Now · Care plan · Phase 3 prep

Phase 3 prep — handoff to the at-home care team

A working checklist for the family as Dad moves from PHP (The Recovery Team) → IOP / at-home (Apollo Beach).

The shape of it

Phase 3 is the at-home stretch. The job of the family in the weeks before he steps down is to line up the at-home care team so the day he leaves The Recovery Team, there's no gap. The first 1–2 weeks home are the highest-risk window.

  • 3–4 weeks before discharge: identify + contact each provider, verify insurance, book first appointments.
  • 1–2 weeks before discharge: warm handoff calls, confirm appointment times, fill prescriptions locally.
  • Discharge day: verify all meds in hand, all appointments on the calendar, emergency contacts visible.
  • First week home: psych follow-up within 7 days is the most important single appointment.

Care team to line up

One card per provider type. Each lists what they handle + what to bring + what to ask.

1. Primary Care Physician (PCP)

Quarterback. The provider who coordinates everyone else.

Bring: Discharge summaries (Haven + Recovery Team), full med list with start dates, EKG, most recent labs, drug allergy list.

Ask: Are you comfortable coordinating with psych + cardio + GI? Will you accept faxed/emailed updates from specialists? Can we book quarterly visits in advance?

Local-first: Pick someone in Apollo Beach so visits don't require a drive.

2. Cardiologist

CAD + AFib + Watchman + stroke history + DAPT step-down.

Bring: Watchman implant date + records, mini-stroke records, quad bypass history (Nov 2023), 2025 lipid panel, current med list with cardio block highlighted.

Ask: When does the aspirin + clopidogrel DAPT step down to aspirin alone? (Standard: 45 days–6 months post-Watchman.) When's the next echocardiogram? Should we get Lp(a) (one-time genetic CAD test)? CYP2C19 test to confirm clopidogrel is working (up to 30% of patients are non-responders)? Vascepa (icosapent ethyl) evaluation given high TG + CAD?

3. Outpatient psychiatrist

Med management — most important specialist for continuity.

Look for: Someone with addiction medicine + kindling literacy. ABPM (Addiction Medicine) board-certified is a strong filter. Don't settle for a general psychiatrist if avoidable.

Bring: Baker Act records (need signed Release Of Information), Haven discharge summary, current med list, Tourette's history, any pharmacogenomic test results.

Ask: Kindling-aware med management — yes/no? Discontinuation roadmap for duloxetine + olanzapine? Bipolar screen done? Ketamine / Spravato available if duloxetine doesn't land?

Timing: First appointment ≤7 days from PHP discharge. No gap.

4. EMDR therapist

Continues the trauma work from Corrin (Haven).

Bring: Continuity letter from Corrin or her sister-facility counterpart at The Recovery Team. Trauma history summary. List of triggers + grounding tools that work.

Ask: Weekly or twice-weekly during the first month home? Coordinate with outpatient psychiatrist?

5. GI specialist

GERD + dual antiplatelet bleed risk + long-term PPI.

Bring: GERD history, pantoprazole start date (5/27/2026), DAPT regimen, any history of H. pylori testing or endoscopy.

Ask: Baseline endoscopy (he's 63 + on DAPT). H. pylori test. Long-term PPI plan + impact (B12, iron, magnesium, bone density). When can PPI step down once DAPT ends?

6. Pain management

Non-opioid path for chronic back pain.

Bring: Back pain history, what's tried + worked, current non-opioid stack (lidocaine patch, acetaminophen).

Ask: Physical therapy referral, dry needling, trigger point injections, possibly RFA if persistent. Critically: no opioid reintroduction. Mind-body options (yoga, CBT-for-pain). Ibuprofen avoided due to DAPT bleed risk.

7. Physical therapist

Reconditioning + back pain + fall prevention.

Why it matters: 90 days of mostly bed-rest at 63 + olanzapine + sleep stack + amlodipine = real fall risk. PT addresses strength, gait, balance, and back pain at once.

Ask: In-home or clinic? Cadence? Coordinate with pain management.

8. Endocrinologist (likely needed)

Insulin resistance + olanzapine metabolic risk + low DHEA + low-normal T.

Bring: 2025 baseline labs (insulin 57, A1c 5.8, lipid panel, DHEA-S 16, total T 304), olanzapine start date.

Ask: Continuous glucose monitor (Dexcom Stelo / Libre Lingo — OTC) for olanzapine monitoring. GLP-1 (semaglutide/tirzepatide) if metabolic worsens. Testosterone treatment consideration.

9. Sober coach / peer recovery support

Equivalent of Gary's role at Haven.

Ask: Local Apollo Beach AA/NA/SMART meetings — map of nearby options. Sober coach (1:1) if budget allows. The Recovery Team should have local referrals.

10. Family therapist

For Angela's caregiver role + family dynamics + boundaries.

Why it matters: Caregiving for someone in recovery is heavy. Angela needs her own support infrastructure. Family therapy also helps sibling alignment.

