A Systems Response to a Complex Case JEFF

A Systems Response to a Complex Case JEFF ROWE, RUBY MARTIN, ERIN CASE, MICHELLE WU, IAN SAWARD, AND KATIE NASH

Case presentation (Ruby)Jane, 14 y. o. , bilingual, bisexual female In 9 th grade Lives with mother and 4 younger sibs Low socioeconomic status, food stamps, cash aid, affordable housing Jane is second generation, parents from Mexico (speak Spanish at home) Father absent (4 years)- DV CWS involvement, DV shelter Family identifies as Catholic, Jane has lost her faith ◦ Family receives lots of support from local church ◦ Lots of local family support

Jane’s clinical situation (Ruby) Referred to therapist when grades started to fall ◦ Lack of interest in activities ◦ Tardiness ◦ Skipping class ◦ Physical altercations with peers At home, mother sees changes ◦ Sleep changes (phase shift) ◦ Angry out bursts over small things ◦ Isolating self ◦ Decreased appetite ◦ Depressed mood Jane reports ◦ Sadness, irritation ◦ Low energy ◦ Concentration problems ◦ Loss of interest in activities; volleyball ◦ Suicidal ideation ◦ Vaping nicotine and cannabis Risks*** ◦ Witnessing DV ◦ Sexual abuse by relative at age 5 ◦ Some trauma therapy and family therapy in DV shelter

First session with therapist (Ruby) “Want to end my life”, ”No one will miss me”, “I’m so stupid, I should just end my life” Denied current plan, but did have current intent, and wouldn’t plan for safety Concerns about risk of suicide

What should therapist do at this point? (Jeff)

Jane at ESU (Jeff) Statements about not wanting to live Unsure if she could remain safe in the home

What should ESU do? (Jeff)

Emergency Screening Unit (ESU) (Erin) What is ESU? What is a 5150 hold? How did Jane meet criteria to stay in ESU overnight?

How does ESU make these decisions? (Erin) What criteria did Jane meet in order to be released from ESU? What does discharge planning look like when a client is released? Is there any follow up?

What should CAC do? (Jeff)

Referral to Crisis Action & Connection (CAC)(Ian) What is CAC? Who do they serve? ◦ Who can’t they serve? Their goals? What do they do?

What happened 1 week later? (Jeff, Ruby Erin) Physical altercation at school with peer Mom takes cell phone away- upsets Jane ◦ Jane grabs knife, locks self into bathroom 911 called, PERT arrives- finds wrist cuts ◦ Taken to Rady’s ER, seen by ER Physician, SW ◦ Packet to ESU ◦ ESU discusses with CAPS Admitted to CAPS

What should happen at CAPS?

Child & Adolescent Psychiatry Services (CAPS) (Michelle, Ian) What is CAPS? What services and activities occur behind the locked doors? What does discharge planning look like when Jane is release? What referrals are made for Jane after her first hospitalization?

Jane’s Hospital Course (Michelle) Symptoms of depression and suicidal ideation with a plan and access to means While on CAPS, participated in individual and group therapy ◦ Met peers going through similar issues ◦ No medication started ◦ Family meeting held ◦ Still considering self-harm Within a few days she was ready for discharge

What should CAC do after hospitalization? (Jeff, Ian)

What happened 2 weeks later? (Jeff or Ruby, Erin) Argument with mother about not being able to go out with friends Jane became upset, tries to grab knife, but they are locked away ◦ Instead uses fork PERT called again Jane continues to make self harmful statements and that she is determined to find the means to do so. Police and PERT respond again, taken to ER ◦ ESU decides to do direct admit Admitted to CAPS for second time

2 nd hospital course (Michelle, Ian) Similar events and complaints to the first time Sees peer from last hospitalization Quickly settles down, able to do some safety planning Issue of trauma exposure is brought up Now it is time to discharge again, but, last discharge plan didn’t work so well (3 contacts with emergency services-ESU and PERT- and 2 hospitalizations in a short period of time) CAC contacted again

Referral to Wraparound Services (Katie) What is Wraparound and how is it different from intensive outpatient care? Given what is known about Jane’s case so far, what can Wraparound bring to the outpatient care that wasn’t there before? Focus on trauma? What do you put into place?

Several weeks later? (Ruby, Katie, Erin) Jane irritated at school, mom tries to talk with her, Jane locks self in bedroom, crying Jane reveals BF has broken up with her ◦ Feels depressed ◦ Makes statements about ”not caring anymore”, “I just want to die”, and “nobody with ever want me” Mom takes Jane to ESU assesses her

Jane at ESU (her 2 nd time at ESU) (Erin) Suicidal ideation, no plan Jane’s mother frustrated ◦ ESU didn’t admit her, discharge home ◦ Updated Safety Plan Jane still has self harmful thoughts

Suicidal Ideation Suicidal Risk Suicidal Act 22

Three days later…(Jeff, Erin) Jane in physical fight with peer at school School staff tries to approach Jane, she runs out of school into traffic Police called, during her interview reports desire to end her life by being hit by car Process of 5150 happens again Admitted to CAPS for 3 rd time in 2 months

CAPS (Michelle) So, Jane is back on the inpatient unit (3 rd time) What should happen next in terms of her hospital stay, her discharge planning, and her services out in the community? Is Jane likely to continue to have problems with getting upset and having suicidal thoughts? What should these providers do to change the course of Jane’s illness(es)?

Coordination of Care or Barrier Busting (all) Discuss next steps of discharge planning? Connect with all providers: therapist and CAC, Hospital, ESU, and Supervising Psychiatrist from County Issue of trauma seems prominent

What should Wraparound Services do (Katie)?

Any clinical follow up? (Ruby, All) Now there are 6 organizations that know Jane (Therapist, ESU, CAPS, CAC, Psychiatrist, and now Wrap) Do we have a more sophisticated understanding of Jane? ◦ Mood disorder, emotional dysregulation (reactions out of proportion), suicidal ideation, ? role of trauma and its impact on development? We know she needs strong, frequent outpatient contact at home, school, and in the community in order to support her

Questions? Comments?