Ancillary Support Service: Children's Mental Health Targeted Case Management

Children’s Mental Health Targeted Case Management involves coordinating and managing mental health services for children and youth to ensure they receive appropriate care and support.

PH-F10-2765

Update 2/22/224- Admission to Grafton tentatively scheduled 2/28/24, can discharge interim pending availability.
Update 2/15/24- waiting admission to Grafton end of Feb- date pending- can discharge home interim, pending availability.
Pt is medically cleared for discharge- parents informed county they need to pursue crisis respite for patient.

Discharge Plan:
Residential treatment referrals-
Grafton PRTF (Accepted, next opening tentative end of February)
Northwood Children’s (Referral not sent d/t insurance)
Nexus-East Bethel (Denied d/t not in 6th grade)
Nexus-Gerard (Denied d/t functioning for programming)
Avanti Center (Referral not sent d/t patient’s age)
VOA-Bar None (Referral not sent d/t patient’s age)
Heartland Girls’ Ranch (Referral not sent d/t patient’s age)
Nexus-Mille Lacs (Referral not sent d/t male only programming)
North Homes (Referral not sent d/t patient’s age)
Newport Academy (Referral not sent d/t patient’s age and insurance)
PrairieCare Residential (Referral not sent d/t insurance)
Village Ranch (Referral not sent d/t patient’s age)
Northwest Passage (Referral not sent d/t patient’s age)
Dakota Boys & Girls Ranch (Referral not sent d/t not ND resident)
Rogers Behavioral Health (Referral not sent d/t insurance)

Plan to bridge until residential availability:
Cradle of Love (Accepted, pending county funding)
Northwood Children’s Shelter (CM placing referral)
Kindred Care (CM placing referral)
MCCP Crisis Respite (CADI CM placing referral)
Trauma focused/attachment therapy (Referrals to be placed by CM)

Continue with established outpatient providers:
Ramsey County CADI- (Shakir Consulting Services)
Ramsey County CMHCM- B
PCP- (Entira Vadnais Heights)
OT- Fairview
CTSS- (Nystrom & Associates)
PCA/companion care 3x/week

PH-M15-3171

Updated 2/22/24: DC Fri 2/23 to Nexus Mille Lacs RTC (County and Nexus recommending PRTF for long term tx). DC pending communication with guardians, have not had a response from them the whole hospitalization.
Update 2/16/24: Nexus Mille Lacs RTC is recommending PRTF level of care for patient. Kanabec County is in support of recommendation and plans to being the referral process.

Case Description:
15-year-old female identifying patient with a history of depression, anxiety, RAD, PTSD, ADHD, and ODD. Patient has been in out of home treatment settings for 3 years. Patient was at an unknown treatment facility and was discharged due to its closing, Northwood Children’s Services PRTF and most recently has been at Nexus Mille Lacs RTC since October 2022. Patient has a history of three inpatient hospitalizations.

Current services:
CMHCM: Kanabec County
RTC: Nexus Mille Lacs

CH-M9-2986

2/15/24/ update. Adjusted meds, doing better. Referring him to CABS, Grafton

Patient admitted to unit after ER boarding within the ER for an extended period as mom didn’t feel safe with him returning home. He has a chronic history of extreme emotional dysregulation with acute worsening since moving to the unit & significant head banging and aggression towards himself and others. He has a history of trauma that is likely impacting his presentation.

PH-F15-2886

Update 2/15/24: DC 2/18 to Gerard on 2/19
Discharge Plan: *Insurance is UCARE MN PMAP * County funding approved 1/30/24*

Residential Treatment – Referrals have been sent to the following facilities- pt is accepted at two- waiting county funding and then admission.
-Avanti (Referral submitted 10/26, DECLINED)
-Gerard Academy (Referral submitted 10/26; Accepted, estimated admission around 2/11)
-North Homes (ACCEPTED; openings in March/April)
-PrairieCare Residential could consider pt in interim should county approve funding