Logistics checklist (pre-discharge)

  • Insurance verification for each provider — confirm in-network, copays, prior auths.
  • Provider scheduling — book first appointments before discharge. Psych ≤7 days from discharge.
  • Medication transition — transfer all prescriptions to a single pharmacy in Apollo Beach (CVS or Walgreens). Synchronize fill dates. Set up auto-refill where possible.
  • Pharmacy buffer — never let any med run out. Refill 5+ days ahead. (Critical for psych meds — abrupt discontinuation triggers kindling cascade.)
  • Home medical equipment — BP cuff (he'll be checking daily), pill organizer or MedMinder, fall mat for bathroom if relevant.
  • Sober environment audit — go through the house. Remove all old prescription bottles (especially benzos, opioids), alcohol, anything that could be a trigger or accidental dose.
  • Driving clearance — confirm with attending psychiatrist before discharge. Olanzapine + sleep stack + duloxetine = real sedation. Probably restricted initially.
  • Emergency escalation plan — written down (see below). Visible on the fridge.
  • Records release — signed HIPAA release for each new provider to talk to Haven + The Recovery Team.
  • Calendar setup — every appointment, every refill, every PT session in one shared calendar. Angela + Dad both have access.
  • Daily structure draft — wake time, med times (9 AM block, 9 PM block), meal times (matters with metabolic baseline + olanzapine), recovery meeting times, MD visits, sleep hygiene routine.
  • Tech enablement (optional but powerful) — CGM (Dexcom Stelo or Libre Lingo, OTC), Apple Watch or Whoop for HRV trend, automatic BP cuff with phone sync.

Family caregiver education topics

What Angela + family should understand before Dad comes home.

Kindling (the most important one)

What it is: Dad's nervous system is sensitized from 30 years of Xanax + the cold-turkey event in April. Every future abrupt withdrawal would be worse than the last — escalating risk of seizure or death.

What it means at home: Never let any psychiatric medication run out. Never skip doses. Refill prescriptions 5+ days ahead. If a pharmacy delay happens, call the psychiatrist immediately. Any future taper must be slow + supervised.

Suicide / mood warning signs

Duloxetine carries a black-box warning for emergent suicidal ideation, especially in the first 2 weeks. That window for Dad has now passed (5/22 → 6/5), but the broader vigilance continues.

Watch for: withdrawal from family, hopelessness statements, sudden calmness after distress, giving away possessions, sleep disruption, alcohol/substance interest, talk of "burden" or "ending it." Trust your gut — call psychiatrist or 988 (suicide & crisis line) immediately.

Falls + sedation

Olanzapine + duloxetine + sleep stack + amlodipine + back pain = real fall risk. He's 63 and just spent 90 days mostly in bed.

Practical: Bathroom grab bars, no loose rugs, well-lit hallway at night, no climbing on chairs, sit-to-stand slowly (orthostatic hypotension from amlodipine).

Bleeding (DAPT)

Aspirin + clopidogrel = both antiplatelets. Bruises easily, cuts bleed longer, GI bleed is the serious risk.

Call doctor for: black tarry stools, coffee-ground vomit, unexplained bruising, blood in urine, persistent headache (could be intracranial bleed). Avoid: ibuprofen (bleed risk on DAPT), NSAIDs in general — use acetaminophen for pain.

BP + heart rate at home

He's on metoprolol + amlodipine + clonidine PRN. Three antihypertensives plus a beta-blocker is a lot. Daily home BP monitoring catches problems early.

Cuff readings: daily morning, log them. Call if systolic <100 or >160, diastolic <60 or >100, HR <55 or >110.

Relapse signs

Recovery is non-linear. Watch for: secrecy around meds or activities, missed therapy sessions, withdrawal from sober support meetings, return of avoidance behaviors, sudden interest in pain meds, "I don't need [med X] anymore."

Plan ahead: What does Dad want you to do if you suspect relapse? Have that conversation when he's stable, not in crisis.

Emergency escalation plan

Print + put on the fridge. Update with real numbers once providers are confirmed.

Imminent danger

SI with plan · overdose · severe bleeding · seizure · unresponsive

911 immediately. Tell dispatcher: "63-year-old male, post-detox, on duloxetine + olanzapine + dual antiplatelet, allergies on file, has Narcan at home."

Mental health crisis (no imminent danger)

SI without plan · acute panic · sudden mood shift · disorientation

988 (Suicide & Crisis Lifeline) — call or text. Then call outpatient psychiatrist within the hour. If 988 isn't enough, ER.

Medical urgent (not 911-level)

BP out of range · chest discomfort that resolves · falls · medication confusion · severe side effects

Call PCP same-day. If after hours, the PCP's nurse line. If symptoms escalate, urgent care or ER.

Medication issue

Missed dose · pharmacy delay · GI side effect · sedation too strong

Call psychiatrist's office same business day. For pharmacy refill issues: call the prescribing provider directly. Never skip psych meds without contacting the prescriber first.

Recovery question

Triggers · craving · meeting question · therapy timing

Sober coach / sponsor / EMDR therapist first. These are the day-to-day support people.

Pre-discharge timeline

  • Week −4 (3–4 weeks before discharge) Identify each provider. Verify insurance + book first appointments. Request medical records release.
  • Week −3 Confirm Watchman implant date with cardiology records. Order home BP cuff + pill organizer. Tour the house for fall-proofing.
  • Week −2 Transfer pharmacy to Apollo Beach local. Sync fill dates. Confirm appointment dates. Print emergency escalation plan.
  • Week −1 Warm handoff calls (PHP staff → outpatient providers). Family caregiver education with The Recovery Team. Sober environment audit.
  • Discharge day All meds in hand. All appointments confirmed. Emergency plan visible. First psychiatrist appointment ≤7 days out. First day home: low-stim, structure, walk if possible.
  • Week +1 First psychiatrist appointment. First EMDR session. Daily BP log going. Daily structure holding.

Open questions to bring back to Paul / family

  • Watchman implant date?
  • Which insurance is Dad on now? In-network providers in Apollo Beach?
  • Does The Recovery Team have referral relationships for outpatient psych in Apollo Beach?
  • Angela's bandwidth — is she the primary caregiver or is a hired aide part of the plan?
  • Does Dad want a sober coach? What's his stated wish for Phase 3?
  • Family therapy yes/no — and which family members participate?