Mental Health Collaboration Hubworking one-on-one with a psychotherapist.
Psychiatric history of PTSD, schizophrenia, and bipolar diagnoses. Patient has two prior inpatient psychiatric hospitalizations (Aug 2024 and Sept 2024). Patient presented to PrairieCare through ED, following and manic-like behaviors, delusions, and aggression during intake with Anthony Louis Center.
Initial treatment recommendation was to discharge patient to Anthony Louis Center, however current clinical indication is for longer term mental health care support.
Previously diagnosed with depression, anxiety, PTSD . Numerous admissions to psychiatric hospitals and Emergency Departments because of suicidal ideation, suicide attempts and self-injury. History of CPS, county mental health case managers and crisis services. Plan to jump off a bridge. Self injury has included cutting, scratching, burning and head banging.
Patient and family moved to Minnesota about a year ago. She has been to acute inpatient MH 3 times since as well as 1.5 months of residential treatment and most recently spent 4 months in juvenile detention center. Court ordered to return home and await a long term placement option. She had been home for 3 days when LE was contacted due to her behavior of kicking the family dog and not obeying the directions of her parents. She has a long standing history of homicidal ideation towards her parents and siblings. She also has self harm history of hitting her head against the wall.
Recommendation is for QRTP or PRTF – either could potentially meet the needs of this patient and limited treatment centers available due to patient’s age. Patient is currently in psychiatric inpatient hospitalization.
Patient is an 8-year-old female. Patient presented to inpatient from the ED due to increase in unsafe and risk-taking behaviors. This is her fourth inpatient hospitalization; one in 2022 and three in 2024. Patient has attended day treatment twice and participated in outpatient psychotherapy and medication management.
Discharge Plan:
PRTF/QRTP: (county funding approved for QRTP)
– Grafton (declined due to not meeting criteria)
– Northwood (referrals submitted 9/9, on waitlist 9/23 – awaiting update on admission timelines)
– Gerard (unable to accept due to age)
– Avanti (unable to accept due to age)
– Bar None Haven (unable to accept due to age)
– North Homes (unable to accept due to age)
– Heartland Girls Ranch (unable to accept due to age
Continue with following outside providers:
– Therapy/Therapist: Solutions Behavioral Healthcare Professionals
– Primary Care Provider: Sanford Health
– Medication Management: Solutions Behavioral Healthcare Professionals
– Case Management: Solutions Behavioral Healthcare Professionals
– Occupational Therapy: Beyond Boundaries Therapy and Wellness
Pursuing QRTP – patient is currently in psychiatric inpatient hospitalization.
Patient is a 15-year-old male. He presented to inpatient via ED due to increased SI and SIB. He has three historical inpatient hospitalizations, has done DBT and outpatient psychotherapy services, and most recently was at Newport RTC – although was discharged early due to aggression and property destruction.
From an acute psychiatric standpoint, youth is safe to discharge form inpatient care and receive services in the community prior to admission to QRTP. He has made significant progress on treatment goals during hospitalization.
Discharge Plan:
Referrals sent to the following residentials:
– Omegon Ascend (Reviewing, no current waitlist)
– Nexus Gerard (Reviewing, waitlist about a week)
– Nexus Mille Lacs (Reviewing, Current waitlist 2 months)
– North Homes (Declined d/t hx of aggression towards others)
– Northwood (Received, 6-9 month waitlist)
– PrairieCare Residential (Reviewing, 2-3 week waitlist)
Alternative Placement through Wright County:
-Wright County unable to identify alternative placement as of 9/24/24
Plan to bridge until residential:
PrairieCare PHP at MOB (unable to pursue establishing care at this time due to pt continuing to be hospitalized)
Continue with established outpatient providers:
Individual Therapist- Bridging Hope Buffalo
Medication Management- LifeSpan Mental Health Monticello
PCP- HealthPartners Elk River
CMHCM- Wright County
Neuropsych Testing- Clary Clinic St. Cloud
6/4/24 admission note: Patient is a 14-year-old female admitted to PrairieCare for suicidal ideation and self-injurious behaviors. Patient was recently discharged from a 45-days residential program. 2 days post discharge patient began threatening to kill her mom and reported SI with plan to jump in front of a car. Pt has a history of recurrent major depression SI, and SIB.
Discharge Plan:
SMRT-Hennepin County (7/8)
PRTF/QRTP – Level 6:
-Grafton (declined due to current milieu at facility)
-Nexus East Bethel (unable to refer due to insurance)
-Leo A Hoffman (unable to refer due to males only)
-Bar None Haven (SW to send referral once consent obtained)
-Northwood (SW to send referral once consent obtained)
-The Youth Village in Tennessee (guardian pursuing)
-Acadia Healthcare (SW to send referral once consent obtained)
Current Providers-
Therapy- Paula Ocampo at Lake Country Associates
EMDR therapy-Tiffany Rundquist, Sanford Health Bemidji
Pediatric Neurology- Dr. Ilgarli, Essentia Health
Psychiatry- Daniel Janiczak, MD and Kayla Scheneit, MD- Sandford Bemidji
CMHCM- Erika Kjellberg, Hubbard County
CTSS- Megan Berg, Hubbard County
EMPATH at Bemidji Sanford 2 times/week
Patient was brought to ED after making suicidal and homicidal statements during his psychiatric medication appointment. He was evaluated and inpatient psychiatric stabilization was recommended. While in the ED he has been calm and cooperative. Denying suicidal ideation or Homicidal ideation at this time. He does recognize that he has been dysregulated and struggling to find effective coping skills. Recent increase in conflict at home. Has been engaging in self-harm. Mom does not feel safe having him in the home at this time.
16 year old female who was brought in by EMS in 4-point restraints after being restrained by PD trying to enter river to “drown herself”. Patient argued with her mother just before she threatened to “drown herself in the river;” destruction of house/property per mother’s report. Patient admits to past similar behaviors and has multiple MH hospitalizations on record.
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.
Update 4/25/25: Patient discharged from inpatient to Willow Trails Group Home on 4/25.
Update 4/24/24: Patient is medically ready for discharge from inpatient. Tentative admission to Willow Trails Group Home on 4/25.
Update 4/18/24: Patient is medically ready for discharge from inpatient. County is their guardian. County is working on finding foster care/group home placement. Patient has been denied at Village Ranch, is being reviewed at Port Place, Hunter’s Place, and Anoka County Juvenile Center.
Patient presented to the ED on 03/15/2024 after making suicidal statements while at school. Patient noted they have been being bullied, which contributed to the increased in suicidal ideation. Patient denied having a plan to complete suicide but was experiencing passive suicidal ideation and indicated that they would “probably do something with cutting.” The school contacted law enforcement and patient was transported to the ED for further mental health evaluation. Patient was unable to contrast for safety, resulting in them being transported via non-emergent transportation to PrairieCare for short-term stabilization.
Patient is under guardianship of Ottertail County at this time. Placement is being pursued by the county to either a Group Home or Foster Home.
Discharge Plan:
Continue care with existing outpatient providers:
-Individual therapy, PCP and Psychiatry at Behavioral Health in Badger, MN
Patient is medically ready for discharge and is awaiting placement in an appropriate group home/foster home, as identified by the county.