Referral Package Contents:

Transcription

1 Referral Package Contents: Pages 2-3: Program Description Pages 4-6: Client Information Package (to be given to client at time of referral) Pages 7-15: Referral Form Last revised: March 16, 2015

2 Referral Package Completion Checklist Please note: This package is intended to be completed by a health care professional in collaboration with the client. Before submitting this package to your local Health Authority for processing, please ensure the following tasks are complete: Complete the attached referral form. Include the following collateral information if available and appropriate: Current psychiatric and/or medical consult Counsellor notes Current MAR In consultation with the client, complete and attach the Early Exit Transition Plan form and Participation Agreement. Please ensure it is signed. Attach current funding for the duration of the 90 day program including coverage for medications while in treatment. TB test (within the last 12 months) complete and attached Reviewed resident guide with client (found at: The above components constitute a completed referral and will be reviewed by the Heartwood Admission Committee once received from the Health Authority screening committee. MSD Funding Verification Instructions: 1. Complete the top part of the form with the referral agent details, the client name and SIN# 2. Client must take the form to their ministry office who will complete it and fax back to the referral agent 3. Please send the completed form together with the referral application 4. For all other funding, please follow the instructions on the referral form Referral Information Package Heartwood, a residential treatment program, is a provincial tertiary 28 bed resource for women with substance use, mental health concerns (including trauma) and primary health and/or chronic disease issues. Program length: 90 days. Inclusion criteria: Current substance use disorder BC females (including transgendered women) ages 19 and older Independence with activities of daily living Not everyone with substance use requires residential treatment. Generally women who will be accessing this program have substance dependence with other health concerns including mental health issues and physical health concerns. Community based treatment services have not been effective or perhaps unavailable for this group of women. They may have had many attempts at treatment across a wide range of services. Heartwood s goal is to provide a safe treatment environment for women to establish a solid foundation of recovery, stabilize all health concerns and plan for ongoing supported recovery in the community following discharge. Program: Heartwood is a comprehensive gender responsive treatment program which addresses women s bio-psycho-social spiritual needs. An interdisciplinary team including nurses, physicians, counsellors, social worker, recreational therapist, dietitian, yoga therapist, expressive art therapist and acupuncturist collaborate with women to help them meet their treatment goals. The program is divided into two. The first is the S.T.A.R. program (stabilization, assessment and retreat). Women are in S.T.A.R. for two weeks. This program assists the women to stabilize in their physical and mental health. Addiction medicine and nursing assessments are completed during this time. Referrals for psychiatric assessments are also completed as Page 2 of 16

3 required. Withdrawal management will be addressed and other treatments such as methadone, tobacco dependence treatments, primary health care, nutritional interventions, acupuncture as well as group work will be provided. The second phase is Treatment. During this phase women can expect to be involved in individual and group counselling (with the emphasis on group), alternative therapies and recreation therapies. Treatment approaches are trauma-informed and include but are not limited to cognitive behavioural therapy, motivational therapy, DBT, mindfulness based therapy, psychoeducation, skill development, pharmacotherapy, nutritional support, 12 step programs and peer support. Treatment Planning: Heartwood empowers women to collaborate with their treatment team to develop a client-centred treatment plan. This plan is reviewed throughout the program. The designated community case manager is contacted to ensure continuity of care during the woman s stay at Heartwood. Transition Planning: Transition plans begin as soon as the women complete their stabilization. The social worker works with women and their treatment team to determine a best-fit for aftercare ensuring a continuum of treatment whenever possible. The Social Worker liaises with the case manager in the home community and collaborates on transition planning throughout the women s treatment. A transition plan is established in case of an early exit from the program in order to ensure safety for the women returning to her home community. In order to ensure a smooth transition it is recommended that the woman have a simple re-entry plan upon referral. A more comprehensive transition plan is developed collaboratively throughout treatment with the woman, the social worker and the support system in her home community. Please review Heartwood s exclusion criteria: Arson/fire setting Sexual activities involving minors Severe violence Please contact Heartwood if your client has a history of severe violence and/or arson/fire setting, current self-harming and/or eating disorder as these criteria can be discussed based on history and severity, but due to the location of Heartwood any sexual activities involving minors will not be accepted. If the client s history with respect to these factors is not known to you, please investigate to the best of your ability. If the client is admitted to Heartwood and it is subsequently found there is a current issue with respect to the factors above, the client will be discharged and responsibility for the community care plan including housing will be the responsibility of the referring Health Authority. Physical violence, alcohol or drug use on premises or on outings with staff, drug dealing/sharing and/or recruitment of other women into gangs or the sex trade will result in discharge from the program. Additional Considerations: The following will also be considered when assessing clients for appropriateness for admission: Current client mix: to ensure a therapeutic environment for all clients, the client mix will be balanced with each admission: i.e. Number of clients with high medical needs, number of clients with severe behavioural issues, number of clients with unstable psychotic/affective disorders. Mental health and addiction team connection: clients must be connected to a mental health and/or addiction team for continuity of care and discharge planning. Activities of daily living: clients must be independent in their activities of daily living including eating, toileting, transferring and mobilizing. Thank you for referring your client to our program. If you have further questions please call or check the website Page 3 of 16

