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The Multidisciplinary Team. In Action. Presented By Jean Craig, MSN,RN, PHN, CNS Lloydel Roesch, MS, MFT Sonoma County Adult Protective Services Human Services Department. Overview Sonoma County APS Team Model. INTAKE UNIT. SUPERVISORS. SOCIAL WORKER. PUBLIC HEALTH NURSE.

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The Multidisciplinary Team

In Action

Presented By

Jean Craig, MSN,RN, PHN, CNS

Lloydel Roesch, MS, MFT

Sonoma County Adult Protective Services

Human Services Department


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Overview Sonoma County APS Team Model

INTAKE UNIT

SUPERVISORS

SOCIAL WORKER

PUBLIC HEALTH

NURSE

MENTAL HEALTH

LIAISON

PUBLIC GUARDIAN

CONSERVATORS

LAW ENFORCEMENT

DISTRICT ATTORNEY

PROBATE COURT INVEST.


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Overview Sonoma County APS Team Model

  • Utilizes scope of practice from each discipline

  • Provides broad prospective to risk assessment and interventions

  • Presentation focus is the social worker and the public health nurse team


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Overview Sonoma County APS Team Model

Intake unit

  • Meets daily with the APS supervisors

  • Reviews and assign cases

  • Consults with supervisors

    • Immediate response

    • High profile cases

    • Liaisons as needed


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Overview Sonoma County APS Team Model

Case assignment

  • Usually to a social worker for initial face to face

  • High risk medical, neglect, or physical abuse joint visit by SW and PHN

  • Medical cases assigned to PHN for the initial visit or as a no initial face to face investigation (NIFFI)


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Overview Sonoma County APS Team Model

Case assignment continued

  • Mental health case assigned to mental health liaison at intake for immediate response to a crisis

  • Mental health referral by the SW or PHN


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Overview Sonoma County APS Team Model

Social worker role

  • Initial face to face visit

  • Assess risk factors & identify protective issues

  • Confirm client capacity to decline services

  • Advocate for client right to self determination

  • Short term case management


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Overview Sonoma County APS Team Model

Social worker role continued

  • Cross report to law enforcement

  • Document

    • Case notes

    • Risk assessment

    • Service plan

    • Conservatorship/Rep Payee referral


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Overview Sonoma County APS Team Model

Social worker role continued

  • Referral

  • Purchase of service

  • Case closure

  • Educate client, family, community


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Overview Sonoma County APS Team Model

APS PHN

  • Located at the Adult and Aging Office

  • Involved with most neglect and abuse cases

  • Fiduciary abuse client assessment

  • Immediate response with SW



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Overview Sonoma County APS Team Model

PHN functions

  • Multifaceted

    • Assessment

    • Documentation

    • Consultation, conference, communication

    • Education, referral and research


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Overview Sonoma County APS Team Model

PHN functions

  • Assessment

    • Client’s health status, health belief system, medical care

    • Compliance with medications and medical treatments

    • Functional capacity

    • Home environment

    • Ability to accept or decline services


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Overview Sonoma County APS Team Model

PHN functions

  • Assessment

    • Caregiver knowledge and competency

    • Capacity to learn and retain information

    • Adaptation to physical and mental deficits

    • Factors causing maladaptive behavior


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Overview Sonoma County APS Team Model

PHN functions

  • Documentation

    • Assessment forms specific to APS

    • Formal letters to physician, family or primary caregiver

    • Documenting protective issues and APS recommendations

    • Public guardian, court investigator


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Overview Sonoma County APS Team Model

PHN functions

  • Consult

    • APS intake and social workers

  • Conference

    • Weekly APS clinical meeting

    • Monthly community MDT

    • Case conferences


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Overview Sonoma County APS Team Model

PHN functions

  • Communication

    • Doctor

    • Health providers

    • Medical facilities

    • Social service agencies

    • Family and caregivers


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Overview Sonoma County APS Team Model

PHN functions

  • Educate

    • Family or client

      • Health, safety, fall risks and prevention

      • Disease prevention and management

      • Level of care options

      • Community resources


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Overview Sonoma County APS Team Model

PHN functions

  • Educate

    • Health care providers, community groups

  • Referral

  • Research

    • Rare or unfamiliar disease process

    • Treatment options and course of illness

    • Infection control issues



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Risk Assessment

Development

  • Combined the psychosocial, medical, and mental health needs of the client

  • Adaptation of standard psychosocial assessment tools

  • Collaborative approach to design assessment tools


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Risk Assessment

Case Example

  • Lorna Doone - crumbles





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Incorporation Of Model In Clinical Practice

History APS team development:

Diane Kaljian,Section Manager


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Incorporation Of Model In Clinical Practice

  • Documentation and Assessment Tools

    • Referral forms

      • PHN

      • Mental Health

      • Public Guardian Conservator

    • Cross Report to law enforcement


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Incorporation Of Model In Clinical Practice

  • Form samples in binder

  • Sign up for e-mail copies


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Sonoma County

Human Services Department

Adult Protective Services

Jean Craig [email protected]

Lloydel Roesch [email protected]

707.565.5900

PO Box 4059 Santa Rosa, CA 95402


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