Care Management Scale--Youth Rev. 10/26/07

Transcription

1 Care Management Scale--Youth Rev. 10/26/07 Client Name: ID: Date: _ Person Completing: Chronicity: Client has a qualifying diagnosis (see attached list) Mental Health condition was first documented to be present: Within the last year 1-3 years ago More than 3 years ago Clinically significant symptoms of the mental health condition have been present without a period of interruption lasting more than 30 days for: Less than six months For six months to 3 years For more than 3 years. Debilitation: Self Care: Youth has not had a period of six consecutive months living in the same living arrangement within the community within the last 2 years. Youth evidences notable deficits in personal hygiene requires substantial cueing to engage in personal hygiene Youth typically fails to complete chores (such as cleaning room) without direct supervision Youth is not able to be left alone unsupervised for developmentally appropriate periods of time (30 minute for youth 9-11, 1 hour for youth 11-12, 3-4 hours for youth 13 and older) Client has been psychiatrically hospitalized at least once in the last year or 2 or more times in the last 5 years Social Interaction Youth does not utilize 2 or more close friends/family members for emotional support on a weekly basis. Youth engaged in interpersonal conflict resulting in outside intervention (police being called, friends/neighbors intervening) one or more times in the last year Youth does not have a best friend Youth has been involved in a close relationship within the last year with someone who engages in destructive behavior including physical violence, substance abuse, or criminal behavior. Youth lives in a home environment that includes violence/substance abuse

2 Vocational/Economic Functioning: Youth has missed more than 25% of school days in the last school year Youth has been placed in an alternate school placement (behavioral management classroom, special education do not check for vocational school or Occupational Work Experience) Youth has been suspended from school in the last year Youth has been terminated from a job in the last year Self-Directed Behavior Youth has engaged in criminal activity at the felony level in the last 5 years Youth has engaged in criminal activity in the last year at the misdemeanor level Youth has been charged with criminal activity within the last year Youth regularly engages in socially inappropriate behavior including verbal outbursts, making threats, fighting, etc. Youth has engaged in self-damaging behavior in the last year (self mutilation, suicide gestures, intentional failure to meet own basic needs do not check for passive failure to meet own needs/neglect). Current Mediating Factors (typically within the last 3 months): Positive Factors (enter 1-3 from the attached key) Has and utilizes social support system outside of the treatment relationship Has and utilizes family or surrogate family support system Engages in treatment Has insight into mental health condition System involvement (Court, Children Services, etc.) Lives in a structured living arrangement (ie. Group Home, Foster Care, etc.) Takes medication as prescribed with good outcome Negative Factors (enter 1-3 from the attached key) _ Uses alcohol/illicit substances _ Engages in regular social interaction with persons who affiliate with the criminal subculture (not including contact through the court and/or treatment programs). _ Acute objective stressor onset within the last 3 months (rejection, loss of significant support, etc.)

3 Qualifying Diagnosis Code Diagnosis Grouping Bipolar I Disorder, Single Manic Episode Unspecified Bipolar I Disorder, Single Manic Episode Mild Bipolar I Disorder, Single Manic Episode Moderate Bipolar I Disorder, Single Manic Episode Severe without Psychotic Features Bipolar I Disorder, Single Manic Episode Severe with Psychotic Features Bipolar I Disorder, Single Manic Episode In Partial Remission Bipolar I Disorder, Single Manic Episode In Full Remission Major Depressive Disorder, Single Episode Unspecified Major Depressive Disorder, Single Episode Mild Major Depressive Disorder, Single Episode Moderate Major Depressive Disorder, Single Episode Severe Without Major Depressive Disorder, Single Episode In Partial Remission Major Depressive Disorder, Single Episode In Full Remission Major Depressive Disorder, Recurrent Unspecified Major Depressive Disorder, Recurrent Mild Major Depressive Disorder, Recurrent Moderate Major Depressive Disorder, Recurrent Severe Without Psychotic Features Major Depressive Disorder, Recurrent Severe With Psychotic Features Major Depressive Disorder, Recurrent In Partial Remission Major Depressive Disorder, Recurrent In Full Remission Bipolar I Disorder, Most Recent Episode Manic Unspecified Bipolar I Disorder, Most Recent Episode Hypomanic Bipolar I Disorder, Most Recent Episode Manic Mild Bipolar I Disorder, Most Recent Episode Manic Moderate Bipolar I Disorder, Most Recent Episode Manic Severe without Bipolar I Disorder, Most Recent Episode Manic Severe with Bipolar I Disorder, Most Recent Episode Manic In Partial Remission Bipolar I Disorder, Most Recent Episode Manic In Full Remission Bipolar I Disorder, Most Recent Episode Depressed Unspecified Bipolar I Disorder, Most Recent Episode Depressed Mild Bipolar I Disorder, Most Recent Episode Depressed Moderate Bipolar I Disorder, Most Recent Episode Depressed Severe Without Bipolar I Disorder, Most Recent Episode Depressed Severe With Bipolar I Disorder, Most Recent Episode Depressed In Partial Remission Bipolar I Disorder, Most Recent Episode Depressed In Full

