Brand New Day HMO: September 2019

Digital Appointment Links

AnimaCules

20190621-F: Page Views = 940: Chartered: 2/9/15

http://ktork46.blogspot.com/2015/02/triple-xxx-dag-digital-appointment.html#!/2015/02/triple-xxx-dag-digital-appointment.html

AnimaCules

201906 - Digital Appointment for Behavioral Health Doctor by Keith Torkelson MS - Torkelson Pathology (201906)

https://ktork46.blogspot.com/2019/06/technologicalneeds-in-human-services.html

20190925-W Page Views = 10 – Chartered: 6/23/19

Feature Image

Buster Reconnects with Representative Lou Correa

Dedicated To:

Sam I Am! [MIA]

In Memory Of: Road Kill Dave & Douglas Keith

Road Kill Mark

"DUG" Keith

Source Document

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08_LS_Medication_Change_Restoril_Working_19052202_Bera
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Blogger Title

Medication Management – Change Request – Rimal B Bera MD – By Keith Torkelson MS – Brand New Day – 2019 – Trying a New Sleeper – Clozapine Contingency
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Partners

Abstract

This report has at its’ core medication change request forms. The client is Keith “Buster” Torkelson MS. Buster’s practicing Behavioral Health Doctor (BHD) is Rimal B Bera MD (RBB). In other words Buster is RBB’s account. RBB and Buster began their association (partnership) on January 3, 2018 when Buster graduated ahead from Bum Soo Lee MD. The change request is comprised of three forms: Physician Information, Alternatives Tried, and the actual Change Request (Experimental Trial). Since 1989 Buster has tried more than eight (8) psychotropic medications that influence his sleeping. This report has some six (6) associated studies some of which will never be published. Since we partnered with RBB we have had seven (7) Medication Management Appointments (MMAs). In 2018 Buster saw RBB four (4) times. So far in 2019 Buster has complete three (3) of his projected five (5) appointments for the year. After this next appointment with RBB scheduled for September 25, 2019 we will close out the year about RBB. We do this for documenting purpose even Buster will most likely have another appointment with RBB in December. When we meet with RBB is counts for us as a Health Related Engagement (MSG-HRE).

Practice Management

This report features an update about a friend and Brand New Day client. His name is Sam. We call Sam – Sam I Am! As we mentioned we have had seven (7) opportunities to observe RBB in action running “His Practice”. On September 23, 2019 (M) we applied MSG’s Beta Practice Management Scale. About Practice Management RBB earned himself a 17.3%. This translates into 0.9 Star Performance. As is usual we accessed the World Wide Web to gather some objective input about RBB. We found a total of 32 ratings or votes. The average of these people’s ratings we approximated at 3.0 Stars. Note our rating was for Practice Management. Practice Management differs from the online raters in that the online raters rate general consumer satisfaction. Our satisfaction score for RBB is higher than what we offered up for his Practice Management.

Clozapine

Remember this report is centered about a request for a trial on a different sleeper medication. As such Buster’s sleeping environment comes into play. We share an image (collage) regarding people that directly influence Buster’s sleep. At one point we consider seven (7) characters influencing Buster’s sleep. Doctor Rimal B Bera (RBB) holds office hours at a facility named Central City Community Health Center (CCCHC). Objectively across thirty-two (32) voters CCCHC (Garden Grove) earned themselves 1.4 Stars. Over and over we say Buster has been relatively stable on Clozapine for more than five (5) years. Buster requires Clozapine to obtain high quality and health promoting sleep. Clozapine has some shortfalls. We calculated for Buster an: Impact of Clozapine Side-Effects Score of 26.5% (20190920) with higher scores being seriously problematic. This report provides our rationale for a Restoril Trial. Our goal is to develop some sound Clozapine alternatives before an emergency such as Sam I Am faced arises.

List of Matrices – Tables

Table - Physician Information – Adapted Medication Change Request

Table - Alternatives Tried / Used By Patient (If applicable) – Influencing Sleep

Table – Over-The-Counter - Alternatives Tried - Influencing Sleep

Table – Adapted - Medication Change Request Form – Impacting Sleep

2018 - Table – Appointment & Key Event Register (RBB Timeline)

2019 - Table – Appointment & Key Event Register (RBB Timeline)

List – Metadata - Associated Papers

Table - Medication Management Appointment Themes Summary – Team Rimal B Bera MD

Table - Medication Management Appointment Themes Summary – Our Part

Matrix – CCCHC – Garden Grove Site Performance (Objective)

Table - Indications for BZD Treatment – FDA

Table - Side Effects – Clozapine – “Busters” Mainstay

Table - Brand V Generic – Cost Containment - Ativan

List of Figures & Prior Report Link List

Figure – Doctor In Charge – Objective Ratings

Figure – Rent A Shared Roommate Collage Impression – 4 Characters

Figure – Current Rent A Shared Roommate - Mikel

Figure – Current Rent A Shared Roommate - William

Figure – BHD Performance – Jon S

Figure – RASR Roommate – Rochester Cannon

Figure – Rent A Shared Roommate - Mikel R

Link - What is Tourette? - Tourette Association of America

Video - Keith Torkelson – YouTube - Mikel Baseline Suffering ReMix Product RASR

Report Link - Housing Advisory Board Orange County Division (HAB-OCD)

Report Link - Brand New Day HMO – COPD Season

Special Topic – Video Study –“Wasting Away!”

