Download CHAPTER VII. VII. Prescribing Psychotropic drugs

CHAPTER VII. VII. Prescribing Psychotropic drugs shall be prescribed only by, or under the documented delegated authority of, a physician properly licensed in the State of Michigan. Licensed Prescribers include physicians and midlevel Clinical Nurse Specialists, Nurse Practitioners and Certified Physician's Assistants. Midlevel preservers will be scheduled for regular supervision meetings with the CMHOC Medical Director, or another designated physician. A. Rationale for Drugs Prescribed: A psychotropic drug that may offer the most effective treatment for the basic psychiatric disturbance exhibited by the consumer shall be selected from medications on the current year's Michigan Medicaid Formulary. Rationale for each prescribed psychotropic drug shall be documented in the consumer's record. The rationale for poly pharmacy will be clearly documented as well. MDCH PIHP/CMHSP Physician Injectable Drug Coverage for Beneficiaries Enrolled in Medicaid and County Health Plans January 2011 PIHP/CMHSP physicians can only bill the Program directly for the following injectable drugs when administered through the PIHP/CMHSP clinic to beneficiaries enrolled in Medicaid and County Health Plans. Procedure Code Description Fee Screen J0171 Injection, adrenalin, epinephrine, 0.1 mg J0515 Injection, benztropine mesylate, per 1 mg J1200 Injection, diphenhydramine HCL, up to 50 mg $0.79 J1630 Injection, haloperidol, up to 5 mg $5.93 J1631 Injection, haloperidol decanoate, per 50 mg J2060 Injection, lorazepam, 2 mg $0.71 J2358 Injection, olanzapine, long acting, 1 mg $2.75 J2426 Injection, paliperidone palmitate extended release 1 mg $6.50 J2680 Injection, fluphenazine decanoate, up to 25 m g $1.70 J2794 Injection, risperidone, long acting, 0.5 mg $5.05 J3486 Injection, ziprasidone mesylate, 10 mg $6.48 S0166 Injection, olanzapine, short acting 2.5 mg $7.35 $0.04 $60.55 $46.95 For injectable drugs administered through the PIHP/CMHSP clinic to beneficiaries enrolled under fee-for-service Medicaid, refer to the Practitioner Database for covered drugs and fee screens. 01/10/2011 Antianxiety Agents Benzodiazepines Alprazolam (Xanax, XR) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Diazepam (Valium) intensol Lorazepam (Ativan) Oxazepam (Serax) Quazepam (Doral) Misc Hydroxyzine (Vistaril, Atarax) Buspirone (Buspar) Max Daily Dose LAB Lithium (Eskalith, Lithobid) 10mg SOOmg 20mg 90mg 40mg 60mg 10mg 120mg 30mg 400mg 60mg SOOmg 250mg 300mg 300mg 300mg 200mg 40mg 20mg 80mg 300mg 62.5mg 200mg 40mg IM Injections Aripiprazole (Ability) Fluphenazine decanoate (Prolixin) Haloperidol decanoate (Haldol) Olanzapine (Zyprexa Relprew) Paliperidone palmitate (Invega Sustenna) Risperidone (Risperdal Consta) Naltrexone (Vivitrol) 400mg 450mg 600mg 100mg 120mg 375mg 225mg A B/P B/P B/P LAB 2400mg B* 30mg 20mg SOOmg 900mg 40mg 100mg 24mg 250mg 80mg 400mg 12mg 20mg 12mg/50mg 64mg 10mg 750mg 16mg SOOmg 60mg 40mg 160mg AB* AB* AB* AB* AB* AB* AB* AB* AB* AB* AB* AB* AB* AB* B AB* AB* AB* AB* AB* AB* 30mg qd 25mg IM q2-3 wk 450mg IM q4 wks 300q2wk.405q4wk 234mg IM q 4 wks 50mg IM q 2 wks AB* AB* AB* AB* AB* AB* 380mg IM q 4 wks Beta Blockers Atenolol (tenormin) Pindolol (Visken) Propranolol (Inderal) 1200 mg 60mg 640mg B/P B/P B/P SNRI for ADHD Atomoxetine (Strattera) Guanfacine (Intuniv) 600mg 600mg 45mg 60mg 90mg 12mg 50ma Max. Daily Dose AntiDsvchotics Aripiprazole (Ability) Asenapine (Saphris) Chlorpromazine (Thorazine) Clozapine (Clozaril) Fluphenazine (Prolixin) Haloperidol (Haldol) lloperidone (Fanapt) Loxapine (Loxitane) Lurasidone (Latuda) Mesoridazine (Serentil) Paliperidone (Invega) Olanzapine (Zyprexa) Olanzapine/Fluoxetine (Symbyax) Perphenazine (Trilafon) Pimozide (Orap) Quetiapine (Seroquel, XR) Risperidone (Risperdal) Thioridazine (Mellaril) Thiothixene (Navane) Trifluoperazine (Stelazine) Ziprasidone (Geodon) Antideoressants Tricyclic Antidepressants Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) SSRI's Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil, CR) Sertraline (Zoloft) Vilazodone (Viibryd) Dopamine Reuptake Inh Bupropion (Wellbutrin, SR) Bupropion (Wellbutrin, XL) 5-HT/NE Reuptake Inh Amoxapine (Asendin) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Venlafaxine (Effexor.XR) Maprotiline (Ludiomil) 5-HT2 Receptor Antag Nefazodone (Serzone) Trazodone (Desyrel) Noradrenergic Antagonist Mirtazapine (Remeron) MAOI Inhibitors Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranvlcvoromine (Parnate) Antimanic Agents D D B/P D A= AIMS monitoring B= Baseline Lab B*=Baseline Lab and Monitoring B/P=Blood Pressure D=Special Diet E= EKG (Routine) Revised 6/2012 1.8mg/kg 4mg B/P, B B/P Hypnotics Diphenhydramine (Benadryl) Estazolam (Prosom) Eszopiclone (Lunesta) Flurazepam (Dalmane) Ramelton (Rozerem) Temazepam (Restoril) Triazolam (Halcion) Zaloplon (Sonata) Zolpidem (Ambien, CR) Max. Daily Dose 300mg 2mg J3rng 30mg 8mg 30mg 0.5mg 20mg 12.5mg LAB j Mood Stabilizers/Anticonvulsants Carbamazepine (Carbatrol) Carbamazepine (Equetro) Carbamazepine (Tegretol) Gabapentin (Neurontin) Lamotrigine (Lamictal) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Phenytoin (Dilantin) Pregabalin (Lyrica) Tiagabine (Gabitril) Topiramate (Topamax) Valproic Acid (Depakote ) 1 SOOmg 1600mg 1200mg 3600mg 700mg 3000mg 2400mg SOOmg 600mg 56 mg 1600mg 60mg/kg B* B* B* 250mg 2mg/kg 1.5mg/kg 2mg/kg 70mg 30mg 60mg 60mg 3mg/kg 400mg B/P B/P B/P B/P B/P B/P B/P B/P B/P B B* B* B* B* Stimulants Armodafinil (Nuvigil) D-Amphet/Amphet (Adderall) Dexmethylphenidate (Focalin, XR) Dextroamphetamine (Dexedrine) Lisdexamphetamine (Vyvanse) Methylpheniate (Daytrana) Methylphenidate (Metadate CD, ER) Methylphenidate (Ritalin) Methylphenidate (Ritalin LA, Concerta) Modafinil (Provigil) B/P.B Miscellaneous Acamprosate (Campral) Benztropine (Cogentin) Buprenorphone/Naloxone (Suboxone) Clonidine (Catapres) Disulfiram (Antabuse) Docusate (Colace) Donepezil (Aricept) Guanfacine (Tenex) Lubiprostone (Amitiza) Memantine (Namenda) Naltrexone (Revia) Pramipexole (Mirapex) Rivastigjriine (Exelon) Ropinirole (Requip) Trihexyphenidyl (Artane) 1 998mg 6mg 32mg 2.4mg SOOmg 300mg 23mg 3mg 48mg 20mg 380mg 4.5mg 12mg 4mg 15mg B/P B/P B/P COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY Prompt for Required Monitoring of Medication Treatment Based on Community Mental Health of Ottawa County's Mediation Committee Manual TYPICAL ANTIPSYCHOTICS Baseline: • • • • Monitor: • CBC with differential AIMS Liver Enzymes Consult with primary physician regarding baseline ECG if history of significant cardiac disorder or age *65 CBC with differential and liver enzymes annually • AIMS quarterly (exception for patients only taking clozaplne) Exceptions: • Clozapine:: Additional weekly WBC and ANC for first six (6) months, then every two (2) weeks for next six (6) months, followed by testing every four (4) weeks thereafter if test results remain within normal range per Fazaclo Laboratory Requirements information