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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

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
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.

overview sonoma county aps team model3
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
overview sonoma county aps team model4
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
overview sonoma county aps team model5
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)
overview sonoma county aps team model6
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
overview sonoma county aps team model7
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
overview sonoma county aps team model8
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
overview sonoma county aps team model9
Overview Sonoma County APS Team Model

Social worker role continued

  • Referral
  • Purchase of service
  • Case closure
  • Educate client, family, community
overview sonoma county aps team model12
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
overview sonoma county aps team model14
Overview Sonoma County APS Team Model

PHN functions

  • Multifaceted
    • Assessment
    • Documentation
    • Consultation, conference, communication
    • Education, referral and research
overview sonoma county aps team model15
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
overview sonoma county aps team model16
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
overview sonoma county aps team model17
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
overview sonoma county aps team model18
Overview Sonoma County APS Team Model

PHN functions

  • Consult
    • APS intake and social workers
  • Conference
    • Weekly APS clinical meeting
    • Monthly community MDT
    • Case conferences
overview sonoma county aps team model19
Overview Sonoma County APS Team Model

PHN functions

  • Communication
    • Doctor
    • Health providers
    • Medical facilities
    • Social service agencies
    • Family and caregivers
overview sonoma county aps team model20
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
overview sonoma county aps team model21
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
risk assessment
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
risk assessment24
Risk Assessment

Case Example

  • Lorna Doone - crumbles
incorporation of model in clinical practice
Incorporation Of Model In Clinical Practice

History APS team development:

Diane Kaljian,Section Manager

incorporation of model in clinical practice29
Incorporation Of Model In Clinical Practice
  • Documentation and Assessment Tools
    • Referral forms
      • PHN
      • Mental Health
      • Public Guardian Conservator
    • Cross Report to law enforcement
incorporation of model in clinical practice30
Incorporation Of Model In Clinical Practice
  • Form samples in binder
  • Sign up for e-mail copies
slide31

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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