Figure - Benzodiazepine Half Life

Form Up Front Method (FUFM)

Table - Physician Information – Adapted Medication Change Request

(Needed for mailing notification - please print legibly)

Pertains to Rimal B Bera MD's Account Keith “Buster” Torkelson

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Demographic		Text
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Physician Name		Rimal B Bera MD
Physician Specialty		Psychiatry Experimenting on Human Subjects
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NPI or Tax ID # (Required)		Unknown
Phone		714-643-7176
Fax		714-643-7180
Physician Address		12511 Brookhurst St
City		Garden Grove
State		CA
Zip Code		92840
Suite / Building		Central City Community Health Center
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Last Reviewed: 20190922-SUN:

Physician Signature: ________________________________: Date: ___________________

Medication History List

Metadata > PHR_Xeno_4.0.1_Medication_History_17121101_Develop RBB V2019

Table - Alternatives Tried / Used By Patient (If applicable) – Influencing Sleep

In Context Prescribed Medications

Pertains to Rimal B Bera MD's Account Keith “Buster” Torkelson

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Chemical or Concoction	Note	Detail
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Ambien	Chandler MD Ambien Fiasco	Cold turkey of after more than five (5) years Resulted in hospitalization
Clozapine	Side effect drowsiness	7-9 hours’ sleep
Haldol	Serious reaction	Walking all night long (Akathisia)
Invega	Doctor Daniels Fiasco	Awake 72 hours straight – resulted in a hospital stay
Lorazepam	Without Clozapine Ineffective for sleep	Helps get back to sleep
Restoril	Prescribed by Bum Soo Lee	2012 Used instead of Clozapine
Seroquel	Bothersome side effects at dose that helps sleep	Akathisia & bizarre dreams
Tegretol	Bothersome side effects at dose that helps sleep
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Last Reviewed: 20190922-SUN:

FYI - Uncontrollable Impulse to Move

“Akathisia is a condition that causes a feeling of restlessness and an urgent need to move. Akathisia is a side effect of older, first-generation antipsychotic drugs used to treat mental health conditions like bipolar disorder and schizophrenia, but it can also occur with newer antipsychotics as well.” May 22, 2017

Table – Over-The-Counter - Alternatives Tried - Influencing Sleep

Pertains to Rimal B Bera MD's Account Keith “Buster” Torkelson

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Chemical or Concoction	Note	Detail
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Alcohol	Cons far out weight Pros	Abstinence since July 2012
Benedryl	Contributes to impotency	No substantial use in last 5 years
Melatonin	Uncomfortable
Reducing Coffee Intake	Helps a bit
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Last Reviewed: 20190921-SAT:

Table – Adapted - Medication Change Request Form – Impacting Sleep

Pertains to Rimal B Bera MD's Account Keith “Buster” Torkelson

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Feature	Text	Detail
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Drug Name	Replace Generic Restoril for Lorazepam	Temazepam
Documentation of Failure of Therapy	Clozapine Contingency	“Story of Sam I Am”
Strength or Dose Requested	Temazepam	Up to 30mg PRN
Quantity per Month	Temazepam	30 of 30mg
Diagnosis	Sleep Disorder
Medical Rationale	Clozapine Contingency
Reason for Drug Therapy	Cannot sleep without pharmacologic intervention
Medication Management	Rimal B Bera MD
Treatment Plan	Crash and Burn Appt 20190403-W	Reaction to investigate Telepsychiatry route
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Last Update: 20190920-F: 20190410-W: Transformation

Client: Keith “Buster” Torkelson MS

Date of Request: _____________________________

FYI - [PDF] - Prescription Drug Medication Request Form (Adapted)

Reference

Http://Content.Highmarkprc.Com/Files/Region/Hdebcbs/Forms/De-Drug-Med-Request-Form.Pdf

Sample Provider Comparison

Update for New doctor RB Bera

Second Appointment Scheduled 4 – April 11, 2018

20180410-TU Preparation for April 11, 2018 (RBB)

Presenting Problem – Sleep Issues Risk of Decline in Health

Consumer finding it hard to get a good night’s sleep with unpredictable COPD noise in room. On one night his shared room partner coughed – snorted and hacked from 10pm till 6am. To cope, Buster, the consumer has taken up an option to sleep out of the room on a hard wood floor. Consumer would like validation about this problem and inspiration that it can be weathered out.

The video captures a roommate during the day.

Sampling Nighttime Sleep Environment

We have been unable to capture nighttime footage because it has proven too challenging. There is another sharing the room who offers peace and quiet at night. If Dr. Rimal B Bera were to address this issue he would earn bonus points for intervention and problem solving. We did a sound study and the perpetrator’s hacking overshadows the noise on the major roadway some thirty (30) feet away.

