BCMHA. Referral Package

Transcription

1 BCMHA The Burnaby Centre for Mental Health and Addiction Referral Package Contents Pages 2 5: Referral Package Information Pages 6 16: Referral Form Pages 17 18: Client Information Page 19: Referral Package Checklist Page 20: Directions & Map Revised January 17,

2 The Burnaby Centre for Mental Health and Addiction Referral Package Information The Burnaby Centre for Mental Health & Addiction (BCMHA) is a 100 bed residential treatment program for BC residents with concurrent disorders. The vision of the program is to provide leadership in multidisciplinary complex concurrent disorders treatment, education, treatment development, and interventional research. The Centre is a provincial, tertiary resource and all referrals must be made through a designated referral agent within one of the provincial health authorities. The program length is 6 9 months. Admission Criteria Clients need to meet the following criteria to be considered for the program at BCMHA: Mandate Complex Concurrent Disorders (Substance Addiction and Mental Health Disorder); BC Resident age 19 and older; and Independent in Activities of Daily Living. The BCMHA mandate is to provide service to clients who present with severe and complex concurrent disorders. In addition, the clients who are typically referred for treatment at the Centre often have: Serious impairment in functioning (employment, personal safety, housing, etc.). Chronic medical issues. Behavioural concerns. High use patterns of specialty hospital, tertiary, or psychiatric emergency services (MHES). High involvement with the Criminal Justice system. Difficulty accessing or maintaining involvement with traditional Mental Health and Addiction services. Additional Considerations The following will also be considered when assessing clients for appropriateness for admission or timing: Current Client Mix: To ensure safety for all, client mix will be considered: e.g. Number of clients with significant medical, behavioural, or severe psychosis/mood will be balanced. Health Authority Resources: The referring health authority must demonstrate they have exhausted the resources in their Health Authority region. Mental Health and Addiction Team Connection: Clients must be connected to a Mental Health and Addiction Team for continuity of care and discharge planning. Activities of Daily Living: Clients need to have the ability to be independent in their activities of daily living including eating, toileting, and mobilizing. Capacity to benefit from BCMHA programming. Revised January 17,

3 Exclusion Criteria Severe Violence Arson/Fire Setting Sexual Activities Involving Minors If you are unsure if your client would be excluded based on the above criteria please contact the Access and Discharge Coordinator or Health Authority Liaison for a further discussion. Due to the location/proximity of the BCMHA to a youth treatment Centre, any clients with a history of sexual activities involving minors cannot 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 a client is admitted to BCMHA, and it is subsequently found there is a current issue with respect to the factors above, the client will be discharged and responsibility for implementing any community care plan will remain with the home health authority. Note: BCMHA building and grounds is a designated smoke free environment in accordance with Vancouver Coastal Health, Municipal, Work Safe and Provincial Guidelines. We have a well established smoking cessation program for clients including a full range of nicotine replacement therapy, medications and smoking cessation programming. Program BCMHA provides specialized, evidence based, services for the assessment, stabilization and treatment of concurrent disorders clients while providing an integrated clinical approach. A full range of pharmacological management, including methadone maintenance, is provided. A multidisciplinary team including psychiatrists, physicians, nurses, occupational therapists, social workers, pharmacist, dietician, recreation therapists, psychologists, mental health & addiction support workers, art therapists, music therapists, spiritual care practitioner, peer support coordinator, family and consumer coordinator, acupuncturist, yoga therapist, physiotherapist and teacher will collaborate with clients to meet their treatment goals. The program is divided into two phases: Assessment/Stabilization (locked unit) and Treatment/Psychosocial rehabilitation (open units). Continuing consultation with the Key Contact Person from the client s home health authority will occur throughout the stay BCMHA. All clients are expected to engage in treatment; including a minimum of three daily groups. Note: Recommendations will be made in consultation with the Key Contact Person in the client s home health authority at the end of the assessment/stabilization period (average 4 6 weeks). Recommendations may include further treatment at the BCMHA or referral to other program/services. Care Planning Each client will be assigned a multidisciplinary team that will work with the client on care planning. The plan will be client centred, evidence based and informed by a strength based, recovery focused, and trauma informed model of Revised January 17,