sheet.fsee Clozapine Prescribing and Management) I. Mellarll: Routine EKG recommended ATYPICAL ANTIPSYCHOTICS Baseline: • Trlglycerldes • Fasting Glucose or A1C • AIMS Testing (not required if only antipsychotic is Clozapine) Quarterly: • Triglycerides. if elevated (or refer to Primary Care Physician for monitoring) • Fasting Glucose or A1C if family history, symtoms or pertinent risk factors (or refer to Primary Care Physician) • AIMS Testing (not require if only antipsychotic Is Clozapine) Annually: • Fasting glucose if no family history, symptoms or pertinent risk factors ANTICONVULSANTS Depakote (Valprolc Acid) Baseline: CBC with differential Liver enzymes Mo itor: CBC with differential annually Liver enzymes annually Serum level within three (3) months and as clinically indicated Tegretol (Carbamazapine) Baseline: • CBC with differential • Liver enzymes Monitor: • CBC with differential and liver enzymes annually • Serum level within three (3) months, and as clinically indicated Topamax Baseline: • Bicarbonate level after one (1) month of therapy (if clinically indicated) ANTIDEPRESSANTS Baseline: • Tricyclic Antidepressant: Consult with primary physician regarding baseline ECG if history of significant cardiac disorder or age *16 or *65 • SSNRI: Blood pressure monitoring (Effexor and Cymbalta) • Asendin: AIMS test Exceptions: • Marplan. Nardil and Parnate: Special diet recommended LITHIUM Baseline: • CBC with differential • Serum Creatinine, BUN. TSH. and UA annually • Consult with primary physician regarding baseline ECG If history of significant cardiac disorder or age +16 or * 65 Monitor: • Serum Creatinine. BUN. TSH, and UA annually FOOTNOTES: • Lithium levels 5-14 days after a dose change, then every six (6) months 1) Drug level monitoring should be trough level ADHD AGENTS 2) Liver enzymes= one or more enzymes Strattera and Provigil (Modafinil): B/P 3) Baseline conditions exist when medication • Liver enzymes at baseline therapy has been interrupted for more than All Stimulants: B/P & Pulse, monitor weight for children 6 months. Michigan Department of Community Health Preferred Drug List Effective 07/17/2012 Bolded Drugs do not require prior authorization, except as noted in chart at bottom of page ANALGESICS NARCOTICS-LONG ACTING Kadian® Methadone Morphine sulfate SA tablets Requires Prior Authorization Avinza® Conzip ER® Exalgo® Morphine sulfate ER capsules MS Contin® Nucynta ER® Opana ER® Oramorph SR® Oxycontin® Ryzolt ER® NARCOTICS- SHORT AND INTERMEDIA TE ACTING Actiq®» Codeine Codeine/ APAP Codeine/APAP/Caff./Butalbital Codeine/APAP/Caffeine Codeine/ASA Codeine/ASA/Caff./Butalbital Codeine Phosphate Hydrocodone/APAP Hydromorphone oral tablets Meperidine Morphine sulf Tabs/Soln Oxycodone (Immed. Release) Oxycodone/ APAP Oxycodone/ ASA Tramadol Butorphanol Capital w/Codeine® Demerol® all forms Dilaudid® all forms Fentora®* Fioricet W/Codeine® Fiorinal W/Codeine® Lorcet® Lortab® Norco® Nucynta® Onsolis® Opana® Opium Oxydose® Oxyfast® OxylR® Pentazocine and Naloxone Percocet® Percodan® Roxanol® Rybix ODT® Roxicodone® Stadol®, Stadol NS® Talwin®, Talwin NX® Tylenol #2® Tylenol #3® Tylenol #4® Tylenol W/Codeine Elixir® Tylox® Ultracet® Ultram®/ Ultram ER® Vicodin® Vopac® Wygesic® Xodol 5/300® Zolvit® Zydone® Requires Prior Authorization Abstral®* 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply - See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history 9 PA required if no history of oral antinausea drugs in beneficiary drug history NARCOTICS- TRANSDERMAL Fentanyl Patches (generic only) Butrans® Noxafil® Nystatin® Tablets Vfend® Requires Prior Authorization Duragesic® ANTIVIRALS - HERPES Acyclovir Famciclovir Valacyclovir NON-STEROIDAL ANTIINFAMMATORY- COXII INHIBITORS Celebrex® z ANTIBIOTICS / ANTNNFECTIVES ANTIFUNGALS ONYCHOMYCOSIS Lamisil®* Griseofulvin Griseofulvin microsize Griseofulvin ultramicrosize Requires Prior Authorization Ciclodan® Pedipirox-4® Penlac® Sporanox® ANTIFUNGALS - ORAL Fluconazole Nystatin Oral Susp® Requires Prior Authorization Diflucan® Ketoconazole Mycelex® Mycostatin® Nilstat® Nizoral® Requires Prior Authorization Famvir® Zovirax ® Valtrex® ANTIVIRALS - INFLUENZA7 Relenza® Tamiflu® ANTIVIRALS - TOPICAL Denavir® Zovirax® Ointment Requires Prior Authorization Xerese® Zovirax® Cream CEPHALOSPORIN 1ST GEN Cefadroxil Cephalexin Requires Prior Authorization Cephradine Duricef® Keflex® Velosef® CEPHALOSPORIN 2ND GEN Cefuroxime axetil Cefprozil suspension 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide » Clinical PA required; refer to MPPL, Ml Provider Manual or michiqan.fhsc.com for other restrictions Version 07172012v1 Michigan Department of Community Health Preferred Drug List Effective 07/17/2012 Bolded Drugs do not require prior authorization, except as noted in chart at bottom of page Requires Prior Authorization Ceclor® / Ceclor CD® Cefaclor/ Cefaclor ER Ceftin® tabs, suspension Cefzil® Lorabid® CEPHALOSPORIN 3RD GEN Cefdinir Cefpodoxime Suprax® suspension Requires Prior Authorization Cedax® Spectracef® Suprax® tablets Vantin® HEPATITIS C Pegasys® Ribavirin Peg-lntron® Requires Prior Authorization Copegus® Infergen® Intron A® Rebetol® Rebetron® Roferon-A® HEPATITIS C-PROTEASE INHIBITORS* Incivek® Victrelis® MACROLIDES Azithromycin Clarithromycin Erythromycin Base Erythromycin Estolate Erythromycin Ethylsuccinate Erythromycin Stearate Erythromycin w/Sulfisoxazole Requires Prior Authorization Biaxin®/Biaxin XL®/Biaxin Susp.® Clarithromycin ER Dificid®* Dynabac® E.E.S.® EryPed® Ery-Tab® PCE® Zithromax® tablets Zithromax® suspension1 Zmax® OXALODINONES Zyvox® QUINOLONES Avelox® Ciprofloxacin Requires Prior Authorization Cipro XR® Factive® Floxin® Levaquin® Maxaquin® NegGram® Noroxin® Tequin® Trovan® OPHTHALMIC FLUOROQUINOLONES Ciprofloxacin Moxeza® Ofloxacin 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply - See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history 9 PA required if no history of oral antinausea drugs in beneficiary drug history Vigamox® Requires Prior Authorization Besivance® Ciloxan® Iquix® Ocuflox® Quixin® Zymar® Zymaxid® OTIC QUINOLONES Ciprodex® Ofloxacin otic Requires Prior Authorization Cetraxal® Cipro HC® Floxin Otic® OPHTHALMIC MACROLIDES Azasite® TOPICAL ANTIBIOTICS Mupiricin ointment Requires Prior Authorization Bactroban® Altabax® ASTHMA/ALLERGY/ COPD COPD AGENTS Atrovent/Atrovent HFA® Ipratropium Spiriva® Combivent® Requires Prior Authorization Daliresp®* Arcapta® ANTIHISTAMINES - 2ND GEN Cetirizine Loratadine/ Loratadine ODT Requires Prior Authorization Allegra®/ Allegra® Suspension Cetirizine chewable tablets Clarinex® Claritin® tablets, syrup Claritin Redi-Tab® Fexofenadine Xyzal® Zyrtec® brand NASAL ANTIHISTAMINES Astelin® Astepro® Requires Prior Authorization Patanase Nasal® BETA ADRENERGICS- SHORT ACTING Maxair Autohaler® ProAir HFA® Proventil HFA® Ventolin HFA® Requires Prior Authorization Alupent® Xopenex HFA® BETA ADRENERGICS - LONG ACTING Serevent® Foradil® 2 