4 Code Diagnosis Grouping Remission Bipolar I Disorder, Most Recent Episode Mixed Unspecified Bipolar I Disorder, Most Recent Episode Mixed Mild Bipolar I Disorder, Most Recent Episode Mixed Moderate Bipolar I Disorder, Most Recent Episode Mixed Severe without Bipolar I Disorder, Most Recent Episode Mixed Severe with Bipolar I Disorder, Most Recent Episode Mixed In Partial Remission Bipolar I Disorder, Most Recent Episode Mixed In Full Remission Bipolar I Disorder, Most Recent Episode Unspecified Bipolar Disorder NOS Bipolar II Disorder Disorder NOS Dysthymic Disorder Cyclothymic Disorder 311 Depressive Disorder NOS Dissociative Amnesia Dissociative Dissociative Fugue Dissociative Dissociative Identity Disorder Dissociative Dissociative Disorder NOS Dissociative Depersonalization Disorder Dissociative Gender Identity Disorder NOS Sexual Dysfunction/Identity Gender Identity Disorder in Children Sexual Dysfunction/Identity Gender Identity Disorder in Adolescents or Adults Sexual Dysfunction/Identity Sexual Disorder NOS Sexual Dysfunction/Identity Pedophilia Paraphilias Pedophilia Paraphilias Transvestic Fetishism Paraphilias Exhibitionism Paraphilias Fetishism Paraphilias Voyeurism Paraphilias Sexual Masochism Paraphilias Sexual Sadism Paraphilias Frotteurism Paraphilias Paraphilia NOS Paraphilias Sexual Disorder NOS Paraphilias V61.12 Sexual Abuse of Adult Paraphilias V61.21 Sexual Abuse of Child Paraphilias Anorexia Nervosa Eating Disorders Eating Disorder NOS Eating Disorders Bulimia Nervosa Eating Disorders Insomnia Related to...(axis I/Axis II Disorder) Sleep Disorders

