Short-term Care Success Stories
Short-term
Care Readmission with Medication and Programming Issues
Ms.
A. was a 44-year old who had been diagnosed with Severe MR and had several
medical issues including; a history of seizures, atopic dermatitis, history of
UTIs, diarrhea-laxative induced and obesity. She had lived at Southern
Center since November of 1964 and was discharged to a Community Based
Residential Facility (CBRF) in 1995. At the time of discharge, she was on
no psychotropic medications. A Behavior Intervention Program (BIP) and an
Active Treatment Program controlled her behavior. She was taking Phenytoin
for seizure control. She was readmitted to SWC in May of 2000. The
reason for readmission was that she became a danger to her smaller and more
vulnerable peers at the CBRF. She was described as aggressive and
destructive. She returned to SWC on
Seroquel, Inderal, Depakote, Clonazepam, Paxil, and Imipramine. All
psychotropics as they were used. Depakote severed a dual purpose to
control seizures as well.
Once
Ms. A. settled in on our short-term care unit, she was given a full medical
evaluation and integrated into a daily program. Over the next few weeks,
her behaviors began improving and her medications began to be reduced. She
was also given an extensive GI work up and it was found that she had
gastritis. A medication for the gastritis was added. Her diet was
adjusted and daily fluid intake monitored. Her laxatives were greatly
reduced. All her psychotropic medications were discontinued except for the
Depakote. Her behavior was manageable again with active programming and a BIP.
She was discharged to another agency in January 2001. She is apparently
doing well.
Short-term
Care Admission Discovers Medical Condition
Ms.
L. was a 20-year old who had been diagnosed since childhood as having autism and
had been in her local school special education program since elementary
school. Although she had been diagnosed as hyperactive since she was five
years old, her parents and the school had learned how to keep things pretty much
under control until a year or so ago. Ms. L. became more hyperactive and
started constantly demanding one thing after another, especially food.
When her mother was not able to meet her requests, she would become physically
aggressive, pushing her mother around and screaming. Similar demanding and
aggressive behavior was occurring more and more often at school. A
community psychiatrist proposed a diagnosis of bi-polar disorder. In
addition Ms. L. was frequently up at night roaming the home and getting her
mother up to get her things. Ms. L. also developed certain peculiar
demands, such as insisting she wear the same outfit of clothes. Her mother
would have to wash them when she slept or she would refuse to get dressed the
next day. After Ms. L. choked, her mother and three people were needed to
remove her. A short-term care admission was requested at SWC. Ms. L.
arrived with her parents and a big bag of chocolate chip cookies to keep her
happy (and quiet) for the ride to SWC.
Her
admission physical found her glucose level so elevated that she was briefly
admitted to a community hospital! Ms. L. had out of control diabetes which
had not been recognized until now. Although she had to start out on
insulin injections, a diabetic diet soon resulted in her blood sugar being
controlled just by diet. Her weight had also decreased during that year
from 210 to 152 pounds; a loss of 58 pounds. Gee, those diabetic diets
sure work wonders!
As
her diabetes was addressed, Ms. L. became much less agitated, had a longer
attention span, less compulsive or ritualistic behaviors, and in general, became
a much more pleasant person. She still demands of a lot of attention, but
her parents and those working with her all say she is now fun to be with.
Consultation
of Client with Successful Behavioral Intervention
A
consultation was requested for Mr. W. who was refusing to follow his diabetic
diet. He was increasingly stealing food at home and at his day program
site. He started engaging in more frequent testing and uncooperative
behavior when supervision was increased. For example, he would turn the
burners on in the kitchen and smile when caught. The provider and treating
physician were convinced it was obsessive/compulsive behavior and had started
him on Zoloft.
Some
in home observation convinced the team that Mr. W. was very aware of the
reaction his behavior was generating, and the attention was driving the
behavior, not an inner compulsion. They suggested minimizing the reaction
to food "stealing" while increasing other opportunities for Mr. W. to
get positive and appropriate attention. The residential provider thought
this suggestion was way off the mark, but said they would give it a chance.
A
couple of months later we heard that things had made a dramatic
turnaround! Mr. W. was being praised when he ate good food or did other
nice things. When he turned a burner on or tried to eat something else, it
was ignored. Pretty quickly those activities disappeared and Mr. W. was
happy doing "good" things.
