Download 6.6 Monitored Dosage Systems and other Compliance Aids

working in partnership with
Kingston
Richmond
Wandsworth
Sutton & Merton
TWC21e
Shared prescribing of psychotropic medication
& Discharge of patients
between secondary & primary care
Trustwide Medication Policy
Accountable Director:
Policy Author:
Date of implementation:
Date of review:
Date reviewed by MHIPF:
Date of next review:
Ref:
Version:
Medical Director
Drugs & Therapeutics Committee
September 2000
January 2011
January 2012
January 2014
TWC21e
3.6
1
Protocol for the shared prescribing of psychotropic medication in
primary care for patients of Trust psychiatric teams
1.
Introduction
1 This protocol has been the subject of review within SWLStG Mental Health Trust,
then revised, updated and approved by the South West London Mental Health
Interface Prescribing Forum, representing both the Mental Health Trust and the
four local PCTs (Kingston, Richmond, Sutton & Merton, Wandsworth).
General Practitioners are asked to share prescribing for their patients who are also
under the care of the South West London & St Georges Mental Health NHS Trust
where it is safe and appropriate for them to do so i.e.:
 where the patient’s condition is stable or predictable
 where they have the relevant knowledge, skills and access to equipment to
monitor treatment
 where they have been provided with relevant clinical details including
monitoring data
Patients to be discharged from secondary care on psychotropic medication should
follow criteria as set out in section 8.
The respective responsibilities of primary and secondary care teams detailed in this
document are briefly summarised in the following table:



2.
Primary care / GP
Share prescribing for appropriate
patients
Monitor the following:
o Mental state
o Any medicine-related clinical
monitoring as advised
o Adverse effects
o Signs of poor compliance
Alert the CMHT about any concerns
regarding
o Compliance with treatment
o Adverse effects
o Changes in mental state
o Abnormal results from clinical
monitoring
Secondary care / CMHT / Consultant
 Write to GP following every
appointment or discharge detailing:
o Working diagnosis
o Mental state
o Medicines, dosages and
intended dosage ranges
o Requested monitoring
(clinical monitoring,
tolerability, compliance)
 Prescribe at least 14 days of
treatment for any medicine changes
or upon discharge from hospital
 Continue prescribing for certain
patients (see section 3 below)
 Provide any further information or
training as required by the GP
Prescribers take medico-legal responsibility for their prescribing,
including the outcomes of prescribing. They must consequently be in
agreement with the monitoring arrangements in place to address efficacy, side
effects and compliance with prescribed medicines.
2
3.
The Trust Psychiatric Team (e.g. Community Mental Health Team,
Rehabilitation Team etc.) will retain responsibility for prescribing in the
following circumstances:
3.1
3.2
Patient is not registered with a GP.
The responsible doctor has agreed for the Trust to retain responsibility for the
patient’s care.
GP has made a specific request not to be involved in shared prescribing for a
particular patient e.g.:
 Patient prescribed unlicensed / off-label medicine or combination therapy
(e.g. a typical and atypical antipsychotic medicine concurrently)
 Where there is a poor or no relationship with the patient
Patient is taking clozapine
The CMHT has made a decision that they would like to continue prescribing
for a particular patient. This can be because:
 The medication regimen is complex, unstable and needs frequent changes
 There are major concerns about compliance and risks associated with noncompliance.
3.3
3.4
3.5
4.
The following principles will apply to community patients:
4.1
The CMHT must inform the GP about the medication, which medications the
GP will be asked to prescribe, any changes that may be made to the dose
or medication prescribed, and any clinical monitoring that the GP should
perform. This should be in the form of a letter from the team to the GP and
the permission obtained from the GP before details of the new arrangements
are communicated to the patient.
For medications that require monitoring, the monitoring arrangements must be
clearly documented (e.g. for patients on lithium, it is essential to document who
is responsible for monitoring blood levels, renal function and thyroid function).
This should be included in a letter to the GP, discharge notification form (for
patients discharged from hospital) and in the care plan (for patients on CPA).
For long-acting or depot antipsychotic injections, the CMHT must ensure that
as well as accepting prescribing responsibility, the GP practice has sufficient
time to establish the arrangements for prescribing, dispensing and
administration of the injection, and systems for calling the patient to
appointments and follow-up should the patient fail to attend.
If a change is made to the medication, or additional medication is prescribed,
the psychiatrist is responsible for writing to inform the GP of the change(s) and
issuing a prescription for at least 14 days treatment. This will give the patient
enough time to make an appointment with the GP for a further prescription, and
for the letter to reach the GP.
Even if no change is made, the CMHT should write to update the GP on the
mental state and progress of the patient, and to confirm that no change in
treatment is required.
The CMHT will liaise with the GP if problems occur with compliance with
medication or the practicalities of prescribing.
The GP will confirm that they are happy to accept clinical responsibility for
prescribing and to prescribe on the basis as agreed with the CMHT.
4.2
4.3
4.4
4.5
4.6
4.7
3
4.8
4.9
The CMHT should ensure that the GP is aware who is monitoring compliance
with medication, when relevant.
The GP will liaise with the CMHT about prescribing changes and noncompliance.
4.10 Trust teams should provide any specific training which may be needed by GPs,
eg disease management, administration of medicines etc.
5.
Referral requirements
5.1
The GP referral letter should include: medicine history, current medicines, any
relevant compliance issues (e.g. compliance aids), previous adverse reactions,
allergies, any significant medical history and reason for referral.
The letter in Appendix 1 or the Trust “Discharge prescription & Brief discharge
summary” or one off “Out Patient Prescription” may be used for this purpose.
5.2
6.
On discharge from hospital
6.1
6.2
The hospital will supply enough medication for 14 days
The GP will commence prescribing 14 days after discharge, unless the CMHT
retain prescribing responsibility (see section 3 above)
The GP should be provided with the following information about the patient's
medicine:
6.3
Essential