List – Metadata - Associated Papers

As is the case most of the time we create ancillary papers in the process of publishing just one. Below is a list of papers we either created a new or updated in the process of writing this Medication Trial Request (MTR) paper.

03_Resources_Telehealth_Telepsychiatry_19042503_P4D_Develop

08_LS_BND_CCCHC_BSL_Sam_I_Am_18092702_Clozapine

13_OS_TD_Clozapine_14102503_Contingencies V2019

Form_MSG_Psychiatry_Treatment-I_18040101_RB_Bera

Medication Management Appointment Themes

08_Medication_15070803_XenoNet2012_RBB V2019 [INCLUDE RX HX]

09_Program_Bera_RBB_Appointment_19052401_Register
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2018 - Table – Appointment & Key Event Register (RBB Timeline)

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Time Stamp	Key Event	Satisfied
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20171024-TU	Base Referral (R&L)	Close five years with Bum Soo Lee Satisfied
20180103-W	Linkage 1 (Referral Part I)	Yes
20180411-W	Linkage 2 (Referral Part II)	Yes
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20180509-W	Charter Bera Standalone	In Consideration
20180718-W	Linkage 3 (Referral Part III)	SoSo
20180718-W	Graduate from Linkage Phase
20181010-W	Wrap up first year	Partnership “Stable”
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Last Reviewed: 20190923-M:

Metadata Source > 09_Program_Bera_RBB_Appointment_19052401_Register

Sample Provider Quality Rating

2019 - Table – Appointment & Key Event Register (RBB Timeline)

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Time Stamp	Key Event	Satisfied
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20190109-W	The Consensus Appointment
20190308-F	Major meeting with JAN	Spend an hour with us Very Satisfied
20190403-W	The Crash Appointment	Treatment Appointment Charter P4D Study
20190621-F	Digital Appointment Method Applied	Feature 5 Images (Teladoc)
20190703-W	The Recovery & Sleep Appointment	System Restore
20190925-W	Promote Telepsychiatry Medication Request - Restoril
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Last Update: 20190521-F:

Metadata Source > 09_Program_Bera_RBB_Appointment_19052401_Register
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Sample Provider Performance
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Feature Case Study – Sam I Am! – Relying on Existing Reports

We decided to write a new paragraph featuring Sam. Sam is (was) a Brand New Day client that was serviced by Chester D Mojica (CDM) and Bum Soo Lee (BSL). We say was because Sam, also known as “Sam I Am!” is Missing In Action (MIA). While Sam was in good enough to still attend Brand New Day (BND) Buster met Sam back in 2012. Sam told Buster that he was university educated in Economics. To cut things short Sam had been stable on Clozapine for years. Then his White Blood Cell (WBC) count dipped too low. Doctor Lee took away his Clozapine Cold Turkey. Cold Turkey is not usual and customary with changing psychotropic medication. The industry standard is increase or reduction by progressive titration. Sam thought that a dose reduction would have been the better approach. When we met Sam for the last time he wasn’t sleeping well. In addition he looked a bit haggard. He was also overly activated as compared with the usual Sam. Sam is now Missing In Action (MIA). Buster thinks her may be able to track him down at a Board & Care called West Glen Manor. The reason Buster would like a Restoril trial is to have some options in the bank if, as with Sam, his Clozapine becomes endangered.

FYI - Search “sam I am”
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[INSERT A PHOTO(S) SAM I AM]
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Report Link - April 2019 - Brand New Day HMO

http://brandnewdayhmo.blogspot.com/2019/04/

Emerging Health Risks for Keith “Buster” Torkelson Via Rimal B Bera MD...We call him Sam I Am! As of 2018 Sam had been “Stable” on Clozapine for years

Table - Medication Management Appointment Themes Summary – Team Rimal B Bera MD

Practice Impressions – Practice Management

Scored by Keith “Buster” Torkelson MS and Avey Asus


##	Observation	20190923 (M-RT)	Note	Detail
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01	“His Practice”	0.00	Sharon Hilliard Monopoly Principle
02	Compare with Control Doctor Bum Soo Lee MD	0.50	Overall superior to current
03	Digital Appointment Teledoc Limit 5 Images	0.00	Trend as less receptive
04	Good listener score [Rapport]	0.50	As Measured By	Having to repeat ourselves
05	Malpractice elimination level	0.50	Marginally improper and negligent activity or treatment	Medical practitioner
06	Medication Preventive Planning	0.00	Poor
07	Operations Documentation	0.00	Failure
08	Policy and Procedures	0.25	Oral only
09	Proof of concept Of practice and services	0.00	Failure Sustained
10	Quality Assurance (QA)	0.25	No evidence	We help him out with our reports
11	Risk Management	0.00	Poor
12	Solidarity score with prior MDs	0.25	Especially Singh, Deutsch & Lee
13	Usual and customary monitor	0.00	Failure
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	CALC	2.25/13
	Practice Management Scale Score =	17.3%
	Star Equivalents =	0.9
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Date Scored: 20190923-M:

Objective Up Front – Reputation

Figure – Doctor In Charge – Objective Ratings

Pooling

This time around we decided not to pool the data or append to that we already have on file.

