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.
Update 5/23/24: Patient accepted to Heartland Girls Ranch with scheduled admission Wednesday 5/29 – county funding was approved.
Patient presents to inpatient from the ED due to an increase in SI. This is her third psychiatric inpatient hospitalization. She has done PHP twice and engaged in outpatient mental health services.
Discharge Plans –
RTC: (JST funding meeting on 5/17)
-Avanti Center for Girls (referral under review)
-Nexus Gerard (referral under secondary review)
-North Homes (pt is on waitlist – 4-6 weeks out)
-Village Ranch- Annandale (pt is on waitlist – end of June)
-Heartland Girls Ranch (referral under review)
Continue with established outpatient providers:
– Therapist: Mayo Clinic Health Systems Austin
– Family Therapist: Albert Lea
– Medication Management: Mayo Clinic Austin
– Case Management: Freeborn County
– Occupational Therapist: Mayo Clinic Rochester
Came to ED on 5/09/24 via police after increase in suicidal ideation. Pt reports being bullied at her group home, was at Divine. Divine is not allowing pt to return. No physical aggression, continues to have suicidal ideation without attempts. County is working on Group Home placements- wait listed at North Crow, has explored shelters, foster cares- denied by those. Referral was made for MCCP crisis bed and working on hotel crisis respite referrals, as well as CRS homes.
Patient was placed at Passageways shelter for 1 month. Near the end of that time, patient became upset that time was ending and would transition back to home. Is not recommended for IP MH care and needs a d/c plan from the ED. Several referrals to shelters have been made.
Pt came to ED after ongoing behavioral concerns at home with guardian/grandmother, physical and verbal aggression, and threats. Previously discharged from CADI GH for physical aggression, went to JDC for that but was released after a rule 20. Declined by North Homes, Northwoods, and CABHH. A CADI home in Duluth that may be an option.
Patient came to our ED after a physical altercation with another resident at Aspen House, is not able to return there. Has been to multiple shelters and RTCs in the past, success with some of these programs. County is looking at other shelters as well as waiting for a previous provider to send recommendation for PRTF. Has been denied by VOA Bar None- all programs, can’t return to Von Wald shelters, discharged previously from Prairie Care, and can’t return to Aspen. 3rd time in the ED in a month.
5/2 Update: Client has been discharged home twice (contracted for safety) and returned within 24 hours due to attempting to run into traffic. Has been approved for PRTF and referrals have been made to Northwoods (2 year waitlist) and Grafton. Inpt behavioral health is not an option due to previous stays. CABHH referral pending and they are attempting to admit pt when they have discharges.
Presented with attempted suicide on 4/4 (superficial laceration on arm). Also attempted to overdose on Lithium on 4/2. Appears to have a developmental delay. Denied at multiple inpt facilities due to previous aggression. Turns 18 in July.
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.
Came to our ED after physical altercation with another resident at Prairie Care Residential, can not return there. History of multiple inpatient admissions and PHP. Grandma is guardian and pt is unable to return there due to another child living there that pt can’t be placed with. CMH worker has made multiple RTC referrals and patient has been denied by almost all. Currently looking into a RTC out of state in TN, however this provider does not have a contract so would be a long time before this placement was obtained. Also looking at shelter options.
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)
