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					                 Kaiser Telecare Program
       for Intensive Community Support
    Intensive Case Management Exclusively for Members within a Managed Care System

12-Month Customer Report, January to December, 2006
Kaiser Telecare Program for
Intensive Community Support
The Kaiser Telecare Program for Intensive Community Support (KPFICS)
has been an integral part of Kaiser Permanente’s behavioral health continuum
of care since 1998. KPFICS is an intensive case management program
specifically for Kaiser members, age 18 and over, in San Diego County, that
are high-utilizers of acute inpatient services or are at risk for inpatient
hospitalization. Many of these individuals are also dually diagnosed with
co-occurring substance abuse disorders. The program is client-centered and
client-driven. Clients set their own goals and determine what is important to
them. Staff support the recovery process, assist clients to improve quality of life, and
collaborate with Kaiser psychiatrists and clinical staff to ensure that clients are successfully engaged, making optimal use
of available Kaiser services. KPFICS is unique among Kaiser’s mental health programs in that services are provided in the
community, at locations of the client’s choice, resulting in strong partnerships and client/staff trust.


Service Goals                                                  Moving Forward
The program was established to support Kaiser in               Last year, Telecare and Kaiser initiated a monthly
accomplishing the following:                                   clinical review to help identify clients that could be
    Reduce inpatient hospitalization                           transititioned from the program to lower levels of care.
    Enhance access to community-based services                 With the participation and assistance of Kaiser PFICS
    Provide crisis intervention and support                    staff; Werner Spitzfaden, LCSW; and Roz Cohen, RN,
    Support clients in strengthening life skills and           of Kaiser Permanente, we have successfully identified
    achieving greater independence                             and transititioned members who no longer require
    Expand housing options                                     intensive services. We look forward to continuing these
    Promote education and vocational goals                     consultations to further refine admission and discharge
                                                               coordination. To the greatest extent possible, we will
Major Accomplishments                                          expand these consultations to individual psychiatrist and
In 2006, KPFICS successfully:                                  therapist teams who have expressed concern or interest in
    Reduced inpatient hospitalizations (down 1,251 days)       the client transition process.
    Reduced inpatient admissions 35% over last three years
    Transitioned long-term clients to other types of           Acknowledgements
    supports; negative impacts were minimized and space        Telecare would like to thank and acknowledge Dr. Dennis
    for new client admissions were made available (50%         Cook, MD, EdD; and Linda Thornton, LCSW; Werner
    of members disenrolled during the year had a length of     Spitzfaden, LCSW; and all staff of the Kaiser Psychiatry
    stay of over 730 days which highlights our efforts to      and Addiction Medicine Department for their support,
    transition long-term clients to less intensive services)   partnership and contributions to the program’s success.
    Exceeded Kaiser Permanente target of 24 discharges
    during the year                                            We look forward to many more years of successful
    Partnered with Kaiser Psychiatry and Addiction             collaboration in the support of individuals in recovery.
    Medicine staff to reduce unnecessary IOP (PHP) days
    from 475 in 2005 to 135 in 2006. This represents a
    72% reduction in IOP days at Mesa Vista PHP.
Demographics
                 Enrollments/Disenrollments                                                                                Age
Enrolled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19   18-25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   12%
Disenrolled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28    26-35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     16%
Total members on 12/31. . . . . . . . . . . . . . . . . . . . 47                    36-45 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   18%
Maximum enrollment . . . . . . . . . . . . . . . . . . . . . . 55                   46-55 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   30%
Average census . . . . . . . . . . . . . . . . . . . . . . . . . . 52               Over 55 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     24%

                Length of Enrollment                                                                                   Gender
                 (Current Members)                                                  Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27%
Average enrollment . . . . . . . . . . . . . . . . . . . . . . . . . 818            Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73%
                                                                                    Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%
                                 Ethnicity
Caucasian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74%                                 Primary Diagnosis
African American . . . . . . . . . . . . . . . . . . . . . . . . . . . 9%           Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32%
Latino/Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8%          Bipolar disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . 36%
Asian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3%    Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22%
Pacific Islander . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1%       Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10%
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5%    Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%
                                                                                                            Axis II
                                                                                    Borderline Personality Disorder . . . . . . . . . . . . . . . 39%
                                                                                    Personality Disorder NOS . . . . . . . . . . . . . . . . . . . . 8%




Client Satisfaction
98%        Staff and I worked together on my treatment                              Member Comments When Asked What They Would
           plan; I felt comfortable asking questions about                          Like to See Changed About KPFICS
           my treatment                                                             “Nothing. Everybody treated me like a person and
100% Staff believed I could change and recover                                      with respect.”
97%        Staff were willing to help as often as I felt                            “Nothing. It’s great the way it is.”
           it was necessary                                                         “After discharge, please check up with clients after four
98%        I liked the services I received                                          to five months again and see if they are still doing fine.”
95%        I would still choose to get services from Telecare                       “The program is very good, and there is not much I
86%        As a result of Telecare services, I feel I am better                     would change. Maybe more meetings.”
           able to deal more effectively with daily problems                        “This is a great program.”
76%+ I am better able to control my life and deal with                              “Quicker enrollment.”
     crisis situations                                                              “Clarification of case manager role early in the
                                                                                    treatment program.”
Areas of Improvement:
Multnomah Community Ability Scale
    Thought processes, mood abnormality, response to stress and
    anxiety, money management, social interest, social network,
    involvement in meaningful activities, and impulse control