Metadata > Assess_Vitals_Plus_Bera_RBB_19061902_Appt-2019-03

Study Question

What does 3.0 Star Performance Translate Into?

Table - Medication Management Appointment Themes Summary – Our Part

Practice Management – Our Part

Scored by Keith “Buster” Torkelson MS and Avey Asus

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##	Observation	20190923 (M-RT)	Note	Detail
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01	Accepting having to Repeat Self	1.00	Concession
02	Busy self during appointment	1.00
03	Conservative Impressions	0.50	Average
04	Contingency/Contingencies	0.75	Not addressed
05	Experimental Mus	0.50	Recouping losses
06	Make Digital Ready	1.00
07	Life Threatening	0.50	Preventable
08	Medication Management	1.00	Good to Excellent
09	Process The Crash Appointment	0.75	20190403-W
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	CALC	7.00/9
	Our Part in Practice Management Score =	78%
	Star Equivalents =	3.9
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Last Reviewed: 20190923-M:

Consumer Driven

For us here at MSG Consumer-driven means that Buster and us do our part to make the most of our health related Face-To-Face (F2F) engagements. We call this process Health Related Engagement (MSG-HRE). We plan to publish our HRE findings later this year (2019). One feature for applying a policy for Consumer Driven is to fire the middle people such as our care coordinator. Buster is with his fourth Brand New Day (BND) care coordinator. Number who we will call Jeff Gibbs has been and is useless. As of September 22, 2019 (SUN) Buster participated in a total of 96 Health Related Engagements (HREs). Of the 96 HREs that Buster participated thirty-five (35) are in the Brand New Day (BND) Network.

[INSERT SAM I AM - Ditto]

20180713-F: Grounds for Sleep Experiment

The benefit of prescribing medications as needed (PRN) is that it gives the consumer more control over poly-pharmacy. Either you believe in your client and their judgment or you don’t? The primary presenting problem for which we consume Clozapine is securing our RIGHT for life-sustaining sleep. Before we were placed on Clozapine in 2007 we used a cocktail of: Melatonin, Benadryl (SPELLED), and Ambien to sleep. We are grateful to be off Ambien. Its' instant removal from our approved medications by Dr. Chandler (Kaiser) resulted in a 2006 hospitalization.

20180720-F: Risk Factors

We have responded well to Restoril for sleep. Restoril was prescribed by Bum Soo Lee MD for us in 2012. Since 2012 we take our Ativan (Generic Lorazepam) prescribed PRN only when we are awakened in the night and can’t get back to sleep within an hour. Initially we also took Ativan (Lorazepam) for situation driven anxiety. A few of our teams know that sleep or the lack thereof is a substantial risk factor for Buster. Thus in several reports we have planned to publish in the future SLEEP as a recurrent theme.

Figure – Rent A Shared Roommate Collage Impression – 4 Characters

20190621-F: Digital Appointment Prep – The Collective

Gary Zager Group Principle - Back in 2011 Buster – The Collective

Back in 2011 Buster enrolled at Cypress College using the Board of Governor’s Fee Waiver. He signed up for 8.0 units of Health & Human Services. Buster took 4.0 units and completed with an “A” grade Crisis Intervention Management. His teacher was department chair Gary Zager MS. Mr. Zager also was program director for Casa Youth Shelter. Casa is a program for runaway pregnant teenage females. The goal of this crisis residential was to reunite the runaway with their family. Mr. Zager indicated in order to succeed with reunification “Casa” needs to treat the car. Basically you need to bring the runaways family into meetings, classes, and groups. We here at MSG propose that in order that a Behavioral Health Doctor (BHD) to succeed they need more situational awareness of their client’s living environment. In the case of how housing effects Buster’s need for a restoril trial doctor Bera would have to address Buster’s home environment. In other words RBB needs to address all in “The Car”.

Digital Appointment – Slide Show

We here at Mentalation Solutions Group (MSG) have been working on our Digital Appointment product for more than five (5) years. In general each update is image based. If Rimal B Bera were to entertain spending less than one (1) minute of digital appointment we would have ready to show using our Smart Phone a half dozen or so photographs. We include some of the key photos below in this report. How is it that these photos relate to a request to try Restoril. They demonstrate behaviors of our roommates captured during the day that continue into the night. These behaviors have substantially impacted the quality of Buster’s sleep.

Link - Double XX – Digital Appointment ... - Brand New Day HMO

https://brandnewdayhmo.blogspot.com/2018/09/double-xx-digital-appointment.html?showComment=1557770680517

Sep 10, 2018 - The Subject for this report is Keith E Torkelson AKA Buster. This report has been developed and published in preparation for Keith's upcoming doctor’s appointment.

Figure – Current Rent A Shared Roommate - Mikel

Sep 25, 2019 - The Subject for this report is Keith E Torkelson AKA Buster. This report has been developed and published in preparation for Keith's upcoming doctor’s appointment.