4 care. BCMHA believes recovery is a process of change through which individuals improve their health and wellness, live a self directed life, and strive to reach their full potential. Discharge Planning Discharge plans will begin prior to admission by the client s mental health and addiction team in their home health authority. This plan will be updated by the BCMHA care team with the client s Key Contact Person from the client s home health authority as soon as the client completes their assessment with appropriate recommendations and treatment goals. The social worker will work with the client, the BCMHA care team, and the client s Key Contact Person to determine a best fit for aftercare ensuring a continuum of treatment whenever possible. The Key Contact Person in the home community will be supported by the BCMHA team on discharge planning as well as throughout the client s treatment. The BCMHA team will provide recommendations based on assessments for the appropriate level of housing and for further treatment/follow up. The home health authority Key Contact Person will be responsible to secure discharge placements and return client to home health authority. Each client will need to arrive with an early exit discharge plan in case of an early, unplanned exit from the program. An early exit could result from: Self discharge of a voluntary client. Client presents with one or more of the following risk behaviours and is unwilling to engage in care planning activities aimed at curtailing behaviours: continued threats, physical or verbal abuse, intentional physical assault, persistent drug and alcohol use, dealing on site, recruiting co clients into illegal or harmful activities. Determination that BCMHA is not appropriate or therapeutic for treatment of the client at this time. At 2 3 months, post transition back to the home health community BCMHA will connect with the Key contact person to understand current client functioning. The feedback received will help us as we continue to develop programming at BCMHA to ensure best results for clients while at the Centre and upon re integrating back to their home community. Referral Process The Referring Professional/Key Contact Person will forward the completed referral package to their Health Authority Liaison for screening (refer to page 5). If the health authority screening process approves the client referral, it is then sent to the Access and Discharge Coordinator. Once all required information is received by BCMHA, the clinical team reviews the referral within two business days and makes a decision on appropriateness of the client to the BCMHA program. If the client is accepted, a bed will be offered. If a bed is not immediately available, the Health Authority Liaison will place the client on their waitlist. Once a bed is available, the Access and Discharge Coordinator will inform the Health Authority Liaison of the available date and time for admission. The Health Authority Liaison will inform the Key Contact Person who will arrange for the client to safely travel to BCMHA and confirm client s admission date/time. If a client is not accepted, the Access and Discharge Coordinator will contact the Health Authority Liaison with a rationale and alternate recommendations. Revised January 17,

5 Thank you for referring your client to our program. If you have further questions please contact the Access and Discharge Coordinator or Health Authority Liaison who will be able to assist you in completing the form and provide you with further information. Please forward the completed referral to the specific Health Authority Liaison. Contact Information of Health Authority Liaisons Vancouver Coastal Health Authority Tertiary Mental Health & Addictions Services Central Access & Discharge Phone: , local 2270 Fax: Fraser Health Authority Referral Coordinator Phone: , Fax: Interior Health Authority IHA Burnaby Centre Access Committee Phone: Fax: Vancouver Island Health Authority MHSU Coordinator Regional Access and Flow Phone: ext Fax : Northern Health Authority Regional Tertiary Bed Utilization Coordinator Phone: Fax : [email protected] BCMHA Access and Discharge Coordinator Phone: , local Fax: [email protected] Revised January 17,

6 The Burnaby Centre for Mental Health and Addiction Referral Form Date of Referral (day/month/year): / / Name of the referrer: Contact number: PLEASE PRINT CLEARLY IN BLACK INK AND LEAVE NO BLANKS Admission criteria Clients need to have the following items to be considered for the program at BCMHA: Both substance addiction and complex mental health disorders; May have complex medical and/or behavioural issues; BC resident age 19 and older; and Independent in Activities of Daily Living. Referral Information Health Authority: Hospital Referrer: VCH DCC PHC PHSA FH VIHA NH IHA Hospital, Unit and Psychiatrist: NA NA Address: City: Province: Postal Code: Telephone: Fax: Mental Health and Addiction Team/Care Team: Key Contact Person: Community Physicians Name: Community Psychiatrists Name: Telephone: Telephone: Telephone: Fax: Fax: Fax: Revised January 17,

