Discharge Plan: *INSURED BY 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 have been 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; 1/10 intake worker states the long term worker will be assigned tomorrow)
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 Ramsey County
-Disability Services intake worker Ramsey County
Case Descreption:
15-year-old female with a history of depression, anxiety, ADHD, PTSD, as well as some behavioral concern. Patient has exhausted several outpatient supports including school in a smaller setting, Childrens hospital, as well as Maplewood PHP, DBT, and engagement with MCRC, JDC and two other shelter placements. Third hospitalization this year.
Twin brother adopted from Ecuador at age 11. DD, operate at about 5-6 year old. No MA or waiver due to parent income. County case manager referred to MSOCS and CSS. Mom working with Kennedy Krieger. Barriers: no MA, waiver or declined due to DD or aggression. DC from Chileda due to behaviors.
Patient has had several disrupted placements over the past year including shelters and foster homes. Patient has extensive trauma history and was most recently at a shelter where they engaged in self harm by cutting and expressed passive SI. Patient was sent to the ED and was not allowed back to the shelter.
UPDATE: 9/7/23 – discharged to AMAS Inc (CADI group home)
UPDATE: 8/31/23 – Care conf tomorrow. Accepted by Sunset House, having zoom meeting with patient today to get to know him better before transition- waiting on them to get licensing.
UPDATE: 8/17/23 – Still in ED. Not able to go to Mille Lacs due to non-participation. There is a CADI group home willing to take him, working on licensing.
UPDATE 7/27 – had a video interview with Nexus Mille Lacs on 7/26, awaiting updates.
Previously MCR 1086: Discharged 6/15/23 to VonWald, returned ED 6/30. 14 year old with significant trauma history, ward of Hennepin County, recent placement at his request with young adult brother that was disrupted due to conflict. Briefly placed at Von Wald shelter but repeatedly eloped in an effort to reunite with his brother, and was brought to the ED. Calm overall except when relocated to a unit that required observation while in the restroom, then repeatedly escalated with verbal threats, closing himself in the bathroom, and hitting the walls. Had an interview with Nexus Mille Lacs on 7/26/23. He is familiar with Nexus Gerard and would feel comfortable there.
Update 7/27 Genesis Group Homes is pursuing an intake to potentially utilize crisis services.
16 year old adopted from Ecuador at age 8 (with twin brother with similar difficulties, as well as 2 other siblings without similar struggles), with ASD and intellectual disability, associated with a microduplication at chromosome 8p23.1, likely in-utero substance exposure, as well as early life neglect (living in an orphanage for much of his young life). Significant aggression difficulties that are becoming more unmanageable by family as he grows larger; unsuccessfully discharged from Chileda in November 2022. Family have financial resources and have purchased a second home for the boys and hired private caregivers in the evenings, but their income limits eligibility for MA and state-funded services. New behavior analyst started working with the family in March. May be on the MSOCS wait list. Currently on the wait list for inpatient care at Kennedy Krieger near Baltimore (brother previously had a good experience there).