notification of diagnosis and reason for admission
medicine on discharge and with an indication of whether the medicine
should be continued after initial supply.
 any
monitoring
of
medicine
required
including
anticipated
increase/decrease in dose

any changes to medication brought in on admission with reasons for
change
Recommended as good practice

6.4
6.5
6.6
details of medicines tried in hospital but which proved unsuitable
A copy of the above summary will be faxed to the GP on the day of
discharge and posted on the first subsequent working day
Patients should be provided with appropriate information about obtaining
further supplies of medicine.
Monitored Dosage Systems and other Compliance Aids
Hospital Trusts are encouraged to develop discharge planning arrangements
for vulnerable patients. Where these include supply of monitored dosage or
other similar systems there should be a policy in place for their use including
making appropriate arrangements for continuity after discharge.
This
arrangement should reflect guidance on support to people with disabilities,
compliance
with
the
Disabilities
Discrimination
Act
(see
4
www.primarycarecontracting.nhs.uk/98.php for a resource tool) and include
community pharmacies, where appropriate.
7.
Monitoring compliance with medication
7.1
During an inpatient stay
7.1.1 Assessment of compliance with medication must form part of the risk
assessment and be documented
7.1.2 Ward nursing and medical staff must take responsibility for identifying and
recording indicators of poor compliance e.g.:
 Does the patient take the initiative in approaching nursing staff and asking
for regularly prescribed medication?
 Do the nursing staff have to encourage the patient to take regularly
prescribed medication?
 Does the patient complain of adverse effects?
7.2
At the pre-discharge CPA meeting
7.2.1 Establish that the patient is registered with a GP and document the details
7.2.2 Assess compliance and decide on specific post-discharge monitoring
arrangements
7.3
After discharge from hospital
7.3.1 The key-worker / care co-ordinator will take appropriate steps to monitor and
improve compliance with medication after discharge from hospital, eg:
 Assess side effects of medication
 Discuss medication with the patient.
7.4
In patients where there are doubts about compliance, the key-worker/care
co-ordinator should:
7.4.1 Ask to see medication containers, check dates and remaining quantity, obtain
an impression of compliance from these
7.4.2 Consider use of monitored dosage system (e.g. pill tray, “Dosette” box etc)
7.4.3 Check with informants
7.4.4 Discuss compliance problems with the clinical team
7.5
If problems with compliance are identified or anticipated
7.5.1 The GP should be alerted
7.5.2 A repeat prescribing system is inappropriate
7.5.3 Monitor the collection of prescriptions by the patient. The following may be
appropriate:
 The GP to see the patient every 28 days to make sure the prescription is
being collected
 The key-worker / care co-ordinator to collect prescriptions from the GP on
behalf of the patient
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
The CMHT to undertake prescribing and monitoring, provided the
responsible doctor agrees (see para 3.2).
8.0 Discharging Patients receiving Medication to care of primary care
As discussed at the DTC October 2010 & MHIF November 2011
8.1 A significant number of patients on CPN case loads are being held just for routine supply
of medication to stable patients. The revised NICE Schizophrenia Guidelines 2009 states
that patients who have responded effectively to treatment and remain stable can return to
primary care for further management. This is also echoed in Trust policy were the
expectation is that service users who have recovered to a degree that they no longer
require specialist mental health services should be discharged back to primary care.
The Trust is committed to the principles of Recovery. For patients with mental health
problems using generic health services will:
 Encourage social inclusion
 Help break down stigma associated with mental health
 Aid recovery by reducing dependency on secondary care
 Ease access to other primary care services
8.2 Characteristics of stable patients that may be transferred to GPs are more stringent than
those for shared care:
 Maintained on a medication and have been mentally stable for a minimum period of 6
months.
 No other areas of concern such as safe-guarding vulnerable adult’s issues or complex
social problems.
 Compliant with a treatment plan including regular collection of medication or
attendance for administration of a depot.
 The use of unlicensed medication or unlicensed use of medication must follow the
Trust policy.
 Patients must not be receiving clozapine.
8.3 Preparing patients for transfer to primary care
 It is expected that from the time a patient is admitted to the service and prescribed
medication the CPN’s will work with the patient towards final management in primary
care.
 Preparation for transfer will be individualised and CPN’s will provide depot injections
in different settings (depending on the patients needs) towards this journey to primary
care.
8.4 Handover from secondary to primary care
 Discuss patients for potential discharge at the GP liaison meeting and
the level of support GP/practice nurse will need in order to give a depot injection.
Agree how and who will provide the support.

