Care Review Referral

Johnston County Care Review Process

Scheduling the Care Review

All applicable sections must be completed prior to requesting the Care Review. Please be sure to provide a detailed description of the current situation, as well as strengths and interests in the last section of the referral form.

Without the informed and willing participation of the individual seeking assistance (and/or their guardians), there cannot be a Care Review. Therefore, it is your responsibility to explain the purpose of Care Review to the participant and/or guardian, ensure that the participant and/ or guardian wants to participate, and review the completed form with the participant or guardian prior to submitting the request for Care Review. We prefer all forms be completed electronically and emailed. All Care Review requests should be emailed to Felecia Ferrell, System of Care Coordinator (SOC) (email: ).

After receiving the referral form, SOC staff will follow up to obtain specific information within 2 business days. If Care Review is appropriate, SOC staff will reserve the next available opening.

  • Youth Care Reviews are scheduled on the 2nd Thursday from 10:00 to 3:00.

You are responsible for arranging transportation to and from the Care Review, ensuring that the participant/guardian attends and providing interpretation as needed. For Youth Care Reviews, you are required to inform and invite all Child and Family Team members to the Care Review and to incorporate their input into the referral form. On the days leading up to the Care Review you should continue to update SOC staff as changes occur. Bring a copy of the updated referral form on the day of the Care Review.

Please provide a copy of the document “What to Expect at Care Review” to the participant.

SOC requests that you submit 1 copy of the Person Centered Plan and 1 copy of the current psychiatric, psychological, developmental and/or educational evaluations to the Thursday prior to the scheduled Care Review. Advise SOC staff of any other pertinent or sensitive information prior to the Care Review.

On the Day of Care Review

Care Reviews are held at the Johnston County Mental Health Center, located at 521 N. Brightleaf Blvd in Smithfield. Participants and team members should sign in at the front desk and wait for their name to be called.

Those referring to Youth Care Review will need to bring 8 copies of the updated referral form on the day of the Care Review.

If the child or youth have the maturity or developmental capacity to understand that Care Review is about making a plan for him or her, the Care Review team welcomes the participation of the youth in the process. However, it may not be appropriate for the youth to participate in the entire meeting as there may be sensitive issues discussed. The Care Review team may designate time during the review for the youth to be included in the discussion. Unaccompanied youth are not allowed in the Johnston County Mental Health Center. Please be sure that there is someone available to stay with the youth.

For Youth Care Reviews, each member of the team will receive a copy of the action plan and the confidentiality signature sheets. Copies of any additional resource information will also be given to the participant/guardian and referral source.

After the Care Review: A SOC staff member will follow up with the participant, guardian and referral source/support team member shortly after the Care Review. This staff member will continue to follow up as often as needed or at least at 1, 2 and 3 months after Care Review to check on the progress of the action plan.

If you have questions please contact: Felecia Ferrell, 919-989-5584,

What to Expect at Care Review

Participants

What is Care Review?

Care Review is a process where you can discuss your needs and wishes with a group of people from the community, known as the Care Review Team, who are there to assist you in finding and accessing the resources you need.

Who is on the Care Review Team?

The Care Review team represents different agencies and organizations in the community from physical health, mental health, substance abuse, school system, employment, social services and public safety. They are all there to support you and help to create an action plan to meet your needs.

Who do I bring with me?

You can bring anyone who is a source of support. Most people bring members of their treatment team as well as family members. Some also bring members of their congregation or other spiritual support.

What do I need to bring to Care Review?

You only need to bring yourself. This is an opportunity for you to share what you have been going through and what you would like to see happen in your life for things to get better.

What if I don’t know what to say at Care Review?

If you’re not sure where to start, we can certainly get the conversation going by asking you some questions. In fact, we end up asking a lot of questions because it helps us to get to know you and your situation. However, if there are questions you do not want to answer, you don’t have to.

How many people are on the Care Review Team?

There are usually around 10 people there in addition to the support that you bring with you. That may sound like a lot but most people are pretty comfortable once they get there and meet the team. Remember, they are there to offer assistance and support; they are not there to judge you.

How long will it take?

Each Care Review is scheduled for 1 hour. Usually that is enough time for you to share your concerns and to create an action plan.

What happens after Care Review?

You, your support team, and members of the Care Review Team will work together to follow up on your action plan. A member of the Care Review Team also checks in from time to time to see that everyone is following through on what they promised to do and to also see how you’re doing.

What if I still have more questions before my Care Review?

Feel free to call Felecia Ferrell 919-989-5584.