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide » Clinical PA required; refer to MPPL, Ml Provider Manual or michiqan.fhsc.com for other restrictions Version 07172012v1 Michigan Department of Community Health Preferred Drug List Effective 07/17/2012 Bolded Drugs do not require prior authorization, except as noted in chart at bottom of page Requires Prior Authorization Brovana® nebulizer soln. Perforomist® BETA ADRENERGICS FOR NEBULIZERS Albuterol sulfate Requires Prior Authorization Accuneb® Duoneb® Metaproterenol Xopenex® BETA ADRENERGIC / CORTICOSTEROID INHALER COMBINATIONS Advair Diskus®/ Advair HFA® Dulera® Symbicort® INHALED GLUCOCORTICOIDS Alvesco® Asmanex® Azmacort® Budesonide nebulizer soln. Flovent® Diskus/ Flovent HFA® Pulmicort®Flexihaler QVAR® Requires Prior Authorization AeroBid® Pulmicort® Respules for nebulizer LEUKOTRIENE INHIBITORS Singulair® Zafirlukast NASAL STEROIDS Flunisolide Fluticasone Nasonex® Requires Prior Authorization Flonase® Nasacort® Nasacort AQ® Nasarel® Omnaris® Rhinocort® / Rhinocort Aqua® Tri-Nasal® Veramyst® BEHAVIORAL HEALTH ATYPICAL ANTIPSYCHOTICS Abilify® Clozapine Fanapt® Fazaclo® Geodon® Invega® Latuda® Olanzapine Quetiapine Risperidone Saphris® Seroquel XR® ANTIPSYCHOTICANTIDEPRESSANT COMB. Symbyax® ANTIDEPRESSANTS NEWER GENERATIONS Bupropion Requires Prior Authorization Buproprion Hydrobromide ER Citalopram Accolate® Cymbalta® Zyflo® 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply - See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history 9 PA required if no history of oral antinausea drugs in beneficiary drug history Emsam® Escitalopram Fluoxetine Fluvoxamine Luvox CR® Mirtazapine Nefazodone Oleptro® Paroxetine Pexeva® Pristiq® Prozac Weekly® Sertraline Trazodone Venlafaxine Venlafaxine ER Viibryd® CARDIAC MEDICATIONS ACE INHIBITORS Benazepril/ Benazepril HCT Captopril/_Captopril HCT Enalapril/ Enalapril HCT Lisinopril/ Lisinopril HCT Vasotec® / Vaseretic® Zestril® / Zestoretic® ALPHA ADRENERGIC AGENTS Clonidine Clonidine/chlorthalidone Guanfacine Methyldopa Methyldopa/HCTZ Requires Prior Authorization Catapres® Catapres TTS® Nexiclon XR® Tenex® ANTIHYPERTENSIVE COMBINATIONS: ACEI-CCB Amlodipine/benazepril Tarka® Requires Prior Authorization Lotrel® Trandolapril/verapamil ANTIHYPERTENSIVE COMBINATIONS: ARB-CCB Azor® Exforge® / Exforge HCT® Tribenzor® Twynsta® Requires Prior Authorization Accupril® Accuretic® Aceon® Altace® ANGIOTENSIN RECEPTOR Capoten®/ Capozide® ANTAGONISTS Fosinipril Benicar® Lotensin®/ Lotensin HCT® Benicar HCT® Mavik® Diovan® Moexipril / Moexipril HCT Diovan HCT® Monopril® / Monopril HCT® Losartan Prinivil®/ Prinzide® Losartan/HCT Quinapril /Quinapril HCT Micardis® / Micardis HCT® 3 Univasc®/ Unirectic ® 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide » Clinical PA required; refer to MPPL, Ml Provider Manual or michiqan.fhsc.com for other restrictions Version 07172012v1 Michigan Department of Community Health Preferred Drug List Effective 07/17/2012 Bolded Drugs do not require prior authorization, except as noted in chart at bottom of page Requires Prior Authorization Atacand® / Atacand HCT® Avalide® Avapro® Cozaar® Edarbi® Edarbyclor® Hyzaar® Teveten® / Teveten HCT® DIRECT RENIN INHIBITORS* Requires Prior Authorization Amturnide® Tekamlo® Tekturna® Tekturna HCT® Valturna® BETA BLOCKERS Acebutolol Atenolol Atenolol/Chlorthalidone Betaxolol Bisoprolol Fumarate Bisoprolol Fumarate/HCT Systolic® Carvedilol Coreg CR® Labetalol Metoprolol/HCT Metoprolol Succinate Metoprolol Tartrate Nadolol Pindolol Propranolol/ Propranolol LA Propranolol/HCT Sotalol/ Sotalol AF Timolol Maleate Requires Prior Authorization Betapace ®/ Betapace AF® Blocadren® Coreg® Dutoprol® Inderal® Inderal LA® Inderide® Innopran XL® Kerlone® Levatol® Lopressor® Normodyne® Sectral® Tenormin® Toprol XL® Trandate® Visken® Zebeta® CALCIUM CHANNEL BLOCKERSDIHYDROPYRIDINE Afeditab CR® Amlodipine Besylate Dynacirc CR® Felodipine Isradipine Nicardipine Nifediac CC Nifedical XL Nifedipine/Nifedipine SA Nisoldipine Requires Prior Authorization Adalat CC® Cardene®/ Cardene SR® Dynacirc® Norvasc® Plendil® Procardia/ Procardia XL® Sular® 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply - See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history 9 PA required if no history of oral antinausea drugs in beneficiary drug history CALCIUM CHANNEL BLOCKERS - NONDIHYDROPYRIDINE Diltiazem/ Diltiazem XR, ER Taztia XT® Verapamil/ Verapamil SR Verapamil Cap 24-hr Pellet Colestipol Welchol® Requires Prior Authorization Calan® Cardizem® LA, SR, CD Covera-HS® DilacorXR® Isoptin® Verelan®/Verelan PM® LIPOTROPICS: STATINS Atorvastatin Crestor® Lescol® Lescol XL® Lovastatin Pravastatin Simcort© 8 Simvastatin Vytorin®8 LIPOTROPICANTIHYPERTENSIVE COMBINATION Caduet® Requires Prior Authorization Amlodipine/ atorvastatin LIPOTROPICS- NON-STATINS: FIBRIC ACID DERIVATIVES Fenofibrate, micronized Gemfibrozil Trilipix® Requires Prior Authorization Antara® Fenoglide® Fibricor® Lopid® Lipofen® Triglide® LIPOTROPICS: NON-STATINS Cholestyramine Cholestyramine Light Requires Prior Authorization Colestid® Questran Light® Questran® Rewires Prior Authorization Advicor® Altoprev® Lipitor® Livalo® Mevacor® Pravachol® Zocor® LIPOTROPICS: NIACIN DERIV. Niacin & Niacin ER Niacor® Niaspan® LIPOTROPICS: OTHER Zetia® Requires Prior Authorization Lovaza® (formerly Omacor®) 4 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide » Clinical PA required; refer to MPPL, Ml Provider Manual or michiqan.fhsc.com for other restrictions Version 07172012v1 Michigan Department of Community Health Preferred Drug List Effective 07/17/2012 Bolded Drugs do not require prior authorization, except as noted in chart at bottom of page CENTRAL NERVOUS SYSTEM DRUGS ALZHEIMER'S DEMENTIA Donepezil Exelon® capsule and patch Galantamine Namenda® Requires Prior Authorization Aricept® Cognex® Razadyne® Rivastigmine capsules ANTI-ANXIETYAlprazolam DRUGS FOR ADHD STIMULANTS* Adderall XR® Amphetamine Salts Concerta® Dexmethylphenidate Dextroamphetamine Dextrostat® Focalin® Focalin XR® Metadata CD® Methylin®/Methylin®ER Methylphenidate Methylphenidate SR Ritalin LA® Vyvanse®: GENERAL Buspirone Chlordiazepoxide3 Clorazepate Diazepam3 Hydroxyzine HCL Hydroxyzine Pamoate Lorazepam Oxazepam Requires Prior Authorization Alprazolam extended release Atarax® Ativan® Buspar® Meprobamate/ Miltown®3 Niravam® Serax® Tranxene® Vistaril® Vistaril suspension® Xanax/Xanax XR® Requires Prior Authorization Adderall Amphetamine Salts, extended release Cylert® Daytrana® Dexedrine® Methylin® chewable/ soln. Methylphenidate LA Procentra® Ritalin® Ritalin SR® DRUGS FOR ADHD NON-STIMULANTS Kapvay® Intuniv® Strattera® AGENTS FOR MULTIPLE SCLEROSIS: Avonex® Betaseron® Copaxone® Gilenya® 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply - See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history 9 PA required if no history of oral antinausea drugs in beneficiary drug history Rebif® Requires Prior Authorization Extavia® NON-ERGOT DOPAMINE