The CPA discharge plan to be discussed with patient and their GP. This must be clear
and explicit and both agencies need to be in agreement with the transfer.

Care coordinator to discuss and give clear and written handover of case history, risk
assessment, risk management plan and relapse indicators to GP/practice nurse.
6

Care coordinator and Practice Nurse to discuss any training / support needs that the
Practice Nurse may have and ensure that this is addressed for administration of
depots.

The Care coordinator to discuss and agree with the Practice Nurse what to do if the
patient misses an appointment or begins to show signs of relapse.

The service user’s Care coordinator to introduce the service user to the Practice Nurse
and give clear explanation to the service user about the process of handover and
accessing support if needed were a depot is to be administered.

The Care coordinator and Practice Nurse to agree a transitory period whereby the
service user visits the surgery to receive their depot from the CPN in the presence of
the Practice Nurse to acclimatise them to the change of clinician and environment.

The Community team will agree to see the patient on re-referral. This may be done
urgently where it is required.
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Appendix 1:
Request for GP to continue supply of a medicine or product
Section A: To be completed by the hospital Dr initiating the treatment
GP Practice Details:
Patient Details:
Name: ………………………………………
Name: …………………………………………
Address: ……………………..……………………… Address:
Tel no: ………………………………………
.………………………………………………
Fax no: ……………………………………
DOB: …….…/…….……/…………
NHS.net e-mail: ……………………………
Hospital number: …………………………
NHS number (10 digits): …………………
Consultant name: ……………………………
Clinic name: ………………………………….
Contact details:
Address: .........................................................................................................................
Tel no: ……………………………………… Fax no: ………………………………………
NHS.net e-mail: ……………………………
Indication:
Drug name & dose to be prescribed by GP:
……………………………………………………
…………………………………………………………….
Next hospital appointment: ……/……/……..
Dear Dr. ……………………..,
Your patient has been prescribed the medicines above for the above diagnosis. I request your
agreement to share the care of this patient in accordance with the attached Shared Care Prescribing
Guideline (Title: Protocol for the shared prescribing of psychotropic medication in primary care for
patients of Trust psychiatric teams and the unlicensed medicines policy).
This patient has received benefit from this medicine and the benefit of prescribing it outweighs
the risk. This medicine is either unlicensed in the UK or is being used for an unlicensed indication.
The evidence for prescribing this medicine may be found on the Trust’s ‘off-label list’.
The following investigations have been performed and I request that you continue to monitor
the parameters recommended below:
Test completed
Result & date
Test recommended to
be undertaken by GP
Frequency
recommended
Other relevant information:
…………………………………………………………………………………..………………...
………………………………………………………………………………………………...……
……………………………………………………………………………………………………..
Section B: To be completed by the GP and returned to the hospital consultant above.
Please sign and tick which applies (return your agreement within 14 days of receiving this request):
□ I accept sharing care as per shared care prescribing guideline and above instructions
□ I would like further information. Please contact me on:…………………
□ I am not willing to undertake shared care for this patient for the following reason(s):
………………………………………………………………………………………………….
GP name: ………………………………………….……….
GP signature: ………………………………………………Date: …/…/…..
8
8.0
Equality Impact Assessment Tool
To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval.
Yes/No
1.
Does the policy/guidance affect one group less
or more favourably than another on the basis
of:
 Race
No
 Ethnic origins (including gypsies and travellers)
No
 Nationality
No
 Gender
No
 Culture
No
 Religion or belief
No
 Sexual orientation including lesbian, gay and
bisexual people
No
 Age
No
 Disability - learning disabilities, physical
disability, sensory impairment and mental
health problems
No
2.
Is there any evidence that some groups are
affected differently?
No
3.
If you have identified potential discrimination,
are any exceptions valid, legal and/or
justifiable?
N/A
4.
Is the impact of the policy/guidance likely to be
negative?
No
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to achieving the
policy/guidance without the impact?
N/A
7.
Can we reduce the impact by taking different
action?
N/A
9
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