Consultation
of
Client with Undiagnosed Medical Problems
Mr.
C. was not sleeping well. He had started throwing things at people as well as
hitting the walls. It was believed he was hallucinating since he was
spending a lot of time seeming to be talking to the walls. He also engaged
in strange behavior such as a session of ripping each page from a hundred
magazines, one at a time. The initial solution proposed was a large
increase in psychotropic medications.
Although
Mr. C. had a possible diagnosis of schizophrenia already, it was found that he
had other medical conditions that were probably driving his disturbed
behavior. Medical follow-ups and testing found severe arthritis in his
knees and also Gastro-Esophageal Reflux Disease (GERD) . Mr. C. was upset
because he was in pain nearly all the time. When these medical conditions
were addressed, his behavior returned to normal.
ADDITIONAL
SUCCESS STORIES
Short
Term Care Admission And Readmission
Mr.
W. was a 33 year old white male admitted from a crisis house in December 2005.
Upon his admission, he carried diagnoses Axis 1: of PDD NOS and Psychosis NOS;
Axis 2: Moderate MR; Axis 3: history of Grand Mal Seizure 1 isolated incident,
seasonal allergies, and history of fracture trauma to face at 4-5 years old. He
had been living with his parents up until he was placed in the crisis house. He
was unable to return to his home or his day program until he was evaluated
medically. He was admitted to SWC for this medical evaluation.
During
Mr. W.'s admission, his behavior was monitored as well as observations made
concerning his allergies and mental status. He was also seen by specialists in
Psychiatry, Neurology, and ENT. Staff noticed his behavior and mental status
deteriorating around the beginning of February. He exhibited an increase in
episodes of non-compliance, confusion, and inappropriate behaviors. It was
observed and reported he had a sinus condition beginning. On February 5, 2006,
he had a major clonic tonic seizure episode. Medical staff had begun to taper
some of his medications by this time. He continued to deteriorate with more
disorientation, aggression, and generalized agitation. Psychiatry and Neurology,
working together, had increased his seizure medications and added another. ENT
and his primary physician found him to have several environmental allergies.
There was aggressive treatment for the allergies and his symptoms subsided. His
diagnoses were re-evaluated and he was given; Axis 1: Bi-polar Affective
Disorder NOS; Axis 3 added with Seizure Disorder and Allergies - ragweed, mold,
grass, dust mites, and cats. Mr. W. remained stable until his discharge back
into the community to an adult family home on April 10, 2006 with a structured
day program. A 30-day follow up found him stable, cooperative, and symptom free.
It seems that with a proper set of diagnoses and treatments to follow, Mr. W. is
a changed man.
Ms.
G. was admitted from an acute psychiatric unit in a community hospital. She had
reportedly been aggressive toward her grandmother/primary caretaker as well as
verbalized some suicidal intent. She was sent to the hospital and then to SWC
for protective placement as she appeared a danger to herself and others. At the
age of 8 years old, Ms. G sustained a severe cranial injury when she was hit by
a car. She developed a convulsive disorder after that and was also diagnosed
with an impulse control disorder. There was some question of exposure to
sexually explicit material during this developmental time and her impulse
control includes hypersexual inappropriate behaviors. After her accident, her
mother could not take care of her and her grandmother became the primary
caretaker. Ms. G. had several admissions to other facilities; schools for the
developmentally disabled, psychiatric facilities, and group homes. Before this
last episode of aggression/suicidal ideation, she had been with her grandmother
for about a year following a group home. At SWC, she was placed on a unit with
female clients. Her day was structured and she was kept busy. A Behavior
Intervention Program was implemented addressing her aggression, hypersexuality,
and self-injurious behavior/thoughts, which included a positive reinforcement
system for low incidence of target behaviors. Her seizures were addressed by
SWC's neurologist and medications were adjusted. Our psychiatrist removed her
Lithium and her appetite improved. Her diagnoses were adjusted to Axis 1- Mood
Disorder due to traumatic brain injury; Axis 2 - Mild MR; Axis 3 - Seizure
Disorder, post traumatic probable focal motor type, left side weakness/unsteady
gait secondary to closed head injury. A structured day, close staff supervision,
and positive reinforcement has worked well with Ms. G. SWC has seen no
hypersexuality or suicidal ideations and very little aggressiveness. The SWC
team thought is would be best if Ms. G was placed with an agency capable of
duplicating the structure, supervision, and implementation of behavior treatment
plans that paralleled those of SWC Ms. G. was admitted August 8, 2005 and
contrary to recommendations, discharged back to the community with her
grandmother October 20, 2005. She was readmitted to SWC July 7, 2006 with
essentially the same problems reoccurring during her placement with her
grandmother. The county is now working with the SWC team to find a placement
with an agency that will provide an active, well-structured day of appropriate
things to do, attentive and well-trained staff, and proper medical assessment as
this should continue to aid her in maintaining some control over her life.