RECEPTOR AGONISTS Mirapex ER® Pramipexole Requip XL® Ropinirole IR Requires Prior Authorization Mirapex® Neupro® Requip® Ropinirole ER SEDATIVE HYPNOTIC NONBARBITURATES Estazolam Flurazepam10 Rozerem®5 Temazepam (excluding 22.5mg)3 Temazepam 7.5mg2'3 Triazolam3 Zolpidem11 Requires Prior Authorization Ambien® /Ambien CR® Doral® Edluar® Halcion® Lunesta® ProSom® Restoril®3 Silenor® Somnote® Sonata®2 Zolpimist® SEROTONIN RECEPTOR AGONISTS Maxalt® / Maxalt MLT® Relpax® Sumatriptan Treximet® Requires Prior Authorization Amerge® Axert® Frova® Imitrex® Sumavel® Zomig®/ Zomig ZMT® DIABETES AMYLIN ANALOGS Symlin® SECRETIN MIMETICS Byetta® Victoza® INSULINS, BASAL Lantus® Levemir® INSULINS. RAPID ACTING Apidra® Humalog® Novolog® INSULIN MIXES Humalog 50/50® Humalog 75/25® Humulin 50/50® Humulin 70/30® Novolin 70/30® Novolog 70/30® 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide » Clinical PA required; refer to MPPL, Ml Provider Manual or michLqan.fhsc.cpm for other restrictions Version 07172012v1 Michigan Department of Community Health Preferred Drug List Effective 07/17/2012 Bolded Drugs do not require prior authorization, except as noted in chart at bottom of page INSULINS. TRADITIONAL Humulin R 500-U® Novolin N® Novolin R® Requires Prior Authorization Humulin N® Humulin R® ORAL HYPOGLYCEMICS ALPHA-GLUCOSIDASE INH. Acarbose Glyset® Requires Prior Authorization Precose® ORAL HYPOGLYCEMICS BIGUANIDES Metformin/ Metformin XR Requires Prior Authorization Glucophage® Glucophage XR® ORAL HYPOGLYCEMICS COMBINATIONS Actoplus Met® Actoplus Met XR®8 Duetact® Glyburide/Metformin Glipizide/Meformin Kombiglyze XR® Janumet® Prandimet® Requires Prior Authorization Avandamet® Avandaryl® Glucovance® Juvisync®12 Metaglip® Requires Prior Authorization Avandia® ORAL HYPOGLYCEMICS DOPAMINE RECEPTOR AGONISTS Cy closet® ORAL HYPOGLYCEMICS DPP4 INHIBITORS Januvia® Onglyza® Tradjenta® ORAL HYPOGLYCEMICS MEGLITINIDES Nateglinide Requires Prior Authorization Prandin® Starlix® ORAL HYPOGLYCEMICS - 2ND GENERATION SULFONYLUREAS Glimepiride Glipizide/Glipizide ER Glyburide Glyburide Micronized Requires Prior Authorization Amaryl® Glucotrol® Glucotrol XL® Glynase® Micronase® ORAL HYPOGLYCEMICS THIAZOLIDINEIONES Actos® 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply - See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history 9 PA required if no history of oral antinausea drugs in beneficiary drug history Requires Prior Authorization Asacol HD® NAUSEA AGENTS - ORAL Granisetron Azulfidine DR® Balsalazide Colazal® Dipentum® Lialda® Ondansetron Sancuso®9 OPHTHALMICS Requires Prior Authorization Anzemet® Kytril® Brand Zofran®/ Zofran ODT® Brand Zuplenz® GLAUCOMA - ALPHA-2 ADRENERGICS Alphagan P® Apraclonidine Brimonidrine tartrate SUBSTANCE P RECEPTOR AGONIST Emend® Requires Prior Authorization lopidine® GASTROINTESTINAL PROTON PUMP INHIBITORS* Nexium® capsules Pantoprazole Prilosec OTC® Requires Prior Authorization Aciphex® Dexilant® (formerly Kapidex®) Lansoprazole Nexium® Susp Pkts Omeprazole1 Prevacid/ Prevacid 24HR® Prilosec® Protonix® Zegerid®/ Zegerid OTC® ULCERATIVE COLITIS - ORAL Apriso® Asacol® Pentasa® Sulfasalazine GLAUCOMA - BETA BLOCKERS Betaxolol Betimol® Carteolol HCI Levobunolol HCI Metipranolol Timolol maleate Rectuires Prior Authorization Betagan® Betoptic S® Istalol ® Ocupress® Optipranolol® Timoptic® Timoptic XE® GLAUCOMA - PROSTAGLANDIN INHIBITORS Latanoprost Travatan Z® 6 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide » Clinical PA required; refer to MPPL, Ml Provider Manual or michiqan.fhsc.com for other restrictions Version 07172012v1 Michigan Department of Community Health Preferred Drug List Effective 07/17/2012 Bolded Drugs do not require prior authorization, except as noted in chart at bottom of page Requires Prior Authorization Lumigan® Xalatan® GLAUCOMA - CARBONIC ANHYDRASE INHIBITORS Azopt® Dorzolamide HCI Dorzolamide/Timolol Requires Prior Authorization Cosopt® Trusopt® GLAUCOMA - COMBINATION ALPHA-2 ADRENERGIC-BETA BLOCKER Combigan® OPHTHALMIC ANTIHISTAMINES Ketotifen fumarate (OTC Only) Pataday® Patanol® Zaditor® Requires Prior Authorization Bepreve® Elestat® Emadine® Ketotifen fumarate (RX Only) Lastacaft® Livostin® Optivar® OPHTHALMIC MAST CELL STABILIZERS Alocril® Cromolyn Sodium OPHTHALMIC NSAIDS Diclofenac Ophth. Flurbiprofen sodium Ketorolac Requires Prior Authorization Acular®/Acular LS® Acuvail® Nevanac® Voltaren® Bromday® MISCELLANEOUS GROWTH HORMONES* Genotropin® Norditropin® Norditropin Flexpro® Norditropin Nordiflex® Nutropin® Nutropin AQ® Requires Prior Authorization Humatrope® Omnitrope® Saizen® Serostim® Tev-Tropin® Zorbtive® OSTEOPOROSIS AGENTS: BISPHOSPHONATES Alendronate Sodium Requires Prior Authorization Actonel® Atelvia® Boniva® Didronel® Fosamax® Requires Prior Authorization Fosamax Plus D® Alomide® 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply - See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history 9 PA required if no history of oral antinausea drugs in beneficiary drug history OSTEOPOROSIS AGENTS: OTHER Calcitonin Requires Prior Authorization Forteo® Fortical® Miacalcin® OSTEOPOROSIS AGENTS: SERMS Evista® URINARY TRACT ANTISPASMODICS Detrol LA® Oxybutynin/ Oxybutynin ER Toviaz® Vesicare® Requires Prior Authorization Detrol® Ditropan/ Ditropan XL® Enablex® Flavoxate HCL Gelnique® Oxytrol® Sanctura® Urispas® TOPICAL IMMUNOMODULA TORS » Elidel® Protopic® ELECTROLYTE DEPLETERS Calcium acetate Fosrenol® Renagel® Renvela® tablets, powder Requires Prior Authorization Phoslo® BPH AGENTS Avodart® Finasteride Prazosin Tamsulosin Terazosin Uroxatral® Requires Prior Authorization Alfuzosin Flomax® Jalyn® Proscar® Rapaflo® BIOLOGIC IMMUNOMODULATORS Enbrel® Humira® Cimzia® Simponi® Requires Prior Authorization Kineret® Orencia® SC HEMATOPOIETIC AGENTS* Aranesp® Epogen® Procrit® ANTICOAGULANTS Arixtra® Fragmin® Lovenox® Pradaxa® Xarelto® Warfarin 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide » Clinical PA required; refer to MPPL, Ml Provider Manual or michigan.fhsc.com for other restrictions Version 07172012v1 Michigan Department of Community Health Preferred Drug List Effective 07/17/2012 Bolded Drugs do not require prior authorization, except as noted in chart at bottom of page Requires Prior Authorization Enoxaparin Fondaparinux Innohep® COMBINATION BENZOYL PEROXIDE AND CLINDAMYCIN Benzaclin® Requires Prior Authorization Acanya® gel Duac CS® SKELETAL MUSCLE RELAXANTS Baclofen Chlorzoxazone Cyclobenzaprine Methocarbamol Orphenadrine citrate Tizanidine tablets Requires Prior Authorization Amrix® Dantrium® Dantrolene sodium Fexmid® Lorzone® Norflex® Orphenadrine Compound Parafon Forte DSC® Robaxin® Skelaxin® Zanaflex® capsules, tablets AGENTS FOR FIBROMYALGIA Cymbalta® Lyrica® Savella® Note: Not all medications listed are covered by all MDCH Programs. Check individual program coverage. For program drug coverage information, go to michigan.fhsc. com Open "Drug Coverage"and click on "MPPL Including Coverage Information" for all programs. Michigan Department of Community Health, in conjunction with Magellan Medicaid Administration, is pleased to offer an alternative means to submit pharmacy prior authorization (PA) requests for prescription drugs. This web-based process is designed to save prescribers time by providing a real-time pharmacy prior authorization. This process will supplement 1 Prior Authorization Not Required for Beneficiaries Under the Age of 12. 