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Adults living with serious mental illness die 25 years
earlier than other Americans due largely due
to treatable medical conditions.
(Manderscheid et al. 2007)
Katherine T. O’Hara, RN, MPH, CHESMary McLaughlin, RN, BSN, MSPamela Jackson-Malik, RN, PhD, MBAAlan Lorry, BS, RPHBeverly Velasquez, MSW, LSW
Philadelphia Veterans Affairs Medical Center, Philadelphia, Pa.
Case Management Team
It is essential to the Model to
have both a Registered Nurse and a Social
Worker (MSW)
Supermarket Model Concept
Identify Population
Persons with Serious Mental IllnessComplex Barriers to Care
Use assessment to identify
barriers to care
Needs AssessmentMedicalPsychiatricSocialFinancialLegalSubstance Use
Identify Resources
ProvidersFacilities
Medical and Mental Health Evaluation
Review current medication ordersEvaluate adherenceEvaluate system of delivery
Who gives medicationsHow are refills and re-orders processed
Verify address and update as indicated
Identify Pharmacy responsible for service
Medical and Mental Health Evaluation
Verify assignment of medical and mental
health providers Review pattern of scheduled appointments
Review pattern of attendanceFacilitate evaluation in a timely manner as indicated
Review history for violence, sexual misconduct, Megans Law Registration
Functional Evaluation
Level of judgmentMoney managementPublic TransportationNutritional statusMeal planningCooking
Functional Evaluation
Meal planningShopping for foodWearing appropriate clothesWearing appropriate shoesClothes shoppingSelf management of medications
Social EvaluationLiving environment
Safety factorsFreedom from abuse
(physical/psychological)Adequate supervision for level of care
Medications, appointments, meals, clothing, spending allowance
Fire and hazardsFamily/community supportHistory of living situations
Multiple moves versus stable environment
Financial EvaluationSource of income
Check for multiple sourcesCheck for presence of financial guardian/fiduciary
Supplemental income by family/friends
Eligibility for increased benefits
Financial fraud or abuse
Financial EvaluationPattern of spending
Amount of debtCheck for money owed to credit cards /loan sharks
Money borrowed from friends/familyHow far into the month do funds last
Check for gambling patterns and addictive behaviorLottery tickets, off track betting, sports betting, numbers
Legal Evaluation
Outstanding warrantsProbationParolePending court cases
Level of offenseOutstanding fines and legal feesLegal representationIs case in regular or mental health court
Substance Use Evaluation
Substance(s) of choiceHistory of usePattern of useLevel of interference in daily activitiesHistory of program attendance
Primary Intervention
If the individual is determined to be a danger to themselves or others, and does not agree to hospitalization an involuntary commitment needs to be
initiatedMedical
Life threatening conditionInability to provide basic needs for life
Mental HealthSuicide or Homicidal ideation or action
Based on evaluation
It is difficult to place an individual who is not stabilized on medications
SheltersFull financial Support
No funds availableHigh risk environment
Have data base of all shelters in the area specifying size and support level
Seek out smaller shelters with capacity of 10 to 20
Identify day programs for the homeless to offer structure and added assistance
Shelters are not a permanent placement. They are temporary until funds can be established or a housing program identified.
Boarding Homes with Services
Quiet stable environmentOffer meals, laundry cues, assistance with
appointmentsAssist with management of medications
Individual needs to be able to take own meds with cues
Recovery HousesOffer meals, laundry cues, assistance with
appointmentsAssist with the management of medications
Individual needs to take own medications with cuesOffer NA/AA meetings both in the facility and in
the communitySponsor general meetings of the residentsSupply options for next step in housing
Boarding home with servicesSupervised apartment
Supervised ApartmentsFully furnished apartment offering meals,
medication administration/supervision, house cleaning service, laundry cues, appointment attendance assistance.
Accommodates the following individuals:Stabilized individuals requiring supervision during
the transitional phase to apartment living.Individuals who cannot live in a group setting due to
violent behavior, poor response to high levels of stimuli, continuing substance use and inability to live with others.
The level of services is based on individual evaluations.
Independent Apartments with Case Management
Individuals who are independent in their activities of daily living
Individuals who are able to take their medications as
prescribed and manage refills and re-ordersIndividuals who can manage and attend
appointments as scheduledIndividuals who can food shop and provide
adequate nutritionIndividuals who can maintain a safe
environmentCase Management is provided as a safety net
Assisted Living/Personal Care HomesIndividuals who do not have the capacity to
manage medications with cues or be self directed.Individuals with complex medical and mental
health issuesMedication administration is supplied. Services: Meals, laundry, activities, hygiene
cues and assistance, attendance at appointments, house doctors, ability to assess medical and mental health problems.
Case Management provided
Design Support Plan Based on Placement
Determine level of careSchedule medical and mental health
appointmentsAssist with legal, social, financial,
substance use issues as identifiedDetermine pattern of visits by case
management team Monitor individual’s satisfaction
Design Support Plan Based on Placement
Scheduled collaboration visits with providers
Monitoring of the following:Medication/appointment adherenceFinancial payments to facility and
personal allowanceVisits to the Emergency RoomHospitalizations
•Individual satisfaction•Reports from facility staff•Reports from family/friends•Pattern of adherence with medications and appointments•Progress reports from medical and mental health visits•Results from diagnostic testing•Visits to the Emergency Room(s)•Hospitalizations
Evaluate Outcomes
Based on Evaluation
Continue PlanReview Process and implement Revisions
Contact Information
Philadelphia VA Medical Center, Phila., Pa
(215-823-5800)
Katherine (Kate) O’Hara, RN (267-761-1801)[email protected]
Mary (Molly) McLaughlin, RN (215-823-4006)[email protected]
Pamela (Pam) Jackson-Malik, RN (215-823-4297)[email protected]
Alan Lorry, RPH (215-823-6363)[email protected]
Beverly Velasquez, MSW (215-823-5800 ext 6134)[email protected]