4 Client Information Package The Heartwood Centre for Women is a community of staff and residents. The overall Heartwood Team includes many professionals that are here to assist you in your recovery. You will have a treatment team who will help guide you through your stay at Heartwood. The community is here to help and support you - we want you to succeed and will help you as much as possible. What we do: The Program will help you to: Identify your strengths and apply them to a long-term recovery plan; Improve your emotional, physical and mental well being; Understand the role drugs and alcohol have played in your life; Understand the role of mental wellness with substance use; Set realistic goals and learn how to live without depending on drugs and alcohol; Learn skills to improve the quality of your family and community relationships; Learn how proper nutrition can contribute to your recovery and overall wellness; Participate in regular fitness and leisure activities to support your recovery; Decrease your involvement with the law; Re-enter the community after treatment; Complete applications for services such as income assistance and housing. The Program: Heartwood Centre for Women provides a full 12 weeks of treatment programming. The first 2 weeks begins as the STAR Program. S.T.A.R. (Stabilization, Assessment and Retreat): In order to focus on your program, you will be on retreat during this time. You will be asked not to have contact with anyone outside of the program unless it is an emergency and organized by staff. You will also not leave the program area without staff permission. The first one to two weeks of the program, you will meet with the nurse, nurse practitioner, physician, and social worker. This is your treatment team and they will help you set goals for your treatment. The goals for this stage include managing withdrawal from substance use, identifying and treating medical and mental health issues, developing stable daily routines, learning to live in a community, developing healthy sleep and hygiene habits and learning to engage in structured programming. If you smoke, on day one of S.T.A.R. you will be asked to abstain from tobacco use and be treated with a variety of nicotine replacement therapies (as appropriate). You will be asked to begin to attend a smoking cessation group which continues throughout your treatment. The Acupuncturist at Heartwood works closely with clients to attend to physical and emotional health concerns through the use of acupuncture techniques and various complementary therapies such as Energy Psychology, ie Emotional Freedom Technique. Acupuncture can treat a wide range of health concerns, including, but not limited to headaches, phobias, asthma, arthritis, addictions, menstrual cramps, lower back pain and carpal tunnel syndrome. Expressive Art Therapy and Yoga also assist you to engage in the STAR program. Treatment Ten weeks of the Heartwood Program is dedicated to intensive treatment. Group programs address substance dependency, trauma, mental and physical health issues. A team of professionals including physicians, nurses, nurse practitioner, social worker, counsellors, recreation therapist and a dietitian work together to provide care for you. Other specializations such as an acupuncturist, expressive art therapist and yoga instructor also provide regular sessions each week to assist you in developing alternative methods of coping with symptoms and managing difficult feelings. Page 4 of 16

