Kaiser Telecare Program for Intensive Community Support Intensive Case Management Exclusively for Members within a Managed Care System

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1 Kaiser Telecare Program for Intensive Community Support Intensive Case Management Exclusively for Members within a Managed Care System 12-Month Customer Report, January to December, 2007 We exist to help people with mental impairments realize their full potential.

2 Kaiser Telecare Program for Intensive Community Support 2008 marks Telecare's 10th year of partnering with Kaiser Permanente! The Kaiser Telecare Program for Intensive Community Support (KPFICS) has been an integral part of Kaiser Permanente s behavioral health continuum of care since KPFICS is an intensive case management program specifically for Kaiser members, age 18 and over, in San Diego County, that are high-utilizers of acute inpatient services or are at risk for inpatient hospitalization. Many of these individuals are also dually diagnosed with co-occurring substance abuse disorders. The program is client-centered and client-driven. Clients set their own goals and determine what is important to them. Staff support the recovery process, assist clients to improve quality of life, and collaborate with Kaiser psychiatrists and clinical staff to ensure that clients are successfully engaged, making optimal use of available Kaiser services. KPFICS is unique among Kaiser s mental health programs in that services are provided in the community, at locations of the client s choice, resulting in strong partnerships and client/staff trust. Service Goals The program was established to support Kaiser in accomplishing the following: Reduce inpatient hospitalization Enhance access to community-based services Provide crisis intervention and support Support clients in strengthening life skills and achieving greater independence Expand housing options Promote education and vocational goals Major Accomplishments In 2007, KPFICS successfully: Reduced inpatient hospital days (down 967 days). Continued to successfully transition long-term clients to lower levels of care and other supports with few program readmissions. Continued to work with Kaiser administration to identify those members ready to transition. Met Kaiser goal of 24 discharges during the year. Although higher than in 2006, KPFICS continues to keep Sharp Mesa Vista PHP days well under 200 per year. Moving Forward The Kaiser-Telecare PFICS set a goal in July of 2007 to hold two Peer Advisory Groups in the fiscal year. Our initial meeting was held in September of We invited eight Kaiser Telecare clients to come as a group and exchange ideas and provide feedback about the services they receive from Telecare. Each of Telecare s Mental Health Rehabilitation Specialists as well as the Team Lead was there to listen, learn and help facilitate the proceedings. Clients readily enjoyed hearing each other s stories and learning about the various resources they have each learned to use. In general, Kaiser Telecare clients liked the program and the fact that program staff meet them in the community. They expressed appreciation for having access to program staff through regular weekly meetings and phone contact. Additionally, whether they use it or not, clients like knowing that the 24-hour support line is there for them. The Kaiser Telecare team will hold another Peer Advisory Group by May Acknowledgements Telecare would like to thank and acknowledge Dr. Dennis Cook, MD, EdD; and Linda Thornton, LCSW; Werner Spitzfaden, LCSW; and all staff of the Kaiser Psychiatry and Addiction Medicine Department for their support, partnership and contributions to the program s success. We look forward to many more years of successful collaboration in the support of individuals in recovery.

3 Demographics Enrollments/Disenrollments Enrolled Disenrolled Total members on 12/31/ Maximum enrollment Average census Length of Enrollment (Current Members) Average enrollment Ethnicity Caucasian % African American % Latino/Hispanic % Asian % Other % Total % Gender Male % Female % Total % Age % % % % Over % Primary Diagnosis Schizophrenia % Co-occuring disorders % Bipolar disorder % Depression % Other % Total % Axis II Borderline Personality Disorder % Personality Disorder NOS % Dual Diagnosis % Service Utilizations IMD (Alpine) Days Acute Hospital Days Acute Admissions Crisis Residential Days IOP Days Client Satisfaction 98% I felt safe to raise questions or complain 96% Staff believed I could change and recover 96% I liked the services I received 96% I would recommend this program to a friend or family 95% Staff respected my wishes about who is and is not to be given information about my treatment 93% Staff and I worked together to plan my treatment 93% Staff were willing to help as often as I felt it was necessary 93% I was able to get all the services I thought I needed Member Comments When Asked What They Would Like to See Changed About KPFICS I really don t see any need for changes. This program brings people who are so emotionally depressed... a chance to have someone come into their home to visit, to take an interest in and care about them. It s a real blessing. I would like my counselor to help me when I call the Crisis Line. Integrate more social events. Nothing, really. I think it is a very supportive program for people coming into, being in, or coming out of a crisis who need more one-on-one therapy.