7 Legal Name: Client Information Preferred Name (s): Date of Birth: (day/month/year): / / PHN: Female: Male: Other: (Please Specify): Marital Status: Married Single Common Law Divorced Address: Contact Number: City: Province: Postal Code: Independent Current Living Situation Partner / Family Treatment Centre Supportive Housing Detox Centre Will client be able to return to the current living situation: Yes No If no, provide rationale: Homeless/Inadequately Housed Children Involvement Family Involved in Care Yes No Does the client have minor children? Yes No Is the client a custodial parent? Yes No Is a Child Protection Worker Involved? Yes No Please provide a brief description details, including contact information: Name (s): Telephone: Revised January 17,

8 Aboriginal: Yes No Cultural Information Status: If yes, provide status number: Non Status: Cultural Group: Cultural/Spiritual specific care practice(s): English French Mandarin Cantonese Spanish Primary Language: German Japanese Hindi Tagalog Arabic Other: Is there a need for an interpreter? Yes No Are there barriers to communication? Yes No If yes, provide a brief description: Emergency Designated Contact Person (Family/Friends) Name: Telephone: Relationship: Is there an identified Substitute Decision Maker (SDM)? Yes No If yes, Please provide contact information for SDM Name: Telephone: Power of Attorney/Trustee Is there a Power of Attorney in Place? Yes No If yes, provide a brief description: (e.g. finances, treatment decisions, etc.) Is there a Trustee? Yes No Name: Telephone: Revised January 17,

9 Government/Service Agency Supports CPP Yes No If no, has an application been submitted: Yes No NA Pension (other than CPP) Yes No If no has an application been submitted: Yes No NA Housing subsidy Yes No If no, has an application been submitted: Yes No NA Disability benefits Yes No If no, has an application been submitted: Yes No NA Plan G Yes No If no, has an application been submitted: Yes No NA PharmaCare Yes No If no, has an application been submitted: Yes No NA Other (i.e.: other insurance) Yes No If no, has an application been submitted: Yes No NA Legal/Forensic History Is client certified under the Mental Health Act? Yes No If yes, please include copy of certification forms and date of review board panel (if available): Does the client have Forensic History/Criminal Record? Yes No If yes, provide a brief description on past and recent history. Provide/attach any relevant information (e.g. forensic assessments and legal documents). Are there current charges pending? Yes No If yes, provide a brief description: Is the client on probation? If yes, attach. Probation Officers contact name: Upcoming court dates: Yes Contact number: No Revised January 17,

10 Diagnostic Information Psychiatric Diagnoses (Axis I): Personality Disorders and Developmental Disabilities (Axis II): Note: For brain injury/fasd or cognitive disorder: provide a brief description of cognitive disabilities and attach any collateral assessment/reports (e.g. most recent assessment(s) from psychiatry, O.T, psychology etc.) Medical and Mobility Concerns (Axis III): Psychosocial and Environmental Concerns (Axis IV): Global Assessment of Functioning (Axis V): History of Substance Induced Psychosis: History of Delirium Tremens (DT s): History of Seizures with Withdrawals: Yes No If yes, indicated last known seizure: Describe any Non Suicidal Self Injurious Behaviours (suicidal behaviour(s) to be noted on pg. 13): History of Aggression: Yes No If yes, attach a brief description of history of verbal and/or physical aggression incidents, out comes and last occurrence (e.g. throwing objects, yelling, under the influence of substances). Effective Intervention(s): History of Arson/Fire Setting: Yes No If yes, attach documents/provide a brief description of the incident(s), out come and last occurrence. Allergies: Yes No If yes, provide type of reaction(s): Provide the status of the following: Hepatitis A: Hepatitis B: Hepatitis C: HIV: Last TB Test: provide date and results: Past Surgeries (Date): Medical Dietary Concerns: Yes No If yes, provide a brief description: Mobility Issues: Yes No If yes, provide a brief description; attach any collateral assessments (e.g. O.T.) Current Medications (List/Attach): Revised January 17,