5 A structured program supports your recovery journey by providing groups and activities focused on substance dependency, trauma, women s wellness issues, pain management, physician-led wellness groups, smoking cessation, mindfulness practice, relapse prevention skills and emotional regulation skills. During your program you will plan your treatment with your team by identifying your strengths, your personal vision of recovery and goals which will lead you towards this vision. Family Programming: The Heartwood Family Program is an information and education group for clients and the allimportant people who support them in their journeys to recovery. All clients attend and it is our hope that those whose families are within travelling distance will encourage their loved ones to participate as often as they possibly can. This is a valuable opportunity for clients and families to meet together in a respectful and supportive learning environment. This is also a chance to come to a clearer understanding of how addiction has affected both client and family members / significant others. Having attended the Family Program together, clients and their loved ones will also have a better understanding of what to expect and how to support one another after treatment, as the journey of recovery continues. Aboriginal Program: Aboriginal specific programming includes a weekly Talking Circle with an Elder, the opportunity to attend sweats, use of smudging, and attending weekly family/pow wow nights at the Native Friendship Centre. Important Information There is a two-week retreat period upon admission whereby you will be asked not to communicate with outside family or supports. In the case of an emergency special consideration will be given through your primary counsellor All rooms are shared occupancy. Physical violence, alcohol or drug use on premises or while on outings with staff, drug dealing, sharing and/or recruitment of other women into gangs or the sex trade will result in discharge from the program. Family visits are on Sunday from 1:00-6:30 pm. Family programming sessions are conducted on Sundays. Family programming attendance and participation is mandatory for all clients Heartwood is a tobacco free environment and abstinence from tobacco is requested upon entry to the program (Nicotine Replacement Therapy is provided). Smoking anywhere in the building will result in being discharged from the program. Cell phones and cameras are not permitted for the duration of your stay. No personal lap tops or other devices will be allowed in the program. If you receive Income Assistance, you will receive only your comfort allowance while in the program. Please ensure that you have made arrangements with your financial worker to cover your entire rent while in treatment. If you are not on income assistance please bring a small sum of money for outings. You are discouraged from bringing larger sums of money to the program or valuables. (Heartwood is not responsible for valuables, personal lockers are in each room and locks are provided). Free laundry facilities are available All food and snacks are provided. Outside food is not permitted while in the program. Day Passes are scheduled with your treatment team as your treatment progresses and are not planned during the S.T.A.R. program. Heartwood and the hospital within which we are located is a scent free environment. Any perfumes or scented products will not be allowed in the building. Please bring with you shampoo, soap, deodorant, toothpaste which is as scent free as possible. Please review the resident guide. Please only bring one suitcase and one shoulder bag with you as we have limited storage space. Page 5 of 16

6 Directions and Map Arriving By Car: Enter the parking lot at 29th and Heather Street. Proceed through the 4-way stop. Heartwood is on the 5 th floor of building 77, the first building on the right. A staff member will meet you in the reception area. Arriving By Bus: A taxi from the Vancouver bus depot will cost approximately $ Tell the driver that you want to go to the 29th and Heather entrance for the Women s Health Centre. City busses stop at 29th and Oak but walking in with luggage is difficult. Public transportation information and routes can be found at: Arriving From Airport: The easiest and quickest way to arrive here from Vancouver International Airport is by Taxi which will cost approximately $ Page 6 of 16

7 Referral Form Referral Criteria A referral may be made by a Case Manager A referral may be completed by another clinician in collaboration with the client s Case Manager Admission Criteria Current substance use disorder Female (including transgendered women) BC resident age 19 and older; and Independence in activities of daily living. Date of referral (day/month/year): Client s Legal Name: Referral Information Preferred Name(s): Health Authority: IHA FHA NHA PHSA VCHA VIHA Referring Practitioner: Name of Organization: Address: City: Province: Postal Code: Telephone: Fax: MH&A Case Manager: Ph: Fax: Address: Physician Name : Ph: Fax: Psychiatrist: Ph: Fax: Client Information Female: Transgendered: M/F F/M Date of Birth: Age: PHN: Address: City: Province: Postal Code: Telephone: Marital Status: Married Common Law Single Divorced Separated Widowed Pregnant: Pregnancy Due Date: Does the client have minor children? Names Age If under 19, what is the child s current living situation? Page 7 of 16

8 Is client custodial parent? If no, who has custody of child(ren)? Please provide details, including contact information and MCFD contact information (if appropriate): Telephone: Fax: Cultural Information Do you identify yourself as an Aboriginal person that is First Nations, Metis or Inuit? If you identify as an Aboriginal person are you: First Nations Metis Inuit Status: Status #: Band: Ethnicity: First Language: We invite you to let us know if there are any spiritual or religious practices or ceremonies that will support your wellness while at Heartwood: Name: Emergency Designated Contact Person (Family/Friends) Relationship: Telephone: Is there an identified Substitute Decision Maker (SDM)? Name: Telephone: Substance Use Treatment Withdrawal management and treatment History (Please list all previous treatment and dates): If no previous residential treatment history, is this due to lack of services available in community? If no, please outline reason why treatment at a different facility has not been considered at this time: Page 8 of 16