5 Code Diagnosis Grouping Primary Hypersomnia Sleep Disorders Hypersomnia Related to...(axis I/Axis II Disorder) Sleep Disorders Circadian Rhythm Sleep Disorder Sleep Disorders Sleep Terror Disorder Sleep Disorders Dyssomnia NOS Sleep Disorders Parasomnia NOS Sleep Disorders 347 Narcolepsy Sleep Disorders Identity Problem Other V-Codes Sexual Abuse of Child (attention focus on victim) Other V-Codes Physical Abuse of Child(attention focus on victim) Other V-Codes Neglect of Child(focus of attention is on victim) Other V-Codes Sexual Abuse of Adult (attention focus on victim) Other V-Codes Physical Abuse of Adult(attention focus on victim) Other V-Codes Anxiety Disorder Due to a General Medical Condition Anxiety Anxiety Disorder NOS Anxiety Panic Disorder Without Agoraphobia Anxiety Generalized Anxiety Disorder Anxiety Panic Disorder With Agoraphobia Anxiety Agoraphobia Without History of Panic Disorder Anxiety Social Phobia Anxiety Specific Phobia Anxiety Obsessive-Compulsive Disorder Anxiety Posttraumatic Stress Disorder Anxiety Dementia of the Alzheimer's Type, with Late Onset Uncomplicated Cognitive/Organic Dementia Due to Pick's Disease' Cognitive/Organic Dementia Due to Creutzfeldt-Jakob Disease' Cognitive/Organic Dementia of the Alzheimer's Type, with Early Onset Uncomplicated Cognitive/Organic Dementia of the Alzheimer's Type, with Early Onset With Delirium Cognitive/Organic Dementia of the Alzheimer's Type, with Early Onset With Delusions Cognitive/Organic Dementia of the Alzheimer's Type, with Early Onset With Cognitive/Organic Depressed Dementia of the Alzheimer's Type, with Late Onset With Delusions Cognitive/Organic Dementia of the Alzheimer's Type, with Late Onset With Depressed Cognitive/Organic Dementia of the Alzheimer's Type, with Late Onset With Delirium Cognitive/Organic Vascular Dementia Uncomplicated Cognitive/Organic Vascular Dementia With Delirium Cognitive/Organic Vascular Dementia With Delusions Cognitive/Organic Vascular Dementia With Depressed Cognitive/Organic Delirium Due to a General Medical Condition Cognitive/Organic Psychotic Disorder Due to... With Delusions Cognitive/Organic Psychotic Disorder Due to... With Hallucinations Cognitive/Organic Disorder Due to a General Medical Condition Cognitive/Organic Catatonic Disorder Due to... Cognitive/Organic Dementia Due to Other General Medical Conditions Cognitive/Organic Dementia Due to Parkinson's Disease Cognitive/Organic Dementia Due to Head Trauma Cognitive/Organic

6 Code Diagnosis Grouping Dementia Due to Huntington's Disease Cognitive/Organic Dementia NOS Cognitive/Organic Autistic Disorder Cognitive/Organic Childhood Disintegrative Disorder Cognitive/Organic Pervasive Developemental Disorder NOS Cognitive/Organic Rett's Disorder Cognitive/Organic Asperger's Disorder Cognitive/Organic Schizophrenia Disorganized Type Psychosis Schizophrenia Catatonic Type Psychosis Schizophrenia Paranoid Type Psychosis Schizophreniform Disorder Psychosis Schizophrenia Residual Type Psychosis Schizoaffective Disorder Psychosis Schizophrenia Undifferentiated Type Psychosis Delusional Disorder Psychosis Shared Psychotic Disorder Psychosis Schizo-Affective Disorder Psychosis Psychotic Disorder NOS Psychosis Paranoid Personality Disorder Personality Schizoid Personality Disorder Personality Schizotypal Personality Disorder Personality Obsessive-Compulsive Personality Disorder Personality Histrionic Personality Disorder Personality Dependent Personality Disorder Personality Antisocial Personality Disorder Personality Narcissistic Personality Disorder Personality Avoidant Personality Disorder Personality Borderline Personality Disorder Personality Personality Disorder NOS Personality Personality Disorder NOS with Antisocial Features Personality Tourette's Disorder Behavioral Stereotypic Movement Disorder Behavioral Pica Behavioral Rumination Disorder Behavioral Enuresis(Not Due to a General Medical Condition) Behavioral Encopresis,wo Constipation & Overflow Incontinence Behavioral Separation Anxiety Disorder Behavioral Impulse-Control Disorder NOS Behavioral Pathological Gambling Behavioral Kleptomania Behavioral Pyromania Behavioral Intermittent Explosive Disorder Behavioral Trichotillomania Behavioral Conduct Disorder Behavioral Disruptive Behavior Disorder NOS Behavioral Selective Mutism Behavioral