11 Home Health Authority Resources Has client exhausted home health authority resources Yes No If no, provide a rationale why a referral has been made: If yes, indicate approximate year and attach/provide the following: A brief description of prior and recent mental health and addition programs client has been involved in. What resources has client attempted/tried. Why the client is not able to benefit further from local resources and requires BCMHA. Note: This information is required to gain an understanding of what services have been utilized. Identify Client Stated Goals: Client s Stated Goals Revised January 17,

12 *Please indicate Primary Substance(s) of choice Primary Route Date last used (Day / Month / Year) Substance Use Pattern # Days of use in last 30 days Typical amount used daily Age at first use Current pattern Stage of change Alcohol Non beverage Alcohol (mouthwash) Tobacco Cannabis Crack Cocaine Cocaine Heroin Opioids Benzo Crystal Meth Amphetamines Hallucinogens Inhalants Gambling Sexual activity Pornography Other (Please Specify) include designer/synthetic drugs Revised January 17,

13 Brief Psychiatric Rating Scale Date Completed: (day/month/year): / / Completed by Health Care Provider Print full name: If you identify a rating of 3 and above of any of the below symptoms: provide/attach a brief description. Symptoms Depressive Mood Suicidal Ideation Elation Grandiosity Hostility Suspiciousness Unusual Thought Content Hallucinatory Behaviour Conceptual Disorganization Disorientation Rating Scale Not Present Mild Moderate Moderate Severe Very Mild Severe States Reports depressed; may States severe feelings discouragement, be some episodes of of despair & not depression; crying, sad tone pessimism; may cry, face does not show throughout interview. moan, show extreme depression. sadness. Patient reports some passive thoughts of suicide but has made no plan. Seems unaccountably happy, too cheerful. Mildly arrogant or boastful but in good contact with reality. Reports minor irritation toward people other than the interviewer. Expresses mild suspiciousness of others Patient presents a hint of unusual or idiosyncratic beliefs, but they are not delusional. Reports one equivocal hallucinations, experience in past 24 hours. Minor difficulty following patient s train of thought, no TF disorder. At one point in the interview, there is a hint of confusion about person, place or time. Patient reports some active thoughts of suicide but has made no plan. Unrealistic high feeling, giddy, demands contact. Inflated self opinion, but not delusional. Reports animosity toward figures in his environment other than interviewer. Pervasively suspicious & tends to blame others but is ordinarily nondelusional Expresses unusual or bizarre ideas; if delusional, distortions can be corrected with assistance. Reports definite hallucinations in past 24 hours, but describes them as unreal. Much difficulty following patients thought, in unstructured parts of interview. Patient has clear confusion re: person, place or time, but confusion can be corrected. Patient reports frequent active thoughts of suicide and has made a plan. Seems almost intoxicated. Laughing, giggling, euphoric. Delusions of grandeur. Expresses intense animosity toward others without out obvious justification. Extreme suspiciousness, with delusions of persecution or ideas of reference Patient expresses bizarre & delusional ideas. Reports definite hallucinations in past 24 hours and describes them as real. TF disorder (confused, disjointed, blocked, confabulated, illogical). There is clear confusion in identifying 2 of the 3 variables, this confusion can't be corrected. RATING N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Revised January 17,

14 Overall Motivation to Engage in Abstinence Focused Mental Health and Addiction Treatment Pre contemplation Contemplation Preparation Action Early Exit Transition Plan The following plan will be put in place if I leave early from the Burnaby Centre for Mental Health and Addiction. I understand that while I continue treatment at Burnaby Centre a 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 my referral liaison and physician will be notified immediately. Client Name: Community / Health Authority: Address and Contact Number: City: Shelter Other MH&A Facility Residence Other (Please Specify): How long would this be clients early exit plan Signatures Client: Date: Key Contact Person: Date: It is the responsibility of the Key Contact Person to enact the early exit plan if indicated. The Key Contact Person agrees to the repatriation of the client upon discharge from the BCMHA. BCMHA is not able to have a client remain at BCMHA until appropriate housing is found nor will the BCMHA team be connecting client to relocation resources. Revised January 17,