PRTF – Referrals to be sent to the following facilities:
-Grafton (Referral submitted 10/23; pt does not meet exclusionary criteria)
-Nexus East Bethel (Referral sent; only accepting pt’s with MA insurance at this time; will refer once County confirms MA insurance)

Outpatient Services:
Establish CMHCM through Ramsey County (Referral submitted 10/23; intake worker confirmed on 1/10 that a long term worker would be assigned next day, now assigned to Clues- they are completing a full intake for CMHCM now, and working on setting up JST meeting with Ramsey County)

Continue existing outpatient services:
-Therapy/Therapist: Minnesota Mental Health Clinic in Woodbury
-Prescriber/Medication Management: Nystrom & Associates
-MCRC Runaway Intervention Program at Children’s
-PO Ari Tresselt Ramsey County
-Disability Services intake worker: Ramsey County

Case Description
15-year-old female with a history of depression, anxiety, ADHD, PTSD, as well as some behavioral concerns. Pt has had three hospitalizations in the past year, has done PHP, JDC, outpatient.

PH-F13-2494

Primary Recommendation – RTC
-Nexus Gerard, accepted, admission 2/9 at 1000

Other RTC referrals:
-Avanti, declined
-North Homes, declined
-PrairieCare Residential, declined due to aggression
-Northwoods, referral made, declined for RTC

Out-of-State:
-Northwest Passages (Prairieview), county made referral, waitlist 2-4 months
-Lad Lake in Wisconsin, county made referral
-Youth Villages in Memphis; county made referral, reviewing
-Lava Heights in Utah; county made referral
-Falcon Ridge in Utah; county made referral
-Newport News in Virginia; county made referral
-Summit Oaks in South Dakota, county made referral, declined
-Provo Canyon in Utah; county made referral, declined
-Rogers, Hennepin County does not contract/won’t provide funding

Due to declines from QRTP, exploring PRTF options:
-Nexus East Bethel; referral made, not covered by insurance, potential to switch insurance, reviewing
-Northwoods; referral made, waitlist 2+ years

Bridge to RTC/PRTF; if warranted:
Establish CMHCM (Assigned to Kimberly Trembley through Hennepin County, 612-743-1549, waiting for QI approval for funding)
Establish PHP (SW to reschedule if/when appropriate)

Other Referrals Made:
Acadia Treatment Placement Specialists; referral made

Outpatient Recommendations:
Establish Individual Therapy
Establish Family Therapy
Continue PCP at Indian Health Board in Minneapolis

INSURED BY PRIME WEST MA

Presenting Problems: Experiencing school stressors, family dynamic changes, depression, mood lability, SI via ingestion.

AH-F15-2953

Presented to the ED for suicidal ideation. Boarded in the ED and attempts were made to safety plan with family but family refused to take patient home. Pt has an extensive history of running away, threatening others, suicidal ideation and there have been concerns (not proven) about patient taking advantage of vulnerable peers and children. Patient was admitted to ANW in early 2023 for 68 days. RTC was recommended but patient was declined from programs in MN and nationwide. Family was resistant to taking patient home but eventually patient discharged home.

PH-F17-2993

Discharged to a friends house 2/2/24
Seeking safe living placement for youth ASAP
Patient is a 17 year old Caucasian female with a history of depression, anxiety, and PTSD. Admitted for SI/SIB related to school stress.
Ukraine Refugee and has been self sustaining since arriving in America. Patient was residing in Duluth with a roommate and roommate will not have patient live with her anymore. Patient does not have any contact with family. Trauma from war in Ukraine.
She has a therapist and psychiatrist in Duluth- will arrange to where she is living. Has completed PHP twice in the past. Pt wants to live in the Twin Cities Metro for access to more resources .Insured by UBH MA plan.

