Cherron's Non-Compliance Case Study

The patient is a 34 year old black male. The patient reports he is single with 3 daughter ages 3, 11, and 13. The 3 year old live with him. He reports currently live with his mother and brother. The patient reports he has 14 years of education however has not received his degree. The patient reports being on probation for Injury to a child for the next two years. The patient is scheduled to be complete his probation in September 2016. The patient reports Cannabis is primary substances and his last use July 20, 2015. He stated on that day he smoked about 5 joint. The patient also report that he tried Xanax . The patient denies any issues with HI/SI. Patient also reports he is taking his medication as prescribed. The patient appear to be in the pre-contemplation stage of change. The patient next scheduled individual session with the counselor is on Thursday, July 30, 2015 at

Same process as above, but everyone knows that the client is going to be sanctioned for something. The clients will try to make an excuse, lie, plead, or whatever else to avoid sanctions. Some of the clients’ stories were good and other times it is better for the client to refrain from talking. Nevertheless, most clients on this calendar were either arrested for a new crime, failed a drug test, missed group or individual therapy sessions, or violated a term of his or her probation. Failing a drug test was an automatic jail sanction no matter what. Even if the doctor prescribed medication, it was the client’s responsibility to notify the doctor that he or she is not allowed to take opiate-based pain relievers. If there was a low-creatinine drug result (urine is diluted to the point where a drug test cannot detect drugs), the court treated it as the same as a failed drug test. So, the client would be sanctioned to jail and ordered to do low-creatinine

Cintron reported he was diagnosed with Anxiety and Insomnia in 2016. He stated experienced sweaty palm, twitching, withdrawals and feeling that someone is out to get him. He further noted these symptoms are mostly presented when he is surrounded by a large crowd. He noted he was prescribed Ambian for his Insomnia and Klonopin to help with his anxiety. When asked about his substance abuse usage, Mr. Cintron reported he started using drugs when he was sixteen years old. He noted while in high school, he was first introduced to "weed", which he used often. The client reported he later tried Percocet, cigarettes and alcohol. He stated he has experimented with several other narcotics, but noted his drug of choice is both "alcohol" and "xanax". Mr. Cintron reported he used daily and last used three weeks ago because he was in detox. When asked about his substance abuse treatment, he reported he has been in treatment programs in the past. He stated his last treatment he discharged himself because he had the urge to use again. Mr. Cintron noted during his time in treatment he participated in AA meetings and found it to be rewarding. He denied ever participating in the 12 Step program. In regards to his legal involvement, he admitted being arrested several times for his drug use, but denied ever being

Frankie Tilmon continues to be out of treatment compliance. Frankie has missed his last four appointments, 7/2/15, 7/9/15, 7/16/15, and 7/30/15. Frankie contacted this provider on 7/6 to apologize for missing his appointment on 7/2 and was reminded of his next appointment on 7/9, which he agreed to attend. On 7/15 Frankie contacted this provider to apologize for missing his treatment appointment on 7/9 and agreed to make his appointment the following day, which he failed to appear for. On 7/16 Frankie contacted this provider to again apologize for missing his appointment and wanted to confirm his next scheduled appointment day/time. I told Frankie that his appointment day and time has not changed; it was on Thursdays at 4pm. Frankie told

D-Spoke with the patient as she was being curbside dose. This writer reiterate about TEAM recommendation, at which the patient declines the notion of being placed in a skilled nursing facility due to her medical issues.This writer informed the patient that her level of care is inappropriate for this treatment and a high level of care would be more efficient. According to the patient, she's working with Chrysalis and is willing to sign an ROI for this writer to communicate with her case worker Anthony, aka Tony. Reported stable on her dose.

CM received report from LAMP VASH worker Laurie Garza regarding client’s missed appointment on 11/25. LAMP VASH worker Laurie Garza inquired about client’s drug use and general well-being due to client’s lack of motivation. LAMP VASH worker suggested client explore different housing programs due to client’s resevations regarding weekly meetings with case manage . CM will discussed new housing referral options with client. CM will notify Laurie Garza about client’s decision regarding housing program.