15 Medication Declaration Medication Dispensing Patient Declaration: Note: this is a requirement for PharmaCare for weekly dispensing. I declare that I need PharmaCare coverage of additional dispensing fees due to weekly requirements of the Burnaby Centre for Mental Health and Addition for dispensing my medications. I provide consent to notify my prescriber. I hereby consent to the release of this information to the Ministry of Health and/or Health Insurance BC. The information will be relevant to and used solely for the purpose of determining and administering my PharmaCare benefits. I understand that my PharmaNet records are subject to routine audits by the Ministry of Health to ensure compliance with Frequency of Dispensing Policy. Personal information on this form is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act. For more information, contact Health Insurance BC. From Vancouver call Client: Key Contact Person: Signatures Date: Date: Revised January 17,

16 Smoke free Acknowledgement for The Burnaby Centre for Mental Health and Addiction Notice of recent change at BCMHA regarding tobacco use: I am aware that the Centre and grounds are a designated smoke free environment. For clients who are motivated there are many resources for staff to empower clients in our smoke free community. I will not use tobacco products anywhere on Centre grounds. I will not smoke in my room, inside the facility, or outside the facility on Centre property. This includes not only clients but also staff and visitors. I will not bring tobacco products, lighters and other smoking paraphernalia onto the treatment units. I will keep all tobacco products in a locker by reception, which is available for rent with vouchers. I understand and accept that all tobacco products and paraphernalia found on the treatment units will be destroyed by Centre staff. No e cigarettes or nicotine free cigarettes are allowed. I understand and accept that repeated violations of smoke free policies will result in discharge from the program. I am aware that the Centre has a well established program for smoking cessation a full range of nicotine replacement and psychosocial treatments are available at the Centre. We are not requiring clients to quit, rather, staff will work with clients to respect the guidelines set out by this provincial mandate. This is similar to smoke free legislation in malls, beaches, parks, etc. Client Name (PRINT) Client Signature Date Witness Signature Revised January 17,

17 The Burnaby Centre for Mental Health and Addiction Program Client Information The Burnaby Centre for Mental Health and Addiction (BCMHA) wants to welcome you and hopes that your stay allows you to achieve your recovery goals. To help you achieve your goals, BCMHA uses the recovery model and believes recovery is a process of change through which individuals improve their health and wellness, live a self directed life, and strive to reach their full potential. All therapy decisions are based on this model. Once you arrive at the Centre, you will meet with the treatment team to identify your strengths as well as medical, mental health and addiction concerns. During your stay, you will be expected to participate in goal setting, care planning and treatment programs. If at any time during your stay, you or the team determine that BCMHA is not the most appropriate care environment for you, we will work with your case manager to find alternate treatment options. After the initial assessment and stabilization period of approximately one month which takes place in a locked unit, you will transfer to the treatment unit. In the treatment unit (one of three open units), many different clinical staff members will support you in achieving your goals. It is expected that you will participate in group therapy that focuses on addiction issues, healthy living and mental health issues. BCMHA will support you in living a healthy lifestyle and achieving the goals that you develop with your treatment team. We base our programs on individual recovery and develop plans for each person coming into the Centre. The Centre offers a wide variety of professional support to meet your needs. While at BCMHA, we will ensure that you have the opportunity to stay in contact with your community health provider to discuss your progress and make plans for your return to your home community. The amount of time spent at the Centre will vary depending on your individual needs, but is typically six to nine months. Nine months is the maximum length of stay. Important Information: BCMHA has both single and double rooms (a single room cannot be guaranteed). Other clients or visitors are not allowed to visit within your room. All meals, snacks, and coffee are provided. You may not store food in your room. Regular visiting hours: 6pm 8pm on weekdays and visiting hours weekends and holidays: 1pm 4pm; 6pm 8pm. The care team and client work together to identify support people in the community who can visit. Do not bring cell phones to BCMHA. Landline phones are available at the Centre for clients to use. I will provide urine drug screens and breathalysers when requested by the staff. Staff may conduct random room searches in my room throughout my stay at BCMHA. Electronic devices that are appropriate are: alarm clocks, small radio and MP3 player. Do not bring computers, laptops, TV s or any devices that have internet access, camera, phone or recording ability. Computers with internet access are available at BCMHA. The BCMHA does not provide any storage. Personal items will need to fit in a Rubbermaid container (107cm: length x 53cm: width x 42cm: height). Excess items will be removed at your expense or donated/disposed of. Revised January 17,

