1. Adults living with serious mental illness die 25 years earlier than other Americans due largely due to treatable medical conditions. (Manderscheid et al. 2007)

2. Katherine T. O’Hara, RN, MPH, CHES Mary McLaughlin, RN, BSN, MS Pamela Jackson-Malik, RN, PhD, MBA Alan Lorry, BS, RPH Beverly Velasquez, MSW, LSW Philadelphia Veterans Affairs Medical Center, Philadelphia, Pa.

3. Case Management Team It is essential to the Model to have both a Registered Nurse and a Social Worker (MSW)

4. Supermarket Model Concept

5. Identify Population Persons with Serious Mental Illness Complex Barriers to Care Use assessment to identify barriers to care

6. Needs Assessment Medical Psychiatric Social Financial Legal Substance Use

7. Identify Resources Providers Facilities

9. Medical and Mental Health Evaluation Review current medication orders Evaluate adherence Evaluate system of delivery Who gives medications How are refills and re-orders processed Verify address and update as indicated Identify Pharmacy responsible for service

10. Medical and Mental Health Evaluation Verify assignment of medical and mental health providers Review pattern of scheduled appointments Review pattern of attendance Facilitate evaluation in a timely manner as indicated Review history for violence, sexual misconduct, Megans Law Registration

11. Functional Evaluation Level of judgment Money management Public Transportation Nutritional status Meal planning Cooking

12. Functional Evaluation Meal planning Shopping for food Wearing appropriate clothes Wearing appropriate shoes Clothes shopping Self management of medications

13. Social Evaluation Living environment Safety factors Freedom from abuse (physical/psychological) Adequate supervision for level of care Medications, appointments, meals, clothing, spending allowance Fire and hazards Family/community support History of living situations Multiple moves versus stable environment

14. Financial Evaluation Source of income Check for multiple sources Check for presence of financial guardian/fiduciary Supplemental income by family/friends Eligibility for increased benefits Financial fraud or abuse

15. Financial Evaluation Pattern of spending Amount of debt Check for money owed to credit cards /loan sharks Money borrowed from friends/family How far into the month do funds last Check for gambling patterns and addictive behavior Lottery tickets, off track betting, sports betting, numbers

16. Legal Evaluation Outstanding warrants Probation Parole Pending court cases Level of offense Outstanding fines and legal fees Legal representation Is case in regular or mental health court

17. Substance Use Evaluation Substance(s) of choice History of use Pattern of use Level of interference in daily activities History of program attendance

18. Primary Intervention If the individual is determined to be a danger to themselves or others, and does not agree to hospitalization an involuntary commitment needs to be initiated Medical Life threatening condition Inability to provide basic needs for life Mental Health Suicide or Homicidal ideation or action

19. Based on evaluation It is difficult to place an individual who is not stabilized on medications

20. Shelters Full financial Support No funds available High risk environment Have data base of all shelters in the area specifying size and support level Seek out smaller shelters with capacity of 10 to 20 Identify day programs for the homeless to offer structure and added assistance Shelters are not a permanent placement. They are temporary until funds can be established or a housing program identified.

21. Boarding Homes with Services Quiet stable environment Offer meals, laundry cues, assistance with appointments Assist with management of medications Individual needs to be able to take own meds with cues

22. Recovery Houses Offer meals, laundry cues, assistance with appointments Assist with the management of medications Individual needs to take own medications with cues Offer NA/AA meetings both in the facility and in the community Sponsor general meetings of the residents Supply options for next step in housing Boarding home with services Supervised apartment

23. Supervised Apartments Fully furnished apartment offering meals, medication administration/supervision, house cleaning service, laundry cues, appointment attendance assistance. Accommodates the following individuals: Stabilized individuals requiring supervision during the transitional phase to apartment living. Individuals who cannot live in a group setting due to violent behavior, poor response to high levels of stimuli, continuing substance use and inability to live with others. The level of services is based on individual evaluations.

24. Independent Apartments with Case Management Individuals who are independent in their activities of daily living Individuals who are able to take their medications as prescribed and manage refills and re-orders Individuals who can manage and attend appointments as scheduled Individuals who can food shop and provide adequate nutrition Individuals who can maintain a safe environment Case Management is provided as a safety net

25. Assisted Living/Personal Care Homes Individuals who do not have the capacity to manage medications with cues or be self directed. Individuals with complex medical and mental health issues Medication administration is supplied. Services: Meals, laundry, activities, hygiene cues and assistance, attendance at appointments, house doctors, ability to assess medical and mental health problems. Case Management provided

26. Design Support Plan Based on Placement Determine level of care Schedule medical and mental health appointments Assist with legal, social, financial, substance use issues as identified Determine pattern of visits by case management team Monitor individual’s satisfaction

27. Design Support Plan Based on Placement Scheduled collaboration visits with providers Monitoring of the following: Medication/appointment adherence Financial payments to facility and personal allowance Visits to the Emergency Room Hospitalizations

29. Individual satisfaction Reports from facility staff Reports from family/friends Pattern of adherence with medications and appointments Progress reports from medical and mental health visits Results from diagnostic testing Visits to the Emergency Room(s) Hospitalizations

30. Evaluate Outcomes Based on Evaluation Continue Plan Review Process and implement Revisions

31. Contact Information Philadelphia VA Medical Center, Phila., Pa (215-823-5800) Katherine (Kate) O’Hara, RN (267-761-1801) katherine.ohara@va.gov Mary (Molly) McLaughlin, RN (215-823-4006) mary.mclaughlin2@va.gov Pamela (Pam) Jackson-Malik, RN (215-823-4297) Pamela.jackson-malik@va.gov Alan Lorry, RPH (215-823-6363) alan.lorry@va.gov Beverly Velasquez, MSW (215-823-5800 ext 6134) beverly.velasques@va.gov