4 Areas of Improvement: Multnomah Community Ability Scale This tool measures staffs perception of member improvement: Significant increases and improvement were noted by staff in following areas over the past two administrations: Mood abnormality, thought processes, independence in daily life, acceptance of illness, participation in meaningful activities, cooperation with medication plan and impulse control. KPFICS Services In 2007, the following services were provided by four full-time staff members including three mental health rehabilitation specialists and one team lead: Assistance navigating medical and psychiatric services provided by Kaiser physicians 24-hour crisis response from Telecare team staff via crisis phone line Case management and advocacy Transitional case management for Kaiser members who have lost their benefits Intervention to prevent and manage crises outside the hospital Substance abuse intervention and counseling Support/education of family and significant others Assistance in development of peer relationships Connection to self-help groups/community resources Assistance with entitlements Vocational services After Hours Crisis Calls 162 Number of after hours crisis calls recorded by team Clinical Outcomes Reduced acute psychiatric hospital days by 967 over baseline 1759 days (annualized using combined acute, Alpine, Crisis House and PHP days) Actual hospital days 614 (includes acute, Alpine, Crisis House, and PHP days) Reduced psychiatric hospital days by 55% (annualized using combined acute, Alpine, Crisis House and PHP days) 14% Improvement in Global Assessment of Function (GAF) scores for current members and those leaving the program Client responses to the California Quality of Life questionnaire said: They have increased their level of relaxation and recreation time Improved family relations Participate more in activities with others Improvement in their overall life satisfaction

5 Real-Life Success Stories Irene s Story: Irene (pseudonym) has been a member of the Telecare program on two different occasions. The first time she came in she initially had difficulty adhering to her medication, working on her personal goals, and with her ongoing methamphetamine drug use. Every day was a struggle to cope with her Bipolar I Disorder symptoms and her substance abuse. She relapsed and underwent treatment at Alpine Special Treatment Facility and Drug Rehab, and then she re-enrolled with Kaiser/Telecare over a year ago. She has been able to stay off drugs and alcohol ever since she came back into the program in Irene began addressing her substance abuse by adhering to her goals, medication, doctor appointments and therapy. With the support of her family she has been now sober for over two years. She has been slowly but steadily achieving all of her interpersonal and mental health recovery goals. Shortly after a year of sobriety, she moved out of her sober-living housing and married her long-time boyfriend, who has also been in recovery and sober for over three years. Irene believes that they have both been an inspiration and support for each other in their recovery and growth. Irene has turned her life around. She often reflects back on her struggles as a personal encouragement to continue improving her life. She continues to be more aware of her symptoms and is medication compliant. Telecare has been able to stand by her, providing her with support by advocating for her to her doctor, therapist and family, and encouraging her to continue adhering to medication, sober living, AA meetings and even personal leisure time. Irene now understands and appreciates the fact that her hard work and compliance to her recovery goals was possible by the availability of Telecare support and its Crisis Line. She now works part-time as a Peer Recovery Support Specialist with NAMI by doing presentations on substance abuse related issues and recovery, and hopes to be a positive influence and example of change for others to follow. She has often thanked the Telecare program and staff for supporting her through her change and evolution.

6 John s Story: John (pseudonym) has been enrolled in the Kaiser Telecare Program for Intensive Community Support for many years. He was initially referred to this program due to difficulties with maintaining stability in the community. He presented with chronic depression, difficulties with job stability, problems with substance abuse, financial stressors, housing issues, and limited social support. Over the years, John has worked closely with his Telecare counselors and has been able to remain successful in managing his psychiatric symptoms. John s Telecare counselors consulted with his psychiatrist and therapist regularly to help provide a more collaborative quality of care. John has established a strong rapport with his psychiatrist, gained insight and awareness of his psychiatric symptoms, learned coping skills to better manage his stress, and developed an understanding of the importance of medication compliance. With guidance and encouragement from his Telecare counselors, John has reconnected with his family and made new friends. He spends time with his family and friends regularly and states that they are very important in his life. When John first enrolled in this program, he struggled with living independently and was even homeless on occasion. His Telecare counselors helped him to find a living environment where he could receive additional structure and support with his psychiatric symptoms. John initially lived successfully in a sober living and recovery supported environment. His Telecare team worked very hard with John to help him better manage and reduce the harm related to his problems with substance abuse. Eventually, John created a goal for himself to live in his own apartment. John has been able to live successfully in his own apartment and maintained a job as a cashier for a fast food restaurant for three consecutive years. He recently started a new clerical position, which he states is a job that he always dreamed of having, but never thought it was really possible. He has been successful in working for this new employer for over one year now. John reports living a more meaningful life and feels that this program has helped him tremendously in improving his quality of life. Telecare Corporation 1080 Marina Village Parkway, Suite 100 Alameda, CA (510) / (510) (fax) (800) Kaiser PFICS 3250 Wing Street, Building C. San Diego, CA (619) (619) (fax) Telecare s Mission: We exist to help people with serious mental impairments realize their full potential

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