18 Important Information continued BCMHA is a scent free environment, any perfumes or scented products will not be allowed in the Centre. Do not bring valuables or large sums of money to the BCMHA. BCMHA is not responsible for any of your personal belongings. You will not be reimbursed for lost/stolen/damaged/missing items. Belongings left at BCMHA following discharge will be donated to charities. Free laundry facilities are available. Physical violence, onsite drug use/possession/dealing/sharing, or recruitment of others into criminal activities will result in discharge from the program. Do not bring weapons or items that can be used as weapons (i.e. knives, razor blades, scissors, tools etc.) to BCMHA. Any items of this nature will be confiscated and appropriately disposed of and may result in discharge. No parking will be provided, so please do not bring a vehicle to the site (unauthorized vehicles will be towed). You are expected to attend a minimum of three or more groups per day. The BCMHA building and grounds are designated smoke free environment in accordance with Vancouver Coastal Health, Municipal, Work Safe and Provincial Guidelines. We have a well established smoking cessation program including a full range of nicotine replacement therapy, medications and treatment programming. Tobacco products and paraphernalia will not be allowed on the units (clients may rent lockers for storage during therapeutic passes). Tobacco products/paraphernalia found on units will be confiscated and disposed of. What Should You Bring? Clothing that is comfortable, appropriate, and suitable for in residence living and outings to the general community (under garments, sweat pants, long/short sleeved shirts, sweater, socks etc.). Personal hygiene items are to be scent free. Bring only two days worth of prescription medications if you are coming from the community. All prescription and non prescription medications will need to be handed to your care team on arrival. Any excess medications will be disposed of by our pharmacy. Small items that are comforting to you (avoid items that are not allowed). Participation Agreement I have read the above Client Information (pages 17 18) and agree follow the above mentioned BCMHA guidelines. Signatures Client: Key Contact Person: Date: Date: Revised January 17,

19 Referral Package Checklist Hospital referrals: (attached collateral: admission notes, updated MAR, recent psychiatric consults, AWOL s, pass levels, substance use pattern prior to hospitalization, forensic assessments, etc). Certified: attached copy of current series of certifications. Please include original Form 4 s. Probation/bail: attach conditions or orders. Medication: attach current list if not listed on p.10 Attach any relevant discharge summaries, psychiatric assessment, clinical assessment, care plans or supporting/legal documents. Aware that not providing information needed may cause delay in processing client s referral. Aware of the Key Contact Persons role as outlined in the referral. Role of the Key Contact Person: The client s Key Contact Person will be a collaborative member in the client s care, will provide collateral information as needed during the referral process and stay at BCMHA, would initiate referrals/transfer to community resources within and outside of the home health authority as needed. BCMHA would be providing assessments, recommendations, and updated collateral. Thank you for referring your client to our program. Revised January 17,

20 Directions and Map: The Burnaby Centre for Mental Health and Addiction is located at 3405 Willingdon Avenue in Burnaby, B.C., V5G 3H4, Building # 28. For further information please call Reception at and press 0. Arriving By Car from Hwy 1: Take exit marked Willingdon Avenue south bound. Head south bound along Willingdon Avenue past Canada Way. There will be a driveway entrance on your right hand side ½ block past Canada Way. You will see a government sign at the entrance to the parking area. Once you turn right into the drive way, over flow parking will be directly in front of you and to your left. To reach the main facility you must go right. Once you turn right from the driveway the Provincial Assessment Centre (PAC) facility will be on your left hand side. Do not park to the right of PAC there as this is another facility not affiliated with BCMHA. BCMHA will be located in a large parking lot towards the corner of Canada Way and Willingdon Avenue. Parking will be located in front of the facility where you will notice a British Columbia flag. Once you have parked a parking pass MUST be placed on your dash. The parking passes can be found at the front reception. Front reception can be found by going up the curved staircase at the front of the building. If you are traveling by bus and or skytrain please contact Translink at for specific traveling details. The following is a Google Map of the area Revised January 17,