2 Quantity limits apply - See MPPL on website for details 3 Prior Authorization Required if Beneficiary is Over the Age of 65. 4 Prior Authorization Required for Beneficiaries Under Age of 6. 5 PA required if a benzodiazepine is found in beneficiary drug history 7 Providers should consult yearly CDC guidelines for Influenza 8 Electronic Step edit: at least 1 component of the product must be in beneficiary drug history 9 PA required if no history of oral antinausea drugs in beneficiary drug history the more traditional means of requesting PAs by phone or fax, which will still be available to providers. In order to use WebPA, provider designees will need to register to receive a logon and password for the WebPA system. Detailed information on user registration and WebPA, including a web based tutorial, and a complete instruction is available at michiqan.fhsc.com. For questions or assistance with registration, call the Magellan Medicaid Administration Web Support Call Center at (800) 241-8726. 8 10 Prior Authorization Required for Beneficiaries Under Age of 15. 11 Prior Authorization Required for Beneficiaries Under Age of 18. 12 Components of product must be in drug history APAP = Acetaminophen ASA = Aspirin CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide » Clinical PA required; refer to MPPL, Ml Provider Manual or rnichiqan.fhsc.corn for other restrictions Version 07172012v1 VII. Prescribing (cont.): B. Dosage Range: Dosage levels shall not ordinarily exceed those specified in the PDR and general guidelines from current psychiatric literature. If dosage levels are prescribed in excess of the maximum recommended daily dose, rationale shall be documented in the consumer's clinical record and the medication consent form must reflect the actual dose prescribed. C. Individualized Care: 1. All individuals receiving psychiatric services from Community Mental Health of Ottawa County (CMHOC) shall be given a Psychiatric Evaluation before the onset of any psychiatric services and/or treatment. 2. Medication regimens must be individually determined by considering the consumer's need, age, sex, weight, physical condition, medical history, other medications and previous medication history including history of adverse side-effects or reactions. If indicated, a non-formulary drug may be prescribed. 3. Psychotropic drugs are medications used for the treatment or amelioration of disorders of thought, mood or behavior. 4. Whenever a consumer is prescribed medication, at least one treatment goal will be written addressing medication. Specific goals might include educating the consumer about medication, eliminating target symptoms, reducing side-effects, monitoring adherence and/or obtaining the minimum effective dosage. 5. Medications shall not be administered unless: a. The consumer/guardian gives written informed consent, or temporary verbal consent. In the event of verbal consent, it shall be followed up by a written consent as soon as possible. b. It is required by court order. C. Individualized Care (cont): 6. Minimal duration of medications and safe termination will be determined by the licensed Prescriber based on the consumer's specific response and accepted medical practice. 7. No medication will be prescribed as a punishment or for staff convenience. 8. Medication will only be administered by licensed medical staff or by personnel trained to do so by the CMHOC Training Center. 9. Any medication administered by CMH or contractual providers will be documented in the consumer's record, including medication errors or adverse reactions. 10. Medication will not be administered in emergency situations as a means of preventing harm to the consumer or others. There will be no standing PRN medication orders for behavioral control. In such situations, emergency personnel will be called for transport to the ER for evaluation. D. Side-Effects: 1. The prescribing professional will assess the consumer's learning needs in the safe and effective use of medication. 2. A plan will be developed based on this assessment to assure consumers are informed of and understand the name and description of the medication, dosage, method of administration, intended outcomes, potential side-effects, drug and food interactions to be avoided, and proper storage and disposal. 3. The consumer will be instructed to report any occurrence of side-effects to the prescribing professional as soon as possible. 4. A Patient Information leaflet will be offered to the consumer/parent/guardian. This medication-specific Patient Information leaflet summarizes common adverse side effects, purpose of medication, etc. E. Request for Refills/Report of Medication Issues 1. Phone calls from consumers with requests for medication refills will be transferred to the Team Nurse's office. 2. Phone calls from consumers with problems and/or issues related to their CMH prescribed medication will also be forwarded to the office of the Team Nurse. 3. New consumers will be informed by the teams members that medication refill requests should to be made one week prior to running out of medication. 4. Signs will be posted in the adult and child waiting rooms, offices of prescribers and nursing offices, reminding consumers of the need to call one week in advance for medication refill requests. 5. Refill requests and medication-related issues will be documented utilizing the Medication Clinic Request progress note option, and forwarded to the To Do List of the consumer's prescriber. (see Operational Guidelines for Medication Clinic Request) 6. Transcription of the phone message, and subsequent calls to obtain additional detailed information regarding the consumer's medication related phone message, will be completed by either a Nurse or CMA. 7. If the recipient's assigned prescriber is not working at CMHOC on that day, the Team Nurse will utilize her professional judgment regarding whether the phone request should be forwarded to another prescriber for handling, or it is able to wait until the assigned prescriber returns to CMHOC. 8. If a CMA transcribes the medication-related phone message, and the assigned prescriber is not present, the CMA will check with the Team Nurse regarding the professional judgment required in #7 above. 