Mr.
M was admitted to SWC on April 8, 2005, from a psychiatric facility he ended up
in when he became aggressive in a hospital emergency room. At that time, he had
toxic levels of Dilantin. He was stabilized medically at the psychiatric
facility from April 5, 2005 to April 8, 2005 before transfer to SWC. Prior to
his admission, he had lived in an adult family home with an elderly caretaker.
Allegedly, the caretaker could not remember very accurately how often the
medications were to be given or if they had been given at all. While at SWC, he
was seen by Psychiatry, Neurology, Gastroenterology, Dermatology, and Urology.
The psychiatrist found no psychiatric pathophysiology and recommended no
psychiatric medications. Neurology adjusted and monitored his three seizure
medications and established that a 0-5 per month frequency range should be the
goal in controlling the seizures. The neurologist added a fourth seizure
medication to help control his seizure frequency and intensity. After the
detoxification of extremely high Dilantin levels, Mr. M. was much more compliant
and behavioral issues no longer were a problem. GI Clinic performed an EGD and
found he had a hiatal hernia. In addition to his Prilosec which was increased, a
stool softener was added and Lactinex to optimize his intestinal health by
adjusting the bacteria. Incontinence of bowel and bladder remains a
developmental issue and good perianal care by staff has kept Mr. M. free of skin
breakdown. SWC worked with Mr. M.'s county and eventually found him an adult
family home with the ability to duplicate the services provided at SWC. He was
discharged to his new home in July of 2005 and has been doing well.
Mr.
K. was admitted to SWC in January of 2005. During 2004, Mr. K. had become more
paranoid, aggressive, and non-compliant. He was picking fights with his support
staff and several had quit because of these behaviors. He would not let staff
leave the apartment if certain things were not exactly in their right place,
position, or in the right numbers. He had also had some verbal and physical
confrontations with random people in his environment. He had attacked a
bicyclist who was riding on the sidewalk and according to Mr. K. he shouldn't
have been on the sidewalk. Confusion also resulted in aggressive behavior. He
came to SWC with Seizure Disorder secondary to brain trauma, Diabetes Mellitus
2, bilateral hearing loss, and bilateral shoulder adhesive capsulitis. He was
initially placed on an SWC cottage with clients who have the most challenging
behaviors. After a few months of assimilation to the Center, he was moved to
another cottage with a less restrictive environment. His seizure medications and
his psychotropic medications were adjusted several times. After finding some
medications caused more confusion and diminished cognition, he was placed on
Abilify 10mgs and three seizure medications at therapeutic doses. His seizures
were reduced significantly. Because of the adjustments in medications, his mood
was more stable and his compliance improved. The team at SWC derived that much
of his negative behavior was to escape from people situations that made him feel
uncomfortable or threatened (real or perceived), and relieve anxiety or
frustration when over stimulated. These behaviors seemed primarily connected to
his brain injury, but are also influenced by his personality traits which
include paranoia, obsession, and narcissism, as well as life experiences and
learned habits. Staff was trained to approach Mr. K. in a non-confrontational
manner, with simple and straight forward instructions. Mr. K. was not asked to
do anything he felt uncomfortable in doing and prompt staff interventions seemed
to curb some of the situational antecedents that preceded the target behaviors.
The frequency and severity of his challenging behaviors were reduced overall.
