Homes (Referral submitted by IT)
– Nexus Mille Lacs (Referral submitted)
– Village Ranch (Referral submitted)

Current Providers:
– Individual Therapy at Rooted Counseling in Moorhead
– Primary Care with Sanford Children’s Southwest Clinic
– Medication Management at Midwest Mental Health
– Group Home Case Management at Valley-Lake Boys Home
– Probation at Clay County
– Group Therapy through Valley-Lake Boys Home
– CMHCM at Clay County

PH-F12-3422

Update 4/15/24: Patient discharged from inpatient on 4/15/24 to home with outpatient services while awaiting level 6 RTC/PRTF placement.

Update 4/3/24: Bar None Haven (Referral submitted, Denied 3.22.24), Northwood Children’s (Referral submitted, On waitlist), Grafton (Referral submitted), Nexus East Bethel (Referral submitted). County also working on referral for MITH program (MN Intensive Therapeutic Homes). MN Choice Assessment done.

12-year-old female with DMDD and RAD presenting to PrairieCare Inpatient Hospital. Patient has had multiple psychiatric hospitalizations, 2 RTC placements and 2 JDC placements.

Discharge Plan:
Locked Level 6 RTC – Bar None Haven (Referral submitted)

Current Providers:
CMCHM at Beltrami County
Individual Therapy
Medication Management
Wavier Case Management Services through Beltrami County (In process)

PH-F14-3375

Update 4/12/24: Patient discharged from inpatient to home, while waiting for RTC admission.

Update 4/11/24: Patient scheduled to discharge from inpatient on 4/12/24, stepping down to outpatient supports, while waiting for RTC. Intake process is moving forward at North Homes RTC, with potential admission on 4/18 or 4/19.

Update 4/4/24: Patient has been accepted at North Homes RTC with a potential admission mid-April. Patient has now been assigned a CMHCM, waiting on screening for county funding.

Update 3/21/4: Pt is under review for acceptance at North Homes pending county funding, Waiting assigned CMHCM, parent is currently doing the intake process at the county to get a CMHCM for the Juvenile Screening.

Patient is a 14-year-old transgender male presenting at PrairieCare’s inpatient hospital. Patient presented to Sanford Bemidji Medical Center on 3/4 when parents brought them. That night while parents were away from home patient was aggressive toward sister. Family called crisis and were directed to bring to ED for evaluation. This is after a similar event last week where patient attempted to stab sister with a knife and father had to intervene.

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