KPFICS Services                                                      After Hours
In 2006, the following services were provided by four full-time
staff members including three mental health rehabilitation
                                                                     Crisis Calls
specialists and one team lead:                                       228     Number of after hours crisis calls
                                                                             recorded by team
    Assistance navigating medical and psychiatric services
    provided by Kaiser physicians
    24-hour crisis response from Telecare team staff via
    crisis phone line
    Case management and advocacy
    Transitional case management for Kaiser members who
                                                                     Clinical
    have lost their benefits
    Intervention to prevent and manage crises outside the hospital
                                                                     Outcomes
    Substance abuse intervention and counseling                            Reduced acute psychiatric hosp-
    Support/education of family and significant others                     italization days by 1,251 days over
    Assistance in development of peer relationships                        baseline of 1,961 days
    Connection to self-help groups/community resources
                                                                           Reduced psychiatric hospital days by
    Assistance with entitlements
                                                                           64% (annualized using combined acute,
    Vocational services
                                                                           Alpine, Crisis House and PHP days)
                                                                           Reduced psychiatric admissions by
                                                                           35% over the past three years.
                                                                           -------------------------------------------
                                                                     16% Improvement in Global Assessment
                                                                         of Function (GAF) scores for
                                                                         current members
                                                                     22% Improvement in Global Assessment
                                                                         of Function (GAF) scores for
                                                                         members leaving the program
Real-Life Success Stories
Paula’s Story:
Paula (fictitious name) came into the Telecare program three years ago with a long history of
alcohol, opioid and amphetamine abuse, along with a psychiatric diagnosis of Bipolar I Disorder.
She had a long list of psychiatric hospitalizations as well as many failed efforts at drug
rehabilitation. She had been sexually molested by her father as a child and had suffered from
suicidal ideation ever since. Since entering the Telecare program Paula has been able to stay off
of drugs and alcohol except for two short relapses. She has worked closely with her Kaiser
psychiatrist and Telecare rehab counselor to gain insight into her illness and traumas, and devel-
op the coping skills necessary to live a life where she is able to find some joy and fulfillment.
She recently exhibited these skills when life threw two more incredibly difficult situations at her.

Just as Paula was about to be discharged from Telecare, her husband of 39 years left her and
moved to Thailand. Paula still had her two adult kids and her grandchildren to support her,
however, this came as a complete shock and was, of course, completely overwhelming. Just two
months later, as Paula was starting to come to terms with this loss, she was hit with the news
that her best friend had suffered a brain aneurysm and had passed away. Despite these dual
traumas, Paula has shown remarkable strength and resilience. She has not turned back to the
escape of drugs and she has not been hospitalized.

While she does still at times have suicidal ideation, she convincingly states she will never act on
it as she has too much love for herself, her children and grandchildren to ever do such a thing.
Paula credits her treatment team for building her up and giving her the skills needed to deal with
life’s traumas. She has stated to her Telecare MHRS that she has amazed
herself by her strength, coping skills and resolve in dealing with her recent
past. She is currently undergoing the process of regaining her
driver’s license and plans to go back to work as a home care nurse
soon. While she is still with Telecare she is again talking about
starting a titration schedule.
Daniel’s Story:
Daniel (fictitious name) has been a long term
participant with the Kaiser Telecare Program
For Intensive Community Support. Daniel has
struggled with many issues but has grown in
personal strength and determination with
Telecare’s assistance. He now experiences hope
and a positive outlook on his world which has
brought stability to his life.

Daniel had originally been referred to the
KTPFICS program due to his multiple
hospitalizations. These hospitalizations were often a result of his trouble with the law secondary to his
polysubstance abuse, hallucinations, and suicidal ideation. Daniel’s lack of social and family support,
erratic lifestyle and inconsistent use of medications were barriers to his recovery. Daniel would often
become confused, disorganized, and delusional and would demonstrate this by barricading himself in his
apartment with the belief that neighbors were trying to steal his belongings. Adding to the complexity
of Daniel’s issues and experience of a Bipolar disorder was his drug and alcohol use which included
methamphetamine, cannabis, cocaine, and shooting up alcohol. This highly hazardous lifestyle led him
on drug and drinking binge south of the border, where he was robbed and badly beaten. Daniel shared
that this particular event was a “wake up call” for him, motivating him to focus on recovery and well
being. His self neglect had caused him to have a foot amputated, after a wound worsened due to his
poor diabetes care.

Daniel has come a long way. He has significantly improved over time and has continued to avoid
relapsing. Telecare and Kaiser have supported Daniel throughout his recovery journey. Daniel
understands the importance of taking his medication consistently and has learned to take much better
care of himself. He now attends therapy and medical appointments on a regular basis and works closely
with his case manager from the Telecare program. Daniel is now much more self-sufficient and able to
take care of many of his personal needs such as grocery shopping, doctors’ appointments, and other
activities of daily living. Daniel’s often states how the Telecare Program and other Kaiser services have
helped him in his recovery.




  Telecare Corporation                     Kaiser PFICS                    Telecare’s Mission:
  1080 Marina Village Parkway, Suite 100   3250 Wing Street, Building C.
  Alameda, CA 94501                        San Diego, CA 92110
                                                                           We exist to help people with serious mental
  (510) 337-7950 / (510) 337-7969 (fax)    (619) 221-6073                  impairments realize their full potential
  (800) 977-7471                           (619) 221-6054 (fax)
  www.telecarecorp.com

				
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