9. All CMHOC prescribers are expected to share the responsibility of refilling medications, responding to medication-related issues and evaluating evaluating consumers in crisis when a consumer's assigned prescriber is not available. COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY OPERATIONAL GUIDELINE Page I of 2 TITLE: MEDICATION CLINIC REQUESTS ISSUED BY: Dr. Bruce Walters, Medical Director EFFECTIVE DATE: May 1, 2010 REVISED DATE: June 23, 2010 APPROVED BY: Dr. Michael Brashears, Executive Director I. PURPOSE: To enact a protocol identifying a consistent manner of documentation for medication related to requests, issues or observations of an active consumer receiving psychiatric services by utilizing the CMHOC electronic medical record system. II. APPLICATION: CMHOC treatment teams serving consumers who receive psychotropic medication. III. DEFINITIONS: N/A IV. PROCEDURE: A. Any CMHOC staff person with access to the CMHOC electronic health record system may utilize the Medication Clinic Request template by performing the following steps: STAFF RESPONSIBILITIES: 1. Log on to AVATAR 2. Select the chosen consumer by name or ID number. 3. Select AVATAR PM > PROGRESS NOTES > PROGRESS NOTE 4. Select active TEAM EPISODE, then OK 5. Choose INDEPENDENT NOTE, then DRAFT 6. From dropdown listing under NOTE TYPE, choose MEDICATION CLINIC REQUEST 7. Type message into body of NOTES FIELD, including name of caller and phone number to return call, if provided. 8. Click arrow on top left of field to advance to 2nd page of progress note (page 2 of 2) 9. Select MENTAL HEALTH 10. Select prescriber's name from dropdown listing near "User to Send Co-Sign To Do item to" if action from a CMHOC prescriber is required. 11 . Return to Page 1 of Progress Note using arrow icon on top of page 12. Change DRAFT to FINAL 13. Utilize SUBMIT icon on top of form to send message to the To Do List of chosen Prescriber. 14. Staff utilizing the Medication Clinic Request template may choose to develop a system (log, list, reminder on Lotus Notes Calendar, etc.) to log communication sent in this manner awaiting a response from the prescriber. NOTE: When selecting a reminder system, consider that it may need to be shared with your supervisor and/or other coworker(s) to follow up if you are off work due to illness or vacation. 1 5. The current AVATAR system does not allow Prescribers to send the item back to your To Do List to alert you when they have responded. You will receive a response via your Lotus Notes email. 16. Medication Clinic Request progress note entries will also be utilized to document other medication related consumer phone or in person contact that does not require Prescriber action. This may include pharmacy contacts, insurance prior authorization requests, questions or education. PRESCRIBER RESPONSIBILITES: 1 Prescribers will regularly monitor their AVATAR To Do List for incoming communication that requires their attention. 2 Prescribers will address items when time permits between appointments, during "paperwork time" or during times when consumers fail to keep appointments. 3 All prescribers have access to check dates of future medication review appointments, past history of "no shows", medication reviews and prescription & pharmacy information on InfoScriber to review on an as needed basis. 4 All Medication Clinic Requests sent to prescriber To Do Lists require written documentation indicating that the prescriber has reviewed the communication, taken some action (or chosen not to) and/or requests that the CMHOC staff member who originated the message take an additional action. 5 By double clicking on an entry in the To Do List, prescribers will be able to review the message and type their response. Prior to submitting the response by clicking on the Submit icon at the top of the page Prescribers will copy and paste the body of the reply into a new email addressed and transmitted to the Medication Request sender The date, time and prescribed name will automatically be attached the AVATAR entry. Operational Guideline Page 2 of 2 Medication Clinic Requests F. Medication Monitoring: a. Consumer's response to medication will be monitored and recorded as clinically indicated. b. After the desired clinical result is obtained and the consumer's condition has stabilized, the medication shall be maintained at the minimum maintenance dose needed, or the consumer may be titrated off the medication. c. If the consumer has stabilized but needs long-term maintenance medication, The prescribing professional shall document such, and specify the frequency of face-to-face medication review appointments. 1. Required Testing: a. Baseline studies for psychotropic drug use are related to the pharmacology of the specific drug used. b. Unless the rationale for delaying/omitting tests is documented in the record, the following guidelines for monitoring of psychotherapeutic medications are required: TYPICAL ANTIPSYCHOTICS Baseline: • CBC with differential • AIMS • Liver Enzymes • Consult with primary physician regarding baseline EGG if history of significant cardiac disorder or age >65 Monitor: • CBC with differential and liver enzymes annually • AIMS Test quarterly. Quarterly AIMS will be done by a medical or nursing professional to monitor involuntary movements, and will be documented in the Psychiatric Evaluation, Medication Review and/or AVATAR CWS. TYPICAL ANTIPSYCHOTICS (CONT.) EXCEPTIONS: • Clozapine: Additional weekly WBC and ANC for first six (6) months, then every two (2) weeks for next six (6) months, followed by testing every four (4) weeks thereafter if test results remain within normal range per laboratory requirements information sheet.(see Clozapine Prescribing and Management) • Mellaril: Routine EKG recommended ATYPICAL ANTIPSYCHOTICS Baseline: • Triglycerides • Fasting Glucose or A1C • AIMS Testing (not required if only antipsychotic is Clozapine) Quarterly: • Triglycerides, if elevated (or refer to Primary Care Physician for monitoring) • Fasting Glucose or A1C if family history, symptoms or pertinent risk factors (or refer to Primary Care Physician) • AIMS Testing Annually: • Fasting glucose if no family history, symptoms or pertinent risk factors ANTICONVULSANTS Depakote (Valproic Acid) Baseline: CBC with differential Liver enzymes Monitor: CBC with differential annually Liver enzymes annually Serum level within three (3) months and as clinically indicated Tegretol (Carbamazapine) Baseline: • CBC with differential • Liver enzymes Monitor: • CBC with differential and liver enzymes annually • Serum level within three (3) months, and as clinically indicated Topamax Baseline: • Bicarbonate level after one (1) month of therapy (if clinically indicated) ANTIDEPRESSANTS Baseline: • Tricyclic Antidepressant: Consult with primary physician regarding baseline ECG if history of significant cardiac disorder or age <16 or >65 • SSNRI: Blood pressure monitoring (Effexor and Cymbalta) • Asendin: AIMS Test Exception: • Marplan, Nardil, and Parnate: Special diet recommended ANTIDEPRESSANT MEDICATION FOR CHILDREN AND ADOLESCENTS Upon initiation of prescribing an anti-depressant medication to a child or adolescent the CMH: • physician/PA-C/NP shall follow the agency Guidelines for the Monitoring of Children and Adolescents being Treated with Anti-Depressants (Practice Guideline 12-008). LITHIUM Baseline: • CBC with differential • Serum Creatinine, BUN, TSH, and UA • Consult with primary physician regarding baseline ECG if history of significant cardiac disorder or age <16 or >65 Monitor: • Serum Creatinine, BUN, TSH, and UA annually • Lithium levels 5-14 days after a dose change, then every six (6) months ADHD AGENTS Strattera and Proviqil (Modafinil) Baseline: • Liver Enzymes at Baseline All Stimulants: • Blood pressure and pulse monitoring • Monitor weight for children ANTICHOLINERGICS/ANTIPARKINSONIAN • May be used as appropriate and monitored in the medication review record.. *Footnotes: 1. 