9 Please provide us with the client s identified goals for treatment (please ensure this is provided by the client) History Substance Use Please fill this section out completely. Please put N/A next to the item if not applicable Drug of choice (list top 3) Primary or Route Date last used (DD / MM / YY) # Days used in last 30 days Typical amount used daily Alcohol Tobacco Cannabis Crack Cocaine Cocaine Heroin Opioids Benzo Crystal Meth Amphetamines Hallucinogens Inhalants Other (Specify): Age at 1 st use Stage of change Gambling Sexual activity Pornography Shopping Do you have any history of disordered eating? If yes, please define: Binge Eating Vomiting Restricting Laxatives Excessive exercising Other, please describe: Have you ever participated in treatment for disordered eating? Is your disordered eating still active? When last active? Page 9 of 16

10 Details: Psychiatric History Have these diagnosis been confirmed by a Psychiatrist? Please attach the most recent psychiatric assessment Psychiatrist name: Phone: Medical History Medical History (please describe): HIV HCV History of seizures: If yes, please detail Last TB Test (Date): Past Surgeries (Date): Attach results with this form (Chest x-ray, Mantoux skin test) Mobility Issues: Details: Cognitive Impairment: Details: Head Injury: Details: FASD: Details: Page 10 of 16

11 Current Medications: (please attach MAR if available) Medication and dose Medication and dose Describe any challenges to participating in a group setting: Education Level: Grade 9 Completed high school Post-secondary Safety Concerns If yes to any below, please summarize and date most recent for each one Suicide Ideation/Suicide attempts: Self harming behaviours: Overdoses: Aggression/anger: Current domestic violence: Risk taking behaviours: Independent Housing Safe Unsafe Homeless Housing Type: (e.g. house, apartment, shelter, SRO, etc.) Where is client currently staying? (Please provide name of facility if possible) Post-discharge housing plan? Details: (e.g. shelter, friend s home, parents, etc.) Details: Access to treatment services within community? Page 11 of 16

12 Does the client have a criminal record? Details: Legal Is the client on probation? Are there current charges pending? Details: Probation Officer s contact name: Phone: Upcoming court dates: Criminal Family Date: (Please attach more information if needed): Details: CPP Pension (other than CPP) Disability benefits Plan G Extended Health Income Assistance Employer Extended Health Benefits Other Financial Please provide details if applicable Page 12 of 16

13 Funding Information There is a per diem cost for Heartwood of $40 per day for 90 days for a total of $3600. There are several ways to receive funding: If on Income assistance an application can be made to Ministry of Social Development (form attached). Please ensure that client s rent is covered while in treatment (maximum allowable is $375 per month) If a First Nations woman with status, the client can apply to Health Canada at First Nations and Inuit Health British Columbia Region (Suite West Hastings Street Vancouver BC V6C 3E6 Tel fax ) or may be able to approach their band for funding Self pay. The client must provide a signed letter indicating that the client is prepared to pay the full amount. They are also responsible for paying for all medications while in the program. Heartwood will provide the client with detailed invoices documenting prescription costs. Extended benefits. Heartwood requires a letter from the client s provider that accompanies this application. Clients may apply to their health authority through their Case Manager/Counsellor for accommodation fee subsidy for partial or full payment Treatment program will be paid (please check one box below): Client/Family Paid Please have the client submit a letter from the payee that is dated with the payee signature, confirming they will pay for treatment and provide the following information: Billed to name: Billed to address: Billed to phone: Please note the Provincial Health Services Authority will bill directly for per diem costs each month. MSD - Please complete the form on the next page. Accommodation Fee Please attach the relevant Health Authority Accommodation Fee Subsidy Approval form. Employer Paid Please have the Benefits Administrator from the client s employer call to confirm treatment will be paid. First Nations Health Authority - Please have a First Nations Health Authority Representative call to confirm treatment will be paid. Page 13 of 16