Snapshot – Mikel Roby

Featured in the photograph above is Mikel Roby. Mikel is a current as Rent A Shared Room (RASR) roommate of Buster. In Buster’s room at the Shanks Truck Stop (STS) facility there are a total of three (3) men. In Buster’s room one co-tenant is gifted with a standalone bed whereas the other co-tenant has an upper birth in a Bunk Bed system. Buster occupies the lower bunk. In general most of the residents at STS fit into the Dying Old Men (DOM) profile. Mikel is different in that he is thirty (30) years old. Mikel is Seriously and Persistently Mentally Ill (SPMI). What little service Mikel receives is associated with the local Mental Health Association (MHA). After observing Mikel for more than three (3) months it is obvious Mikel is both inappropriately and under-served. We have already published a paper featuring Mikel and his nuances. Mikel is restless day and night. In a fifteen (15) minute period he can get up from his bed and down again fifteen (15) times. His doctor admits making medication errors. Mikel scores high for positive symptoms of schizophrenia. Rather than describe again more of our observations let the video and report speak for themselves. Since Mikel’s moving in during May 2019: With Mentalation Solutions Group (MSG) help Mikel has started to measurably improve. For one his Activities of Daily Living (ADLs) score has improved.

Figure – Rent A Shared Roommate - Mikel R

[INSERT MIKEL ON FLOOR]

Seriously and Persistently Mentally Ill (SPMI) Populations

When you concentrate SPMI peoples too tightly it may lead to amplification of number of problems per living unit. Some of the problems such as learned helplessness can have two results. One result is that problems such as low Activities of Daily Living (ADLs) scores have little impact. Another outcome such as impairing sleep of others will have far reaching consequences. We feel that sleep and SleepAbility should be a priority in the community. In the photo above our Rent A Shared Room (RASR) roommate is featured eating crunch food while sitting on the floor. Since May 2019 Mikel has taken better control over sitting, lying, and sleeping on the floor.

Figure – Current Rent A Shared Roommate – William

[INSERT WM LOOK OF DEATH]

Snapshot William – Violent Outbursts – Shaking the Bunk Bed

During the 2018/2019 COPD season the top bunk of the unit were Buster sleeps has been hard to fill. In other words it has been hard to get a placement that is PEACEful for all of quiet time (830p – 830a). Mike O and William have been rotated in and out of the top bunk twice. The photograph above features William. William is the current incumbent in the top bunk. William presents with violent outbursts. For the first two weeks of September 2019 he has improved as measured by all in the room being able to get a full night’s sleep. We tracked down and assessment for Tourette’s Syndrome. William scores high for Tourette’s. When William is bad his violent vocal and physical outbursts can last for four hours through the night. William is classic example of a: Dying Old Man (DOM). For real! Sometimes William looks like he is dead.

Figure – RASR Roommate – Rochester Cannon

[INSERT TYPICAL ROCHESTER]

Snapshot – Rochester Cannon - Wounded Warrior

We feature Buster’s one time Rent A Share Room (RASR) roommate Rochester Cannon in the photograph above. We will not delve into Rochester much because we already wrote and published a report on him. Leave it to be that our tenure with Rochester was seriously problematic. Buster finally got the help he needed and the landlord relocated Rochester back in May of 2019. Now September 24, 2019 Buster shares a room with Mikel and William. Mikel sleeps in a standalone bed whereas William sleeps on the bunk above Buster. We have included the link to our primary report on the Rochester-Buster association below.

Report Link - HEALTHMAN By Keith Torkelson MS UCD Educated

https://healthman2059.blogspot.com/2018/05/mental-health-association-orange-county.html

May 4, 2018 - Mar 30, 2017 - With MSG Abstract – This report is about a Wounded Warrior who is lost but not forgotten

You've visited this page 4 times. Last visit: 8/12/19

Figure – RASR Success – Mark Barnes

[INSERT TYPICAL MARK]

Mark Barnes 2007-2008

Snapshot – Mark Barnes – Positive Control

Buster met Mark Barnes back in 1997. They were both enrolled in a residential treatment program called the Wit’s Inn. During Buster’s three (3) month stay at the Wit’s Mark and Buster formed a bond. Years later (2007) Buster found the need to move into a Rent A Share Room environment. In 2007 Mark contacted Keith saying he was having trouble with his wife and needed a place to stay. A so Mark became Buster’s RASR roommate once again. Buster never had trouble sleeping with Mark in his room. Thus when it comes to sleep Mark is one of Busters positive controls.

Housing Advisory

Report Link - Housing Advisory Board Orange County Division (HAB-OCD)

https://housingadvisoryboard.blogspot.com/

Aug 28, 2019 - It pertains to Keith “Buster” Torkelson MS…Buster shared a room in a RASR environment with retired and wounded…investigating Rochester as a Wounded Warrior.

