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 2^nd edition

Suggested Reading

Substance Abuse Treatment for Persons with HIV/AIDS. Treatment Improvement Protocol (TIP) Series, No. 37.

 INFORMATION SOURCES

• The National AIDS Treatment Information Project – http://www.natip.org/index.html

• The Measurement Group – www.themeasurementgroup.com

• JAMA HIV-AIDS information center – http://www.ama-assn.org/special/ hiv/hivhome.htm

• Critical Path AIDS Project – http://www.critpath.org/critpath.htm

• HIV/AIDS Treatment Information Service (ATIS) – http://www.hivatis.org

• AIDS Clinical Trial Information Service (ATCTIS) – http://www.actis.org

• Centers for Disease Control and Prevention (CDC) – http://www.cdc.gov