1. Today’s Date: / 2.MR# (if applicable): / 3.Type of Care Review Referral: Youth
4. Urgency of Care Review Request: Emergency First Available Within 30 days
PARTICIPANT INFORMATION
5.Individual’s last name: / Individual’s first name: / Middle:
6.Gender: M F / 7. DOB: / 8. Age:
9.Participant/guardian address:
City:
State: ZIP Code: / 10. Number of people in household: / 11.Phone : ()
12.Legal Guardian:
Relationship: Self Parent Relative DSS Other, please specify:
13.Race/Ethnicity:
Alaskan Native
Native American
Asian
Black/African American
Hispanic/Latino / Native Hawaiian
Pacific Islander
White/Caucasian
Other, please specify: / 14. Does the participant/guardian speak English? Yes No
If no, please specify:
Will the individual need an interpreter? Yes No
(*If participant does not speak English or does not communicate verbally,
referral source is responsible for securing interpretation)
15. Is the participant a US citizen?
(Note: This will not affect the individual’s participation in Care Review. We ask this to help us identify other resources.)
Yes No / 16. Does the participant have a valid Driver’s License?
Yes No
If not, does participant have a valid state ID?
Yes No
17. Does the youth have a Child and Family Team Yes No
REFERRAL INFORMATION
18.Referral Source (name/title of person): / 19.Name of Agency/Supervisor:
20.Email address: / 21.Phone: ()
22.Reason for referral (choose up to two):
Follow up from previous Care Review
Develop plan for housing
Residential placement for child/youth, please specifylevel recommended: / Service coordination
Technical Assistance
Assistance with transition
Other, specify:
23.
Has individual/guardian agreed to participate in Care Review? Yes No
ADDITIONAL INFORMATION
24.Housing:
Type of Housing
Permanent
Supportive Housing (ex. Andover, Independent Living Program)
Transitional (ex. 30-day programs)
Recovery/Halfway house(long term)
Family/Friend (temporary, not on lease) / Group home: specify:
Adult
Child, specify level:
Foster Care (DSS)
Rapid Response, how long:
Therapeutic foster care
Runaway status / Institution (jail, detention, hospital, prison, PRTF)
Boarding house or other unlicensed facility
Homeless, please specify: streetshelter
campsitehotel car other:
If at shelter, how long?
Other, please specify:
25. Housing Stability
Stable (safe, affordable housing that is the appropriate level of care for the individual)
Unstable, specify: facing eviction insufficient income unsafe living condition homeless
inappropriate level of care need for transition other, specify:
26.Source of income (check all that apply):
No income
SSI/SSDI
Death benefits
Employment
full time
Part time
Day labor / Child support
Parent/guardian
Work First
Unemployment benefits
Retirement benefits
VA benefits / 27.Source of benefits:
No insurance
Medicaid
Medicare
Medicaid/Medicare
NC Health Choice
Private
IPRS (MH Only)
VA Benefits
Other, explain: / 28. Other Income:
Food and Nutrition Program (Food Stamps)
Yes
No
WIC
Yes
No
29. Disability Benefits
If not currently receiving SSI/SSDI has individual applied? Yes No N/A
Status: 1st Application Pending Reconsideration Appeal
30. Medicaid Status
If not currently receiving Medicaid has individual applied? Yes No N/A
Status: 1st Application Pending Reconsideration Appeal
31.Educational and Vocational information:
Highest grade completed:
Currently enrolled in school: Yes No
If applicable, name of school:
Currently job seeking: Yes No
Enrolled in job skills program: Yes No
Enrolled in VR services: Yes No
Enrolled in volunteer/day program: Yes No / If youth, IEP completed:
Yes No N/A
If youth, 504 Plan completed:
Yes No N/A
If known, please indicate IQ:
If youth, educational classification:
If youth, participating in CFST?
Yes No
Behind grade level/held back: Yes No
32. Complete only if applicable:
Mental Health, Development Disability and Substance Abuse Information:
Is participant currently receiving mental health, development disability and/or substance abuse services? Yes No N/A
Please list the name of the DSM IV diagnosis as well as the code (you may list more than one per axis):
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Currently prescribed psychiatric medication: Yes No Unknown
If connected to MH/DD/SA, what type of service:
Child (choose all that apply):
Day treatment MST Intensive In Home
Case ManagementOPT Residential Level II or TFC Level III group home Level IV group home
PRTF Other, specify:
Name of provider:
33. Juvenile or Criminal Justice involvement:
Has individual ever been convicted of a crime? Yes No
If yes, please explain:
Is s/he involved with DJJDP or the courts? Yes No
Is individual currently on probation/parole? Yes No
If yes, please provide the name of the officer and/or court counselor and contact information:
Does the individual have any pending charges? Yes No / 34. DSS Involvement
Is the participant currently involved with DSS?
Yes , Describe:
No
Has the participant had past involvement with DSS?
Yes , Describe:
No
35. Medical Care:
Does the participant have a primary care physician?
Yes No
Is the participant able to access medications?
Yes No
Please describe any relevant medical conditions that impair individual’s functional capacity: / 36. Spiritual supports:
Does participant have a source of spiritual support?
Yes No
37. Please list other natural supports or agencies involved in the participant’s care:
Contact information:
INSTITUTIONAL AND OUT OF HOME PLACEMENTS
Was participant admitted to the hospital for psychiatric care in the last 6 months?
Yes, how many times: 1 to 3x 3 to 6x > 6x times
No
Was participant admitted to DCA in the last 6 months?
Yes, how many times: 1 to 3x 3 to 6x > 6x times
No / Was the youth admitted to a rapid response bed in the last 6 months?
Yes, how many times: 1 to 3x 3 to 6x > 6x times
No
For Youth and Transition Care Reviews, please provide a detailed placement history as an addendum.
THIS SECTION MUST BE COMPLETED FOR REFERRAL TO BE PROCESSED
Discuss the participant’s strengths, resources, goals and interests:
Describe the reason for referral, areas of concern and what needs to be accomplished at Care Review:
Discuss factors/accommodations to consider when scheduling this Care Review (i.e. parent/guardian schedule):
For Youth Care Reviews, who attends your monthly CFT meetings (list name and affiliation)?