You've visited this page many times. Last visit: 9/20/19

RASR – Summary Table – More Characters (7)

	-
#	Character	Permits Permitted Sleep	Appropriately Served	Note
	-
1	Jon S	NA	No
2	Mark Barnes	Yes	SoSo
3	Mike O	No	No
4	Mikel	Yes	No
5	Rochester	No	No
6	Waste Away John	No	SoSo
7	William	SoSo	SoSo
	-

Last Reviewed: 20190924-TU:

Figure – BHD Product – Jon S

[INSERT TYPICAL JON S]

Jon S - Existence Lying About

Snapshot – Jonathan S

Featured in the above photograph is Jonathan or Jon. Jon is a co-resident with Buster at Shanks Truck Stop Rent A Shared Room (RASR) facility in Santa Ana California. Fortunately Buster has never shared a room with Jon. We include Jonathan because he is an example of a Rimal B Bera MD partnership. Lying on the ground at home and out in the community demonstrate two of Jon’s primary behaviors. Jon gets aggressive and in other people faces. His aggressive behavior is the worst at nighttime. In over five (5) years Jon has demonstrated little improvement. We here at MSG are impressed such that we think Jon needs better service from his Behavioral Health Doctor. A general takeaway for making here is that: If a BHD drops the ball with their client it adversely impacts the people in their client’s life.

Special Topic – Mikel In Depth

Link - What is Tourette? - Tourette Association of America

In May of 2019 Buster is paired with Mikel Roby. Mikel is different from the typical resident in Buster Rent A Shared Room (RASR). Mikel is younger than average. Mikel is thirty (30) years old. Mikel is treated with monthly injections of Invega. Mikel is restless and cannot sit still day or night. Mikel demonstrates repetitive movements. In Google we described his signs and Google served up Tourette Syndrome.

FYI > https://tourette.org/about-tourette/overview/what-is-tourette/
-

“Tourette Syndrome is one type of Tic Disorder. Tics are involuntary, repetitive movements and vocalizations.”

Buster Video Taped Mikel for the purpose to play it back for Mikel in order Mikel get in touch with his un-usual behaviors and vocalizations. We here at MSG uploaded the video on August 11, 2019. The video lasts 88 seconds or 1 minute and 28 seconds. As of September 23, 2019 (M) You Tube counts 7 views. We have more footage of Mikel and since his behavior is so unique and dramatic at times we are planning a best of mix.

Video - Keith Torkelson – Mikel Baseline Suffering ReMix Product RASR

https://www.youtube.com/watch?v=ejvzKYS7R7U&t=25s
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Chronic Obstructive Pulmonary Disease (COPD)

Unfortunately Buster smokes cigarettes. For the most part we delineate COPD season as November to February each year. The last COPD season was incredibly hard on Buster. It began early and lasted late. For the most part a course of antibiotics is necessary each COPD season to address secondary bacterial infections. As of May 2019 Buster has a new shared room roommate. His name is Mikel Roby. Although Mikel is Seriously and Persistently Mentally Ill (SPMI) he receives no tangible help apart from what Buster can offer him. Mikel has come in under the radar in that he does not substantially interfere with Buster’s sleep. We wrote and published a report regarding Mikel and his situation. About Mikel we discovered something new: “Pseudobulbar affect (PBA), or emotional incontinence, is a type of emotional disturbance characterized by uncontrollable episodes of crying and/or laughing, or other emotional displays. PBA occurs secondary to a neurologic disorder or brain injury.”

Report Link - Brand New Day HMO – COPD Season

http://brandnewdayhmo.blogspot.com/

Sep 10, 2019 - 2018-2019 COPD Season By and For Keith “Buster” Torkelson, MS - Adjustment & Control Respites – Centered About Mikel Roby

You visited this page on 9/19/19.

Special Topic – Video Study –“Wasting Away!”

Buster shares a room at any given time with two (2) severely disabled men. At one point about 2 ½ years ago he was paired with “Waste Away John” (WAJ). Waste Away John is about sixty-five (65) or more years old. For all practical purposes WAJ is deaf. WAJ is a tobacco smoker and suffers COPD symptoms. His coughing and hacking at night makes it impossible to sleep. Before asking for any intervention Buster captured a little footage on WAJ’s in bed existence. WAJ substantially interferes with both rest and sleep of those within earshot. We here at Mentalation Solutions Group (MSG) believe that: “Without sleep there can be no health”.

You Tube Short Film…Housing sleep issues a short film

Video - Keith Torkelson

https://www.youtube.com/watch?v=1mx95-AqQr0

[INSERT STILL OF TYPICAL JOHN]

Video Specifications

The “Waste Away John” video was captured by Buster using a Motorola Smart Phone. It was captured in MP4 format. On March 23, 2018 (F) Buster uploaded the video without editing to You Tube using said Smart Phone. The video is 63 seconds long. The date and timeframe would put WAJ and Buster’s partnership in the 2017/2018 COPD season. Twenty-two (22) seconds into the video we note as remarkable. As of September 23, 2019 there are 36 incidents of viewership. On April 11, 2018 we published another video staring WAJ. We named it 20180411 Sleep Cough Impression Edit. It lasts 1 minute and 54 seconds. As of September 23, 2019 there are 970 incidents of viewership. We will let the videos stand as evidence and testimony.

