Week 12 Integration Question

Week 12:
HBSE/Macro: How can you determine what the formal and informal boundaries are in a community?
First I could research cultural differences to find out what is and is not appropriate. Many smaller communities have their own newspapers, often containing more items than what larger news organizations write about, such as events and small happenings. Just going out in the community could prove valuable as well by staying attentive to what others are wearing, their behaviors, manners, and other subtle signs.
Also, I could look for training on what is and is not appropriate, and search out stigma words. I can look for events going on in the local community. For example, they may have a day of the week that is a sacred day or certain days that may be celebrated for some reason.

Week 15 Integration Question

Week 15:
Practice/micro: How have you experienced successful endings? What do you already do now to help your clients experience successful endings?
In this, endings could be qualified as any ending with a client, whether it is the end of the day, end of treatment, or end of a medication. The most important ending though is the ending of treatment with a client. In this regard, here at Cummins we do not encounter as many endings as most other facilities since most of our clients are here for extended periods of time for treatment, some lasting several decades. For those who do end their treatment, many just move along to other programs that may be able to serve them better, such as the ACT team.
Cummins has procedures they use for all endings with their consumers. During discharge they utilize a discharge summary that has a plan they are supposed to follow for months after they leave. Some items may include a follow up with doc or meds, or to start other programs. They also make another treatment plan at discharge and help clients contact agencies or whatever else they need to follow up and be successful with the new treatment plan. Prior to their discharge (or ending) workers help the consumers learn coping skills or aid in beginning recovery for when they leave the program. Consumers can then become successful with medication and a better life style than when they originally sought out treatment.

Week 14 Integration Question

Week 14:
Research/micro: What are the ways you can evaluate your practice with clients?
Cummins utilizes anonymous consumer satisfaction surveys that are sent out in bubble envelopes so the workers cannot see the surveys. Each survey is done through the different departments. These surveys are done once a year to give the consumers a voice in what they do or do not like from employees.
Consumers also used to be able to read their progress notes and change what they felt was not relevant, or they could add things the consumer says they think believe should go in it. This is a practice no longer used, as it would cause dissatisfaction and controversy between consumer and employee. For example, there would be times when the employee would write that the consumer was experiencing paranoid delusions that day, but the consumer did not believe they were having any delusions and would want this taken off the record.
There are also peer review audits that are done for each worker to see if they did everything in the chart correctly. This is done at random, and not done all the time.The supervisor meets with the executive to evaluate the program and redo what needs to be updated.

6-25-08

I came in an hour late today, so when I arrived the consumers were already playing bingo. Once bingo was over Amanda informed me about a consumer who was having some difficulties recently. She wanted me to go over coping skills, warning signs, and ways to handle if he had outbursts. Amanda made a notebook for him where he could enter such things, and so that he could use the notebook as a coping skill to write in at times when he was having problems. He decided to leave early this day since because of his problems, so I only had a short 10-15 minutes to go over these things with him.

Pam taught me about how they use a progress note for consumers, called the rehabilitation services progress note. On it they list the consumer’s stressor or extraordinary event for needing the note, then any behavioral strengths the consumer exhibits. They have selections for language/motor activity including restless, slurred speech, pacing, and agitated; selections for mood/affect including euphoric, anxious, angry, apathetic, and appropriate; and selections for thought/perceptions including hallucinations, paranoid, obsessive, and delusions. Then one can select case management (CM) or Activities of Daily Living (ADL) and described items in either category such as contacted, informed, facilitated, monitored, or obtained for CM, and assisted, guided, reminded, demonstrated, directed, or trained for ADL.

Next the writer describes in detail what all happened and was gone over. This is done through PIRP: Problem, Intervention, Response, and Plan (of Action). The writer always follows this when writing these notes. Next the administrative items are filled in such as the writer’s credentials, billing codes, date of service, times, duration, consumer name and clinical record, and the consumer’s goal and objective that is being worked on.

After lunch Amanda helped me get the necessary tax information that is needed for the donation letter I had to write. She gave me information I needed to write the letter, such as Cummins’ value statement and mission statement. She left me in the back to work on the letter while she ran the rest of the groups for the day.