7 Code Diagnosis Grouping Oppositional Defiant Disorder Behavioral Reactive Attachment Disorder of Infancy or Early Childhood Behavioral Disorder of Infancy, Childhood, or Adolescence NOS Behavioral Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type Behavioral Attention-Deficit/Hyperactivity Disorder Combined Type Behavioral Attention-Deficit/Hyperactivity Disorder Predominantly Hyperactive- Impulsive Type Behavioral Attention Deficit Hyperactivity Disorder By History Behavioral Attention-Deficit/Hyperactivity Disorder NOS Behavioral Encopresis,w Constipation & Overflow Incontinence Behavioral V61.13 Physical Abuse of Adult Behavioral V Physical Abuse of Child Behavioral V Neglect of Child Behavioral V71.01 Adult Antisocial Behavior Behavioral V71.02 Child or Adolescent Antisocial Behavior Behavioral Alcohol Dependence Substance Use Opioid Dependence Substance Use Sedative, Hypnotic, or Anxiolytic Dependence Substance Use Cocaine Dependence Substance Use Cannabis Dependance Substance Use Cannabis Dependence with Early Full Remission Substance Use Amphetamine (or Amphetamine-Like) Dependence Substance Use Hallucinogen Dependence Substance Use Inhalant Dependence Substance Use Polysubstance Dependence Substance Use Phencyclidine Dependence Substance Use Other (or Unknown) Substance Dependence Substance Use Nicotine Dependence Substance Use Conversion Disorder Somatoform/Factitious Factitious Disorder w/predominantly Psychological Signs & Somatoform/Factitious Symptoms Factitious Disorder w/combined Psychological\\Physical Signs & Somatoform/Factitious Symptoms Factitious Disorder w/predominantly Physical Signs & Symptoms Somatoform/Factitious Factitious Disorder NOS Somatoform/Factitious Hypochondriasis Somatoform/Factitious Body Dysmorphic Disorder Somatoform/Factitious Undifferentiated Somatoform Disorder Somatoform/Factitious Somatoform Disorder NOS Somatoform/Factitious Somatization Disorder Somatoform/Factitious Pain Disorder Associated w/psychological Factors Somatoform/Factitious Pain Disorder Associated w/psychol. Factors & Gen. Medical Cond. Somatoform/Factitious

8 Positive Factors Social support system Family support system or surrogate family support system Engages in treatment Insight into mental health condition System involvement (Court, Children Services) Living arrangement (ie. Group home, foster care etc.) Medication Does not use social support person on a weekly basis No contact with family for support Talk with support persons 1-2 times per week Has failed to schedule appointments for treatment or has missed more than 50% of scheduled appointments or does not participate in sessions when forced to attend or this is first appointment Does not understand diagnosis and has no insight into factors contributing to mental health issues No external systems involved Lives independently with no supervision/structure other than selfimposed or lives in a chaotic home environment Refuses to take prescribed medication, reports no benefits from medication prescribed Utilizes family support 1-2 times per week Has missed 25% of scheduled appointments or has scheduled appointments less than the recommended frequency or actively resists engaging in sessions Has limited understanding of diagnosis and has some insight into contributing factors 1 external system that provides monitoring Has imposed supervision and structure to a moderate degree Complies with medication by taking prescribed medication at least 4 days out of the week Can identify 5 or more support people and talks with support person 3 times a week or more Utilizes family support 3 or more times per week Has attended appointments at the recommended frequency and engages in the treatment process Understands diagnosis and is aware of factors that contribute to increased mental health symptoms Has 2 or more systems involved Has imposed rules and supervision 24 hours a day Complies with recommended medication regime and reports medication is effective OR does not require medication

9 Negative Factors Alcohol/ Illicit Substance Use Engages in regular social interaction with persons who affiliate with the criminal subculture Current acute stressor(s) (rejection, loss of significant support, etc.) No reported use 3-4 drinks per More than 5 drinks per week and/or uses week and/or uses illicit illicit substance 1- substances 3 times or 2 times per week more per week and/or has unlimited access to alcohol/illicit Spends no time with antisocial peers No significant stressors (0-3 on a 10 point scale of severity) Spends some free time with antisocial peers Some stressors (4-7 on a 10 point scale) non-life threatening illness, breakup of long term relationship, unplanned move substances Spends most of free time with antisocial peers Significant stressors (8-10 on a 10 point scale) death of loved one, expulsion from school, recent victimization, multiple moderate stressors