Staff at SWC emphasized that due to his brain damage, his behaviors would likely
continue to surface at times related to stressors and perceived threats. Mr. K.
was discharged to the community in April 2006. So far, he seems to be doing
satisfactory.
Mr.
C. was admitted to SWC for the first time in January 1992 after several
placements in other ICF/MRs, group homes, and State institutions. This was
primarily due to depression brought on by the loss of his mother, and primary
caretaker in November 1979. He was living at SWC until April of 1995 when he was
placed back into the community after his mood was stabilized and an intervention
program was used successfully. When the AFH he was living in closed in 2001, he
spent 3 years living in CBRF's with some intermittent times spent in hospitals
and an ICF/MR recuperating. In July 2004, Mr. C. was admitted back to SWC's
medical unit to address medical needs (specifically pressure ulcers and urinary
tract infections related to catheter use). While at SWC, there was a treatment
regimen implemented to address the pressure ulcers. Healing was slow and the
medical team decided to surgically repair the site. Treatment continued until
Mr. C.'s ulcers were healed completely. Urology intervention and eventually
dilatation of the urethra allowed unrestricted flow and elimination of further
catheter use. Mr. C. was discharged to a community CBRF in June 2005 and is
doing great. SWC's team recommended some good health and behavior interventions
and with well-trained staff and good nursing intervention, he should continue to
do well.
Ms.
B. was admitted to SWC in November 2005 from Mendota Mental Health Institute.
She had lived with her parents until 2002 and was then placed in a CBRF due to
unmanageable behaviors at home (i.e., property destruction, aggression, and
non-compliance). She was incapable of following a diabetic diet or administering
her insulin properly. She was subsequently sexually assaulted at her residential
placement. After moving to another CBRF, she trashed an office when a favorite
staff left for vacation and when the police were called she tried to take the
policeman's gun and threatened to shoot a replacement staff member. While she
was living at SWC, her diabetes, hypertension and seizures were well maintained
. She was provided with Neurology, Dermatology, Cardiology, Endocrinology, and
Podiatry services with improvements in all these areas. Ms. B. had only one act
of aggression (a slap), and 3 incidents of disturbed behavior, (yelling out)
during her stay at SWC. There were no reports of hallucinations during the last
2.5 months of her stay. Hallucinations may have been related to situational
stress coupled with PTSD from an assault history. Ms. B. was stable and socially
appropriate for most of her stay, with improvements after medical, behavioral,
and psychiatric interventions were modified. Ms. B. was placed in the community
in February 2006 into a CBRF with well-trained staff who monitor her diabetes
and other medical problems and continue to provide a safe and structured
environment for her.
Ms.
L. was admitted to SWC in June 2005 after numerous incidents of property
destruction, aggression, self-injurious behavior, elopement, and suicide
gestures. She had several medical problems beside her emotional and psychiatric
issues. She had a history of alcohol and other substance abuse, obesity,
diabetes mellitus, hypertension, sleep apnea. She also had PTSD related to
verbal, physical, and sexual abuse, mixed personality disorder, and mood
disorder. While at SWC, she followed a diet to control her diabetes and improve
her weight. She did her own blood glucose monitoring after receiving training
and her diabetes improved somewhat during her stay at SWC. She had one episode
of self abuse every two weeks or so, consisting of superficial cuts/gouges to
her arms and occasional head banging, one elopement attempt the first week,
property damage once per week, aggression once every two weeks, and disruptive
behavior several times per week. While at SWC, she saw a psychologist who helped
her to use more appropriate problem solving skills. She began to improve
somewhat from her baseline behaviors. The treatment team suggested that she
continue to see a therapist in the community to address her mixed personality
disorder and PTSD. With the help of the SWC team, she was placed in an adult
family home where the staff has been trained to care for clients with
personality disorders and PTSD. She was successfully placed in the community in
August of 2005.
Contacts
Jennifer Nora,
Treatment Specialist
(262) 878-2411 Ext 2227
Todd Redalen,
Treatment Specialist
(262) 878-2411 Ext 2521
Robert
Eisenbart, Nurse Specialist
(262) 878-2411 Ext 2459
James
Henkes, Director
(262) 878-2411 Ext 2200
Last Revised: December 02, 2008 |