2. 3. Drug level monitoring should be a trough level Liver Enzymes refers to one or more enzymes (ALT, SGPT, ALP, LAP, 5'NT, LD, GGT and/or GGTP) Baseline conditions exist when medication therapy has been interrupted for more than six (6) months COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY Prompt for Required Monitoring of Medication Treatment TYPICAL ANTIPSYCHOTICS Baseline: • CBC with differential • AIMS • Liver Enzymes • Consult with primary physician regarding baseline ECG if history of significant cardiac disorder or age >65 Monitor: • CBC with differential and liver enzymes annually • AIMS quarterly (exception for patient on no antipsychotic except clozapine) Exceptions: • Clozapine: : Additional weekly WBC and ANC for first six (6) months, then every two (2) weeks for next six (6) months, followed by testing every four (4) weeks thereafter if test results remain within normal range per Fazaclo Laboratory Requirements information sheet.(see Clozapine Prescribing and Management) 1. Mellaril: Routine EKG recommended ATYPICAL ANTIPSYCHOTICS Baseline: • Triglycerides • Fasting Glucose or A1C • AIMS Testing Quarterly: • Triglycerides, if elevated (or refer to Primary Care Physician for monitoring) • Fasting Glucose or A1C if family history, symptoms or pertinent risk factors (or refer to Primary Care Physician) • AIMS Testing (not require if only antipsychotic is Clozapine) Annually: • Fasting glucose if no family history, symptoms or pertinent risk factors ANTICONVULSANTS Depakote (Valproic Acid) Baseline: • CBC with differential • Liver enzymes Monitor: • CBC with differential annually • Liver enzymes annually • Serum level within three (3) months and as clinically indicated Teqretol (Carbamazapine) Baseline: • CBC with differential • Liver enzymes Monitor: • CBC with differential and liver enzymes annually • Serum level within three (3) months, and as clinically indicated Topamax Baseline: • Bicarbonate level after one (1) month of therapy (if clinically indicated) Prompt for Required Monitoring of Medication Treatment (cont.) ANTIDEPRESSANTS Baseline: • Tricyclic Antidepressant: Consult with primary physician regarding baseline ECG if history of significant cardiac disorder or age <16 or >65 • SSNRI: Blood pressure monitoring (Effexor and Cymbalta) • Asendin: AIMS test Exceptions: • Marplan, Nardil and Parnate: Special diet recommended LITHIUM Baseline: • CBC with differential • Serum Creatinine, BUN, TSH, and UA annually • Consult with primary physician regarding baseline ECG if history of significant cardiac disorder or age <16 or > 65 Monitor: • Serum Creatinine, BUN, TSH, and UA annually • Lithium levels 5-14 days after a dose change, then every six (6) months ADHD AGENTS Strattera and Provigil (Modafinil): • Liver enzymes at baseline All Stimulants: B/P & Pulse for all Monitor weight for children FOOTNOTES • Drug level monitoring should be trough levels • Liver enzymes = one more liver enzyme (ALT, SGPT, ALP, LAP, 5'NT, LD, GGT and/or GGTP) • Baseline conditions exist with therapy has been interrupted for more than 6 months. COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY OPERATIONAL GUIDELINE TITLE: Monitoring of Children and Adolescents Being Treated with Antidepressants REVIEW DATES: EFFECTIVE DATE: 5/19/10 AUTHORED BY: Muskegon County CMH SUBJECT: Monitoring Children and Adolescents being treated with Antidepressants. SCOPE: CMHOC Prescribers. PURPOSE: To ensure that all children and adolescents who are prescribed antidepressants from Agency Physicians or Physicians Assistants are monitoring for suicidal thoughts and behavior. PROTOCOL: The frequency and nature of the monitoring should be individualized to the needs of the Family and the consumer. CMH staff should enlist the parents/guardians in the responsibility of monitoring the individual at time of the prescription. The primary care worker or program Registered nurse will contact the family during the first month of initiation of an antidepressant to monitor progress. If Family members become concerned about changes they should contact Ottawa County Community Mental Health if the child: 1. Expresses new or more frequent thoughts of wanting to die, or engages in self destructive behavior; 2. Shows signs of increased anxiety/panic, agitation, aggressiveness, or impulsivity; 3. Experiences involuntary restlessness (akathisia), or an extreme degree of unwarranted elation or energy accompanied by fast, driven speech and unrealistic plans or goals. Adverse reactions to antidepressants are more likely to occur early in the course of treatment or in changes of the dose. It may become appropriate to adjust the dosage, change to a different medication, or stop using the medication. The Physician/PA should warn the parents/guardian of abruptly discontinuing the medication due to possibly adverse withdrawal effects such as agitation or increased depression. The Psychiatrist/PA should convey the importance of consulting with their Provider before changing or terminating their child's antidepressant treatment. G. Prescription Quantity and Refills: 1. Medication quantity for all community-based programs will be based on sound clinical judgment. Requests for medication refills for consumers who have missed 2 consecutive psychiatric appointments will evaluated on an individual basis by the prescriber. 2. Unless other clinical reasons are present, prescribers shall authorize enough prescription refills to last until the date the consumers is to schedule a follow-up medication review appointment. 3. Consumers will be issued medication refill authorizations for no greater period than 90 days. H. Changes in Medications. 1. If a consumer's medication is changed between Medication Review appointments, a progress note stating the rationale, shall be written by the prescribing professional or other staff person to correspond with that change. 2. If a medication change occurs at the time of a Medication Review appointment, the AVATAR CWS documentation of this appointment will include the rationale for all medication changes. 3. When a medication is initially prescribed, or when a significant change occurs, the consumer's primary care physician and/or other service provider will be notified (only when a release of information form is complete and up-to-date). I. Prescriptions: 1. Written Orders a) The prescription shall be signed only by a physician or a PA-C./N.P. 1) Prescription medication for all consumers may be up to three month's supply. 