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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. INTAKE UNIT. SUPERVISORS. SOCIAL WORKER. PUBLIC HEALTH NURSE.

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The Multidisciplinary Team

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  1. 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

  2. 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.

  3. 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

  4. 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

  5. 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)

  6. 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

  7. 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

  8. 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

  9. Overview Sonoma County APS Team Model Social worker role continued • Referral • Purchase of service • Case closure • Educate client, family, community

  10. 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

  11. PHN Functions

  12. Overview Sonoma County APS Team Model PHN functions • Multifaceted • Assessment • Documentation • Consultation, conference, communication • Education, referral and research

  13. 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

  14. 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

  15. 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

  16. Overview Sonoma County APS Team Model PHN functions • Consult • APS intake and social workers • Conference • Weekly APS clinical meeting • Monthly community MDT • Case conferences

  17. Overview Sonoma County APS Team Model PHN functions • Communication • Doctor • Health providers • Medical facilities • Social service agencies • Family and caregivers

  18. 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

  19. 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

  20. Risk Assessment

  21. 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

  22. Risk Assessment Case Example • Lorna Doone - crumbles

  23. PHN Health Assessment

  24. Service Plan

  25. Interactive Case Studies

  26. Incorporation Of Model In Clinical Practice History APS team development: Diane Kaljian,Section Manager

  27. Incorporation Of Model In Clinical Practice • Documentation and Assessment Tools • Referral forms • PHN • Mental Health • Public Guardian Conservator • Cross Report to law enforcement

  28. Incorporation Of Model In Clinical Practice • Form samples in binder • Sign up for e-mail copies

  29. Sonoma County Human Services Department Adult Protective Services Jean Craig jcraig@schsd.org Lloydel Roesch lroesch@schsd.org 707.565.5900 PO Box 4059 Santa Rosa, CA 95402

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