6-23-08

This morning Amanda was back, but Pam was not here. I ran canteen while the consumers updated me on their weekends. One consumer lives with her family and she goes out with her mother every weekend to a movie. She told me about how this weekend they “changed things up” by staying in for a movie. The consumers always ask how my son is doing so I told them about going to PBS Kids in the Park, and going fishing.

After I did the progress notes Amanda already had a worksheet for the first group (stress management/coping skills). The worksheet was titled “Getting Along with Anger”, and discussed times when the consumers get angry and things they do to cope with it. It was hard to getting the consumers to think of situations that made them angry. I had to keep giving them suggestions, and most of everything included things other people said or did to make them angry. The consumers said things like, “people talking inappropriate, people borrowing money, people insulting me or cussing at me, people expecting too much, and people telling my personal business”.

The consumers could not think of any coping skills or ways to deal with their angry situations. I started giving suggestions, then they finally starting saying when people make them angry they either “leave the room, ask them not to talk that way, just be quiet, walk away, ignore them, or tell them off”. I explained the difference between defensive and offensive ways of dealing with things, and showed how most of their suggestions were defensive.

When I just asked regular coping skills for any situation they did not know any. I gave examples of counting to 10, talking calmly and softer, or writing a nice letter. The rest of the worksheet had the consumers list things that made them angry, angrier, then angriest. They were not able to differentiate between the three, although they still listed things like “missing a doctor’s appointment, can’t decided what to wear, people saying my work or cleaning is not good enough, running out of things, jewelry breaking, and parents in general”.

This activity did not seem to go very well since the consumers were not very involved. I always have to work at getting the consumers to participate and enjoy the activities we do. I have to try to improvise when needed but also remember to include models of practice that I have learned in the classroom. For instance when a consumer complains that they cannot do the activity everyone else is doing I try to help them see what they can do. One elderly consumer has difficulties during budgeting and cannot do the multiplication that others do. She will never use that information; therefore there is no reason to make her try to learn. Instead I help her see that she can do addition problems by herself, and that she can operate the calculator on her own. The point isn’t to make them feel bad for what they cannot do, but instead to help them feel good about what they can.

For nutrition group the consumers played bingo. In this activity they are pretty self-sufficient, except for a few consumers who were not present today. This left me time to continue my project of scrubbing down the kitchen. Since I have been staying until the end of the day I have been trying to get things more organized, clean, and sanitary.

While making sure I am keeping up with my learning plan activities I discussed some of the things I still need to do with one of the case managers, Lenice. She said she had a good opportunity for me to go with her while she took a consumer to a Medicaid appointment. Amanda said it would be a good experience as well. The appointment started at 1:30pm, and we stayed for an hour. I will write about the appointment in another post since it was an activity to be included as part of my learning plan.

Once I returned I assisted in finishing the end of the day activities, such as cleaning and putting things away. I also entered the consumers’ times into the Excel program. I sat in Amanda’s office at the end of the day, discussing my hours, time sheets, and learning plan.

Amanda told me I can go work with case workers more often and also suggested some ways to write my donation letter for the learning plan. We also discussed completing the e-learning and other times I can do it at home. I updated my time sheet and made a copy for Amanda, but I also made a projected time sheet so that we all have an idea of when I should be done with my hours at Cummins. Last time I do not think everyone was prepared for how quickly my last days came, so I wanted to make sure I was prepared as well as everyone else. According to my projected time sheet, if I continue to work 3 days a week, 7 hours a day, I will have completed my hours within the next two weeks. This will leave me a few weeks to also make sure I get everything done and together for my learning plan by July 30^th.

6-19-08

Today was the last day of Amanda being gone and I know Pam is glad it is over. When I came in I went straight to running canteen and getting the progress notes going. For the first group we had a worksheet titled “Conformists”. Consumers learned a conformist is someone who usually does what he thinks others expect him to do. We discussed this, and why it is not always good to just conform to what others want. We also worked on a sheet titled “Communicating with body language”. In this we went over different ways people use body language, and all the different things some common actions mean. For example, when someone crosses their arms many people believe it means they are shutting others out, are unwilling to cooperate or participate, or could just mean they are cold. The consumers did a good job with this activity by identifying different things that each behavior could mean.

