ALAKA’I NA KEIKI
QUARTERLY CASE REVIEW WORKSHEET
Youth:______Age:____Date of First Service______Today’s Date______
Dx:______Therapist:______Paraprofessional:______
Care Coordinator:______FGC:______
1. Services being provided by provider/others/non-Alaka’i provider [Note levels of care and hours per
week, name(s) of providers and affiliations if other than Alaka’i]:
2. Is individual taking any medications? What medications? [Also note name of psychiatrist]:
3. Short-term Tx Objectives/Goals of person/legal guardian [toward Long-range goals – think in terms of
4 weeks, and address transition/contingency plans]:
4. Long-range goals of person/legal guardian [Consider desired outcomes – including transition/contingency needs]:
5. What evidence-based intervention strategies are being used? [also address cultural factors.]
6.* What is your schedule for services? (location, days of the wk, e.g. MWF A+, T Th Home 6-9pm)
7. How is progress toward short-term tx objectives being measured?:
8. If inadequate progress is being made, consider why [e.g., assess fidelity to Treatment/Service Plan goals/objectives; intervention strategies; cultural factors; barriers to treatment plan, etc.]
9. Recommend changes needed if inadequate progress is being made [to service plan, change in
intervention strategies; providers; etc.]
10. Does the individual exhibit dangerous behaviors? If so, describe and indicate where? (Home, School, Work, Community) Note any sentinel events, and indicate whether they have been reported.
* Note to Supervisor: Please ensure that location is safe and addresses confidentiality and client boundaries. Days and times should be specified at the beginning of treatment. Service times should be reasonable for youth, e.g., not after 9:00 p.m. unless crisis.
11. What is the crisis plan to handle the dangerous behaviors?
12. Are all of the following criteria met as determined by this case review:
1. All admission criteria continue to be met.
2. Progress in relation to specific targeted symptoms or impairments is clearly evident and can be described in objective terms, but the goals of treatment have not yet been achieved. Data on progress have been presented in a visual or tabular format showing changes over time, and reviewed with the family and treatment team.
3. The documented treatment and safety plan is individualized and appropriate to the individual and appropriate to the individual’s changing condition with realistic, measurable and achievable goals, objectives and discharge criteria directed toward stabilization to allow treatment to continue in a less restrictive environment. The treatment plan has been shared with relevant treatment team members.
4. The treatment plan includes a formulated discharge plan that is directly linked to the behaviors and/or symptoms that resulted in admission, and begins to identify appropriate post Intensive In-Home resources.
5. There is documented evidence of active family involvement in the treatment plan or there is active documented efforts to involve them unless it is documented as contraindicated.
6. There is reasonable expectation that continued treatment will remediate the symptoms and/or improve behavior or there is reasonable evidence that the youth will decompensate or experience relapse if services are discontinued; and
7. There are documented active attempts at coordination of care with other relevant behavioral health providers when appropriate. If coordination is not successful the reason(s) are documented.
13. Recommendations:
Signature of Supervisor/Monitor: ______Date: ______
Revised: 6/13/13