Matrix – 20190920-F: CCCHC – Garden Grove Site Performance (Objective)

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Time Stamp	Review Site (*)	# of Reviews	Rating (Stars)	Unweight
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20190920-F	Google	10	2.0	20.0
20190920-F	Yelp	8	1.0	8.0
20190920-F	Mapquest	8	1.0	8.0
--
	CALC (SUM)	26
	CALC			36.0/26
	Pooled & Remixed Stars =			1.4
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Date of Calculations – 20190920-F: CCCHC = Central City Community Health Center

About Rating Sites

Usually we rely on sites that rate doctors rather than facilities. The facility that Rimal B Bera MD associates with in the case of serving Buster is Central City Community Health Center (CCCHC). We feel that a facility impacts a practitioner. We gather objective facility ratings for CCCHC on September 9, 2019. With a total of 26 ratings across 3 online rating services CCCHC earned themselves 1.4 Stars with 5.0 Stars meaning superior.

Table - Indications for BZD Treatment – FDA

Renting A Shared Room – Benzodiazepines (SPELLED)

Pertains to Rimal B Bera MD's Account Keith “Buster” Torkelson

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Indication	Ever	20190920 (F-RT) AC2-2013	Note
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Generalized anxiety disorder (GAD)	Severe and debilitating	Moderate
Social phobia	Moderate	Less
Panic disorder	Severe and debilitating	Less frequent
Insomnia	Severe and debilitating	Daily

Status epilepticus/seizures	NA
Premedication for anesthetic procedures	NA		2019 had Fentanyl for the first time
-

Last Reviewed: 20190923-M:

Dosing Pattern - Ativan (Lorazepam)

The literature indicates that there are multiple generic manufacturers for Lorazepam. That is probably why it is so reasonably priced. Buster takes his Lorazepam by mouth (PO) in the tablet form. Typical dosing for “Lorazepam is 0.5 to 1 mg three times a day-four times a day”. Originally Buster needed Lorazepam to help with daytime anxiety as well as nighttime sleep. After about three (3) years of addressing the causes for his anxiety Buster rarely needs any daytime Lorazepam. Buster’s primary “Sleeper” is Clozapine. If Buster is awakened between 10pm and 4am he may have to take 0.5 mg of Lorazepam to complete his night’s sleep. In this manner Buster takes Lorazepam As Needed (PRN). Buster suffers an intractable sleep disorder and requires Clozapine nightly in order to achieve a full night of rejuvenating sleep.

Figure - Benzodiazepine Half Life

[INSERT FIGURE]

FYI - Benzodiazepines

Paul M. Kim, M.D., Ph.D., Sujin Lee Weinstein, Pharm.D., BCPP

https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787140/all/Benzodiazepines

Individualized Paradox

Back in 2012 Bum Soo Lee MD prescribed Restoril (PRN) to help Buster sleep. Later that same year Dr. Lee and Buster agreed to replace Restoril with Lorazepam (PRN) to help Buster with both anxiety and sleep. Buster noted that the sleep profile of Restoril as a substitute for Clozapine is superior to that of Lorazepam augmenting Clozapine. A Clozapine contingency is a principle reason for Buster needing to give Restoril generic (Temazepam) an experimental trial. The chart above indicates that Lorazepam is a better fit for Buster. Yet, that is just an indication of the Individualized Paradox. In other words what might be indicated is not always in the best interest of the client.

Table - Side Effects – Clozapine – “Busters” Mainstay

Success of Ravinder P Singh MD

Pertains to Rimal B Bera MD's Account Keith “Buster” Torkelson

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##	Side / Adverse Reaction		Impact 20190920 (F-RT)	Note
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	A-Secondary Drowsiness	R	0.00	(*)
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01	Blurred vision		0.10
02	Constipation		0.00
03	Dizziness		0.50	Use divided doses to reduce risk of falling
04	Dry Mouth		0.10
05	Fast heart rate		0.10
06	Headache		0.25
07	Increased salivation		0.20
08	Increased sweating		0.20
09	Serious movement disorder		0.50
10	Severe dizziness		1.00	Use divided doses to reduce risk of falling
11	Sudden cough		0.25	May contribute to COPD issues
12	Tremor		0.25
13	Weight gain		0.00
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	CALC		3.45/13
	Impact of Clozapine Side-Effects Score =		26.5%	High Scores are more problematic
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Last Reviewed: 20190922-SUN:

(*) – Secondary Drowsiness - Clozapine

We have repeated this again and again in our reports. Sleep is essential for Buster’s wellbeing. Most of his hospitalizations were associated with sleep problems. In 2006 Ravinder P Singh MD on her third attempt prescribed Clozapine for Buster. Clozapine took care of the chemical aspect of sleep. For Buster Clozapine poses some challenging adverse effects. Because of these adverse effects Buster loosely agreed to try an experimental medication in 2012. In less than a week’s time off Clozapine Buster was not able to sleep. After seventy-two (72) hours without sleep Buster was back in the hospital. One of Clozapine’s primary effects is to address psychosis. For Buster this has been helpful. Yet the most important, a secondary, effect of Clozapine is that it causes drowsiness. For Buster this translates into chemically mediated sleep. On a total of 200mgs, 100mg in two (divided) doses, Buster may get adequate sleep. This for Buster averages 8 hours of rejuvenating sleep per night.