*Barrier to Discharge is housing:
The Bridge for Youth (Referral made, declined due to recent suicidal ideation)
Aspen House (Referral made, pending response)
Hope House (Contacted, no available bed at this time)
Brittany’s Place (Referral made, call at noon to review patient)
Von Wald Shelter (Referral made, pending response)
Life House (Contacted, waiting response)
Hennepin County Front Door (Contacted, they directed to call Homeless shelter, thus unable to help with housing/shelter resources)
Lutheran Social Services (Contacted, no available bed at this time)
UMD Campus Housing (Contacted campus housing, they don’t have campus housing for PSEO students)

AH-M15-2038

UPATE: 1/18/24: Still inpatient. May be going to crisis programming in the near future, but no date yet.
UPDATE 11-15-2023: Still inpatient 1:1 staffing, strict behavior plan.
Patient is a 15 yo M with a past psychiatric history of RAD, PTSD, and ADHD as well as unspecified mood disorder (MDD vs DMDD), spells of trembling, and unspecified anxiety disorder, mostly documented as GAD. Multiple previous inpatient admissions, most recently Feb 2023. Has had numerous ED visits since 02/2023 for aggression. He has a psychosocial history of early parental loss, institutional care, neglect, and profound physical and sexual abuse while living in an orphanage in Ghana following the death of his biological mother in child birth. He was adopted when he was seven years old. Since that time, he has struggled with physically aggressive behavior, typically triggered by losing control of situations by not getting what he wants, being challenged, etc., assaulting both parents and endangering siblings. He can also become agitated and engage in aggression and property damage at the school. When he is not aggressive, however, he presents as extremely polite, pleasant, playful, and affectionate, and he does not struggle with chronic irritability or agitation. His family has worked to keep him in the home and community by maintaining two residences, with father caring for him in a rental and his mother caring for his sibling in their family home for safety over the past three years. He has had numerous inpatient stays, crisis placement, shelter, and residential stays as well as outpatient psychiatric and counseling services in clinic and in the home. Still, his behaviors remain persistently dangerous, culminating in the sexual assault of his father on 10/21/23.
Reach out to Heather Hanson, Social Worker at Abbott with questions or possible matches. She can be reached at 612-863-8569 and/or heather.hanson2@allina.com

CH-F15-2882

Patient presented to the ER after 3 other ER visits from outside ER for physical concerns that were determined to be panic symptoms verses a physical abnormality. Patient has a chronic history of mood and behavioral dysregulation, self-harm, multiple suicide attempts, truancy, and parent child relationship difficulties. She has a history of trauma in the form of witnessing domestic abuse, physical abuse, possible sexual abuse, and the death of her dad due to an OD 4-5 years ago. She has had 2 inpatient hospitalizations along with 2 PHP admissions with little benefit and participation. Mom struggles with following through on recommendations and struggles with alcohol/substance use. A child protection report was filed last year and she moved in to her neighbors though this is no longer an option. She denies any passive or active suicide ideation, plan, or intent. Inpatient hospitalization is not recommended. Mom is not willing to bring her back home at this time due to disruption in the home.

PH-F15-2859

Discharge Plan: *Insurance is BCBS MN PMAP
Residential Treatment – Referrals have been sent to the following facilities:
-Avanti (Referral submitted 10/26, DECLINED)
-Gerard Academy (Referral submitted 10/26; Update received 12/14: Unable to admit due to elopement risk but otherwise approved, will leave on list to review level of risk moving forward; currently under re-review)
-North Homes (ACCEPTED; County funding needed; openings in March/April)

PRTF – Referrals to be sent to the following facilities:
-Grafton (Referral submitted 10/23; pt does not meet exclusionary criteria)
-Nexus East Bethel (Referral sent; only accepting pt’s with MA insurance at this time; will refer once County confirms MA insurance)

Outpatient Services:
Establish CMHCM through Ramsey County (Referral submitted 10/23; intake worker confirmed on 1/10 that a long term worker would be assigned next day)

Continue existing outpatient services:
-Therapy/Therapist: Minnesota Mental Health Clinic in Woodbury
-Prescriber/Medication Management: Nystrom & Associates
-MCRC Runaway Intervention Program at Children’s
-PO Ari Tresselt Ramsey County
-Disability Services intake worker: Ramsey County

Case Description
15-year-old female with a history of depression, anxiety, ADHD, PTSD, as well as some behavioral concerns. Pt has had three hospitalizations in the past year, has done PHP, JDC, outpatient.