D-The patient was advised that her bottles are in fact suspended due to the incident that occurred on 02/08/2017 of which the patient needs to accountability of taking a second dose of her methadone even though she has taken her methadone at home. The patient admits her accountability of her actions of taking the second dose. The patient then asked about how she can regained her take home bottles of which this writer explained the policy of take home bottles, referring to the reinstatement process. The patient is referred to attend the Take Home Bottle Group on 03/9/2017 to have her bottles reinstated. Then the patient shared that she wrote a grievance letter and still plans to submit it for the Program Director to review. Furthermore, this

First, we will examine my initial clinical note on 8/15/16 with client, Rhonda Smith, session one. During this first session, I collected Rhonda’s demographic and intake information (Murphy & Dillon, 2015; Reamer, 2001). This included a signed consent for treatment, which we reviewed and all her questions were answered, as well as signed medical releases for previous therapy and agency records, i.e., DVIS, CPS, CASA, that will be requested (Murphy & Dillon, 2015; Reamer, 2001). Additionally, she was informed about HIPAA, patient privacy rights, billing practices, professional boundaries and expectations, and how to contact me during business hours, and after-hours crisis lines, and on-call assistance phone numbers for resources if it is outside of my business hours (Murphy & Dillon, 2015).

D-The patient was placed on HOLD to see this writer to address her no show for counseling on Friday and missed dose as well. According to the patient, she had transportation issue. The patient admitted that she relapsed by using crack cocaine-$20 bags by smoking. Addressing the relapse is due to stressor of her current residency with her "baby-daddy," according to the patient. Alternatives were discussed. The patient asked this writer for assistance again for the contact number to CHR and CVS of which this writer provided. In addition, this writer questioned the patient about her living situation as she reported about it being a stressor in her life. According to the patient, she is no longer residing at her "baby-daddy" resident as she reported

Patient didn't call or show up for his scheduled individual counseling session today at 7 am; however, he received his dose of methadone at the Clinic around 9 :30 am. This writer called pt.’s phone number on file to reschedule a mandatory individual session. Counselor will be flag pt. in the system to see counselor before dosing tomorrow, 12/15/16 to discuss his recovery progress, what the program expects of him at this stage and how to get the most of out

CM was out on vacation for the period of 5/2/2016 to 5/9/2016. On 5/19/2016, CM met with the client to update Assessment and to complete Other ILP Review. In the meeting client appears to be friendly and cooperative. She appears to have some cognitive impairment. Client reported WECARE/Wellness referred the client to see Dr. Larissa Lempert/Neurology. Next upcoming appointment is scheduled for 5/26/2016. During the meeting session, client was dressed appropriately for the weather and had good hygiene. She ambulates with a cane due to leg problem. Client affect was flat. Client denied suicidal or homicidal ideation.

Patient is a 30-year-old Caucasian Female who presents to CRU 2 via ambo from PRC West. She is on ACOT for non-compliance with her court order terms and outpatient treatment plan. Partners In Recovery is her OP treatment agency. Heather is currently homeless, and on SSD income. She is alert and oriented 4x and cooperative with intake assessment. She reported that she has been taking Ativan and Klonopin, she insisted that I call the provider for those orders. She denies DTO/DTS, vital signs WNL's. She will benefit from meeting a provider to discuss med stabilization and therapy.

D-During the course of the session, the patient appears to be anxious because she cannot make reasonable decision about her treatment whereas the patient expressed she wants to decrease on her dose, even though a dose change request was completed on 03/02/2016 and hasn't been approved. This writer addressed with the patient about the program policy. Furthermore, the patient appears to be ignored by this writer when she addressed about obtaining take home bottles/special bottles if she's unable to come to the clinic and this writer informed the patient about the take home policy/procedure, including special bottle. In addition, the patient is uncertain if she has gotten the full time position as she is currently awaiting on the status today

Counselor met client to complete Addiction Severity Index (ASI). The client is a 24 year old black female with a history Cannabis Abuse uses. The client report using about 1 gram of marijuana a daily. She started (“I started smoking when I was 15years old”). She also reports drinking Smirnoff Ice two weeks ago and only drinks occasionally. The client smokes about a half pack of cigarette a day. Client denies any prior treatment episodes. Client denies any HI/SI at the time of the session. Client reports taking her medication as prescribed. Client appears to be in the pre-contemplation stage of change. Client next scheduled individual session with a counselor is Monday, July 13, 2015 at 2:00pm.

D-The patient reports being stable on her dose and denies the need for an decrease. Denies any sort of cravings/withdrawals. Then the patient spent the session discussing how she spent her Mother's Day, competing with her mother in the game of Scramble, and her commitment to her recovery process. Lastly, the patient discussed the abusive relationship that her son is in with his girlfriend, who the patient son has been in the relationship with his girlfriend since he was 15 years old. The patient discussed about the family intervention and then asked this writer about a referral to a professional, who can come to her son's apartment to provide further intervention. This writer provided the patient with the 211 referral line to assist with the intervention.