14 TO: MINISTRY OF SOCIAL DEVELOPMENT - FUNDING VERIFICATION FORM Residential Services: Heartwood Centre for Women Ministry of Social Development Office Attn Fax Tel FROM: Name Position Tel Client Name Fax SIN# The above named client has been referred for admission to a qualifying residential addictions program, Heartwood Centre for Women. Prior to admission, the facility requires confirmation that the client s per diem costs (less and non exempt income) will be paid by the MSD (Ministry of Social Development) while in receipt of, and eligible for, income assistance. Client Authorization I, authorize the Ministry of Social Development to confirm my eligibility for funding, and to release any related information to the above name staff. Client Signature Date MINISTRY OF SOCIAL DEVELOPMENT COMPLETE & FAX ABOVE Client has an open and active file YES NO Client has NOT applied for MSD within the last 30 days YES NO Client funding eligibility ELIGIBLE INELIGIBLE Client s per diem will be paid by the MSD as per current eligibility less a non exempt income from other. Sources: Per Diem Rate $40 If applicable Less any non exempt income (monthly amount divided by 30 days) $ Non exempt income from MSD Per Diem for client If applicable Nutritional Subsidy per month Completed by (print name) Signature MINISTRY OF OFFICE STAMP Date Page 14 of 16

15 Early Exit Transition Plan The following plan will be put in place if I leave early from the Heartwood Centre for Women. I understand that as I continue treatment the social worker will assist me to develop a more complete transition plan to ensure my continued support and recovery when returning home. It is understood that if I leave the program on short notice or if I do not arrive for my scheduled intake, my referral liaison and my emergency contact will be notified immediately. Client Name: Date of Birth (Day / Month / Year): Community / Health Authority: Destination upon early exit: Address: City: Shelter Other MH&A Facility Residence Other (Please Specify): Independent Supportive Housing Key Contact for Transition Plan Community Contact for Early Exit Support Name: Telephone: Emergency Contact and/or Next of Kin Name: Telephone: Address: Signatures By signing below, I consent to my referral liaison and emergency contact being contacted. I also understand that If I leave the program early, my physician will be sent an early discharge summary. Client: Date: Health Authority Referral Agent agrees to the repatriation of the client upon discharge from the Heartwood Centre for women Health Authority Referral Agent: Case Manager: Date: Page 15 of 16

16 Participation Agreement I have agreed to apply for treatment at the Heartwood Centre for Women and have reviewed the program services available. I understand that Heartwood is an abstinence-based program and I agree with the following: I will participate in the following activities upon arrival to Heartwood and commit to the 90 day treatment program: Complete a physical examination with the program physician and nurses Meet with the psychiatrist if it is recommended Participate in a medication review upon intake. Will participate in the required bed bug protocol: shower and wash clothing on admission Will treat others with respect, dignity and without discrimination. Participate in an assessment and development of a treatment plan and follow this treatment plan Participate in group and individual counselling programs Will follow the retreat time (2 weeks) of the program and not have contact with outside people unless prearranged with my Treatment Team if there is an urgent need and will not leave the unit without staff permission Work with the Heartwood social worker in order to plan a successful return home after treatment Follow program guidelines including no violence and no recruitment of others into gangs or prostitution. Will restrict or not use any tobacco products during my treatment, consider the goal of tobacco abstinence Will abstain from all drugs, alcohol and over-the counter and pharmaceuticals except medication prescribed by the program physician during my treatment Will not use scents during my treatment Will not leave the program area unless it is planned with my Treatment Team Will restrict visits from family and supports to visiting hours unless otherwise authorized by my Treatment Team Will not bring cell phones, cameras, mp3 players, Ipods or personal data devices Will keep all information about other program participants confidential Will provide urine drug screens and breathalysers when requested by the staff Will provide all prescription and non-prescription medications to the nurse Will share a room during my stay with up to three other women Will not have or store any food items in my room or other non-designated areas of the centre Will keep my room clean and clutter free Will not have individuals in my room except for staff and my roommates Staff may conduct random room searches in my room throughout my stay at the centre Will take all my belonging upon discharge. Belongings left after discharge from the centre will be donated to charity Signatures Client: Referral Agent: Date: Date: Page 16 of 16