Next we went over narcotic medications for nutrition group. We discussed not only narcotic medications, but many of the scheduled drugs, such as benzos and illegal drugs like marijuana. We discussed taking medications properly, illegally, following doctor’s orders, and why people take drugs illegally, or take illegal drugs.

After lunch we had our regular walk, then cut out topics for current events. Pam led the rest of the groups for the day while I straightened the kitchen and organized the back room. I was trying to get things cleaned up for when Amanda came back. After the consumers left I worked with Pam on progress notes, discussing what each consumer that day.

My outing with a case manager on 6-23-08

Lenice told me she had a Medicaid appointment to go to with a consumer, and asked if I wanted to go with her. So I asked Amanda if she needed me, or if I could go with Lenice to complete one of my learning plan activities. Amanda said she thought it would be a good experience for me, and that I should go. The Medicaid appointment itself was not what I what curious to experience; I was more interested in just seeing how Lenice acted and handled things when she went to appointments with consumers.

When Lenice and I left for the appointment she started explaining the process to me of how applying for Medicaid. She explained that one has to first go to the office and fill out an application, and then a caseworker would set up an appointment. When one comes to the first appointment they have to bring certain documents that the caseworker uses to determine the applicant’s eligibility. She asked if I was familiar with this process at all and I told her I have been on and off Medicaid for years.

Lenice laughed and stopped there saying that I already know all about it, so she didn’t need to explain. Even though I did already know all about it, I had let her explain to me what she thought I needed to know anyway because there could always be something she says that I did not know and would have missed otherwise. I remember on my midterm evaluation Amanda said something towards the effect that I need to stop always telling people what I know, and instead be more receptive to learning what others are offering or trying to teach. If I am always showing what I know then I am not in a position to learn something new.

I have learned there is a big difference between many of the same services offered in Hendricks and Marion County. The Office of Family and Children, now called the Office of Child Services, toted a greatly different atmosphere in Hendricks County than anything I was used to in Marion County. Marion County always seems run down, dirty, and uninviting. When I walked into the Hendricks office I felt comfortable and welcome.

As soon as Lenice and I walked in we immediately went to the caseworker’s office where Lenice’s consumer was. I will call the consumer Sara to make this easier to understand. While in the office I just sat in the back out of the way since I was only there to observe. Lenice sat next to Sara and aided her by answering questions at times when she did not know the answers. Most of the questions Lenice helped with were regarding finances, medications, or medical diagnosis. When asked Sara said she was not sure what she was applying for, and was not sure about all her meds or bills.

The case worker was nicer than others I have had dealt with in Marion County, but then again she may have acted different than normal since it was not only a client in the office this time. Just as workers act different when supervisors are around, she could have been acting different since there was a case manager there, and a student to observe. This caseworker had a nice demeanor, yet did not engage with the client. She seemed to just do her job, input the information, and nothing further.

Sara had been on SSI, SS, and Medicare Part D. She was at this appointment because her benefits had been cut off and she did not know why. Lenice has different levels of involvement with each client. With Sara, I learned that she had helped her fill out the reapplication papers and had turned them in herself.

After the caseworker asked several routine questions about Sara’s finances, living situation, employment, history, etc, she asked about her medical history. Sara was not sure about her diagnosis, so they had to look at the papers from her doctors. She had depressive diagnosis disorder/bereavement, PTSD, and borderline or histrionic personality disorder. She also has been legally blind since 1966, but can see with her glasses.

Next the caseworker said she wanted to get a ‘social summary’. She asked about other medical things, such as Sara’s medications and if her diagnosis limits her. She also asked if she drives, has a degree or GED, if she is working, her last job title, if she has had vocational rehab, how she got to the appointment, and her relationship to the person who gave her a ride. Next she asked things I would expect more of a doctor to ask: if she uses recreational drugs, if she hears/sees things that are not there, if she understands all the questions she was asked today or if she needed assistance, if she has been having suicidal thoughts, what a good day is like for her, if she often leaves the house on her own, etc.

Overall, I was surprised by some of the questions that were asked. I have been to several Medicaid appointments, but have never been asked some of the things this caseworker asked. I was left wondering if it was because of the client’s medical history and diagnosis, or if it was something the caseworker asked all her clients. I also wondered if this was something just this caseworker did, or if this is part of the difference between Marion and Hendricks County offices.