Contributor: Yvette McBride Thomas
Dimension 2: Biomedical Conditions and Complications
Problems (need)
- Patient has a medical condition (e.g. high blood pressure, asthma, diabetes, etc.) and has not consistently participated in recommended medical care.
- Patient has a serious illness and needs to continue medical care with his/her primary care physician/specialist
- Patient is pregnant and needs to engage in regular high risk prenatal care
- Patient is in need of dental treatment
- Patient is in need of prophylactic for treatment /prevention of active TB
- Patient is in need of healthcare information on HIV/AIDS, TB, and Hep that include the effects of illicit drugs on the body.
- Patient is in need of CXR after positive PPD (TB)
- Patient is in need of HIV education as part of preventive care
- Patient needs to engage in regular preventive medical care
- Biomedical condition may be exacerbated by illicit drug/alcohol use.
- A positive test for HIV/AIDS
- Patient has a history of neglecting his/her physical and medical health
Goal (I will)
- Secure medical care
- Engage in regular medical care for management of chronic medical condition
- Continue specialized treatment for serious medical condition
- Secure high risk prenatal care
- Secure dental care
- Receive screening and/or treatment for prevention of active TB
- Learn effects of illicit use on medical condition
- Participate in regular prevention medical care
- Ensure coordination of care including primary medical provider and treatment provider
- Medically stabilize physical condition
- Accept chronic medical condition with proper medical attention given to it
- Take responsibility for maintain physical health and well being
- Establish chemical dependency recovery that leads to improved physical health
Intervention (objective)
- Patient to secure medical appointment with primary care physician to follow up on abnormal labs within one month or earliest available appointment
- Patient to discuss in counseling session the benefits of complying with recommended medical care; monitor on going medical compliance
- Patient to verify available coverage and report back to staff: verify medical coverage as needed and offer patient appropriate referrals based on source of coverage.
- Patient to become aware of negative effects of illicit drug use on biomedical condition after reviewing in counseling: address ongoing through course of treatment.
- Patient to register all prescription medication and update prescription verification throughout course of treatment
- Patient to use referral list and call for dental appointment: target date one month or first available appointment
- Patient to bring verification of attendance at high risk prenatal clinic: monthly throughout the course of pregnancy
- Patient to be able to name benefits of regular prenatal care: address in counseling throughout period of pregnancy
- Patient to become aware of illicit drug/alcohol abuse/use on pregnancy: address in counseling session throughout period of pregnancy
- Patient to receive HIV/AIDS as well as TB risk reduction education: target date within six(6) weeks of entering treatment and update as needed throughout the course of treatment
- Patient to attend post-partum medical appointment within eight (8) weeks of delivery or first available appointment
- Treatment staff to consult with patient primary medical doctor as needed to ensure ongoing appropriate care
- Patient to discuss importance of preventive medical care for self and family
- Patient to bring in verification of TB screen (PPD)
- Patient to bring verification of prophylactic treatment for prevention or treatment of active TB
Diagnostic Suggestions (taken from DSM-IV codes associated with presenting problems)
- Axis 1
303.90 Alcohol Dependence
304.20 Cocaine Dependence
304.80 Polysubstance Dependence
Behavioral Definitions
- A positive test for HIV/AIDS
- History of neglecting his/her physical and medical health
- Medical complications secondary to chemical dependence
Long Term Goals
- Accept chronic medical conditions with proper medical attention given to it
- Take responsibility for maintaining physical health and well-being
- Establish chemical dependence recovery that leads to improved physical health
Therapeutic Interventions
- Make any necessary arrangements required for patient to obtain the medical services needed
- Refer patient to physician for complete physical
- Help patient understand his/her medical problem and the need to cooperate with doctor’s recommendations
- Monitor treatment effectiveness and document patient’s follow-through on doctor’s orders; redirect when patient is failing to comply
- Consult with physician and review doctor’s orders with patient
- Provide patient with any appropriate literature that will increase his/her understanding of medical condition
- Arrange for consultation with dietitian to explain proper nutrition that will enhance medical recovery
- Explore and assess the role of chemical abuse/dependency has on medical condition
- Refer patient to public health of physician for STD and/or HIV testing, education and/or treatment
- Help patient identify and express his/her feelings connected with medical condition
- Assign patient to make a list of things he/she could do to help maintain physical health; process list
Progress Note:
Note: each note ins is the order of the therapeutic intervention
- The patient presented with serious medical problems that are having a negative impact on his/her daily living
- The patient has pursued/refused treatment for his/her medical condition
- The patient has not sought treatment for his/her medical condition because of a lack of insurance and financial resources
- The patient’s serious medical condition has been under treatment and is showing signs of improvement
- The patient reports that he/she has tested positive for HIV/AIDS
- Patient has been HIV positive for several months but has had no serious deterioration in his/her condition
- The patient is obtaining consistent medical care for his/her HIV status
- The patient has refused medical care for his/her HIV-positive status and tends to be in denial about seriousness of this situation
- The patient’s HIV-positive status has resulted in the development of AIDS
- Because of the patient’s chronic chemical dependency history, he/she has developed medical complications
- The patient has accepted that he/she has deteriorated medically because of his/her chemical dependency pattern and has terminated substance abuse
- The patient is in denial about the effects of his/her substance abuse and continues this self-destructive pattern
- The patient’s medical condition has improved subsequent to termination of substance abuse
- The patient described a history of neglecting his/her physical and medical problems
- The patient continues to refuse medical evaluation and treatment for physical problems
- The patient agrees to seek medical treatment and has followed through on this recommendation
- After receiving medical treatment, the patient’s physical and medical condition has improved significantly.
Reference: Jongsma, A.E. Jr and Peterson, L. Mark The Complete Adult Psychotherapy Treatment Planner 2nd edition
Suggested Reading
Substance Abuse Treatment for Persons with HIV/AIDS. Treatment Improvement Protocol (TIP) Series, No. 37.
INFORMATION SOURCES
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The National AIDS Treatment Information Project – http://www.natip.org/index.html
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The Measurement Group – www.themeasurementgroup.com
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JAMA HIV-AIDS information center – http://www.ama-assn.org/special/ hiv/hivhome.htm
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Critical Path AIDS Project – http://www.critpath.org/critpath.htm
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HIV/AIDS Treatment Information Service (ATIS) – http://www.hivatis.org
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AIDS Clinical Trial Information Service (ATCTIS) – http://www.actis.org
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Centers for Disease Control and Prevention (CDC) – http://www.cdc.gov