Division of MSG - Transparency & Accountability

Himasira De Silva

Nothing Online originated from Doctor

...to demonstrate how successful he was as a Behavioral Health Doctor

Table - Brand V Generic – Cost Containment - Ativan

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Dose	Number	Brand Ativan	Generic Lorazepam	Note
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0.5 mg	100	$898.14	$67.75
1 mg	100	$1199.78	$88.25	July 2019 Prescription Drug Summary Actual – 15 Tabs/Mos (PRN) Plan Paid $2.00 You Paid $0.00 Other Payments $0.00
2 mg	100	$1912.10	$128.45
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Last Reviewed: 20190923-M:

Table - Cost Containment

Metadata > Clozapine Practical 4.5_Cost_Containment_17071903 V2019

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Charge	Invoiced	Note
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Office Visits	No	Accountability Issue
Lab Work	No
Clerical Efforts	No
Medications	Yes	Full breakdown lacking
Errors	NA
Transportation	NA	Our cost to get to an appointment
Consults by Phone	NA
Record Requests	Yes	Policy is defective
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Last Reviewed: 20190923-M:

Special Topic – Paralleling Effort

Both of Buster’s doctors appear to be short on time when it comes to Time Spent with one of their accounts during an appointment. One of the doctors is Buster’s Primary Care Physician (PCP) whereas the other is a Buster’s Behavioral Health Doctor (BHD). We suggest that each parallel their efforts to improve efficiency. More clearly they do the same thing, exactly.

Rimal B Bera MD

"Adequately Dressed"

Looks like De Silva is going to stop experimenting on human subjects

Evidence of intense experimentation using Human Subjects

BZDs FYI

Summary

We write this summary to combine our interests. In general we here at Mentalation Solutions Group (MSG) have a stake about housing the disadvantaged of Orange County and large counties across the United States. The Rent A Shared Room (RASR) environment needs some improvement that they may provide a fix for some consumers’ housing needs. We here at MSG are working towards meeting with US Representative Lou Correa to discuss housing fixes. Buster met with Jeffery A Nagel PhD (JAN) back in March of 2019. They discussed some of MSG’s housing fixes for those residing and with need in Orange County. We here at MSG are working on some materials to update JAN as to our progress. When a consumer is in need of a new (great) bed the last thing they need is to fall into a room where they cannot sleep. We argue that not only is sleep a right it is essential to health and wellbeing. Family or natural supports often help their loved one move. Families can only do as well as the resources provided them. As the photographs pinned into this report earlier might indicate: Peoples afflicted Serious & Persistent Mental Illness (SPMI) suffer a degree of social poverty. Sometimes they interfere with others’ sleep just to act out their misery. Rochester over and over stated about his hacking and coughing: “I can’t help it!” Rochester knew he was causing harm yet could not help it.

Looking Forward to Our Book

An excerpt and potentially more than one excerpt of this report will be published in our Psychiatry For Dummies (P4D) Blog-book. After all the efforts made by Team-Buster to move ahead with Buster’s health it would be a shame to lose any substantial ground. As this report indicates, sleep is not just important to Buster yet those that are in earshot of each other in a RASR homestead. Sleep measurably impacts both Buster’s Satisfaction with Life and his Quality Of Life (QOL). We here at MSG are a proponent for “Technology that Facilitates Recovery”. With those consumers that make use of technology we define a divide. First there are consumers that use technology to develop and maintaining literacy. Writing and publishing this paper is an example of using Technology to promote recovery through literacy. Second there are consumers that use technology for everything but literacy. Obviously Buster is part of the first group. Years ago we here at MSG began working on our Digital Appointment tool. So now at this point, September 24, 2019 we have done enough to be Appointment and Digitally Appointment ready.

Protective Factors

Because we here at MSG have not fully developed our Protective Factor survey series we find it hard to determine how writing and sharing a report such as this might protect Buster. We do know that it helps Buster understand his social relationships especially those people that he can hear at night during quiet time. Buster is now sixty (60) years old and is showing signs of dementia. Reporting helps Buster to stay focused and follow through with what he began. Reporting has helped Buster “bounce” back after his seriously debilitating episode of 2012. We are going to further investigate an assessment tool called: The Scale of Protective Factors (SPF). As far as protecting Buster about his sleep we can’t see anything super beneficial with publishing this. Will this report protect Buster from “Violence” in the night – probably not. Will this report help Buster face the 2019/2020 COPD season? I a manner Yes! Because we get to remind ourselves of how intensely others can harm Buster while he still advances forward with his missions.

List – Integrated Interest Summary

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Interest
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Housing
Housing and Jeff A Nagel PhD
Family
@ Social Poverty
Pro-P4D
Health
Sleep
Satisfaction
Quality of Life
Technology for Recovery
Digital Appointment
Protective Value
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