2) Prescribers will use CMH InfoScriber only for CMH recipients. 1. Written Orders (cont.) b) Regular prescriptions shall be documented on InfoScriber. 1) The original shall be given to the recipient or guardian,or sent via eRx or Fax to the pharmacy or CMH program, as needed. c) A Health Practitioner may call or fax the prescription in to a pharmacy. This shall be documented on the prescription with the name of the pharmacy, date and the initial's of the Health Practitioner. d) All written prescriptions should have corresponding documentation. e) Class II substances shall be documented on InfoScriber, printed and signed prior to giving it to the consumer to bring to the pharmacy for filling. 2. Verbal Medication Orders a) Verbal medication orders from physicians, NPs or PA-Cs to RN staff will include the name of the drug, strength, dosage, and rationale for the medication change. b) Nursing staff will enter the order into InfoScriber, noting on clipboard feature that this was a verbal medication order & stating rationale. c) Only a Health Professional may make telephone orders to a pharmacy. d) Consent for new medications initiated by verbal order shall be obtained. e) All changes in medication regimen shall be accompanied by documentation in InfoScriber and a progress note J. PRN Medication: 1. When PRN orders are written, the prescribing profession shall document in the progress note or Medication Review documentation the justification of such. 2. There shall be an order and a dose for the specific conditions in which the PRN order is to be administered. 3. PRN orders shall limit the number of doses to be administered within a 24 hour time period. J. PRN Medication (cont.) 4. The total daily dosage of PRN orders shall not exceed those specified in the PDR or general guidelines from current psychiatric literature. 5. PRN medication will not be administered in emergency situation as a means of preventing harm to the consumer or others; or for behavioral control. ((INSERT SCREENING FOR MEDICAL COMORBIDITIES (DR. WALTERS IS SUPPOSED TO WRITE THIS PROCOTOL) K. Screening for Medical Comorbidities COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY OPERATIONAL GUIDELINE TITLE: CLOZAPINE PRESCRIBING AND MANAGEMENT EFFECTIVE DATE: REVIEW DATES: 8/23/10 AUTHORED BY: Bruce Walters. MD SUBJECT: Guideline for prescribing Clozapine when medically indicated, and to do so in accordance with the special prescribing and monitoring requirements unique to this medication. SCOPE: CMHOC MI treatment teams serving Ottawa County consumers with significant and persistent mental illness. PURPOSE: To establish an operational guideline for the prescribing and management of Clozapine (name brands Clozaril and Fazaclo). 1. Clozapine prescribing and management practices shall be in accordance with the Full Prescribing Information (package insert) approved by the FDC for publication by manufacturers of Clozapine medications. Algorithms provided in current FDA-approved prescribing information guides are to be followed when making clinical decisions regarding prescribing Clozapine. It is the responsibility of the prescriber to ensure that the most recent edition of FDAapproved full prescribing information is being followed. 2. Clozapine prescribing requires the registration of prescriber, pharmacy, and patient (consumer) in a national registry, and periodic monitoring of WBC with ANC for as long as Clozapine treatment continues. The results of periodic lab testing have to be reported to the pharmacy before Clozapine can be dispensed. 3. Prescribers may exercise clinical judgment in also following recommendations and practices regarding the use of Clozapine which may be cited in reputable psychiatric literature and/or in generally accepted prescribing practices within the psychiatric medical community. The clinical rationale for any deviations from recommended prescribing practices needs to be clearly documented in the medical record. CLOZARIL: Starting a Patient 1. 2. 3. 4. Call the CLOZARIL National Registry (CNR) to obtain a rechallenge number and to confirm that you and your pharmacy are registered. Obtain a baseline WBC with ANC from patient. If within normal limits, WBC > 3500/mm3, ANC > 2000/mm3, prescribe CLOZARIL tablets. Submit WBC and ANC information to the registered pharmacy. Please be prepared to provide your DEA # to the CNR when you are registered for the first time. For forms, patient enrollment, or medical information call the CLOZARIL National Registry: 1-800.448-5938 Recommended CLOZARIL (clozapine) dosage titration at start of therapy' hs (mg][ . Total [rr am (mg) haL(mgJ 12.5' | 12.5-2 50 100 100 100 100 100 50 50 100 100 'Optional 200 200 200 200 Total (mg) 150 200 200 250 250 300 300 Subsequent dosage increments should be made no more than once or twice weekly, in increments not to exceed 100 mg. CLOZARIL: Managing the Patient Current Monitoring Frequency Eligibility for Monthly Monitoring Every 2 weeks (biweekly) for 6 continuous months, following 6 continuous months of weekly monitoring prior to May 12, 2005. Every 2 weeks or weekly. Therapy interrupted after May 12. 2005, due to moderate leukopenia and/or granulocytopenia*. with consecutive monitoring since restart {rechallenge) of therapy. YES. Only if all WBC counts > 3000/mm' (and ANC >1500/mm3 if reported) NO. Patient must have 6 continuous months of weekly monitoring, followed by 6 months of continuous monitoring every two weeks with all WBC/ANC above increased monitoring frequency values'". Weekly therapy for <6 months Weekly therapy for >6 continuous months, but never monitored biweekly. NO, Only after 1 year of continuous weekly monitoring and then 6 months of continuous every two weeks monitoring from the date of restart (rechallenge) with all WBC/ANC above increased monitoring frequency values**". NO, Patient must have 6 continuous months of monitoring every two weeks with all WBC/ANC above increased monitoring frequency values". Increased Monitoring Frequency Requirements Patient is currently monitored monthly and experiences a WBC < 3500/mm- and/or an ANC < 2000/mm1. Monitoring should be done twice weekly until WBC/ANC values are >3500 and > 2000, respectively. The patient can return to monthly blood work. Patient is currently monitored every 2 weeks and experiences a WBC < 3500/mrrT and/or an ANC < 2000/mmJ. Monitoring should be done twice weekly until WBC/ANC values are >3500 and >2000, respectively. The patient should then be monitored every two weeks for 6 continuous months before progressing to monthly blood work. Patient is currently monitored weekly and experiences a WBC < 3500/'mmJ and/or an ANC < 2000/mmJ. Monitoring should be done twice weekly until WBC/ANC values are >3500 and >2000, respectively. The patient should then be monitored weeWy for 6 continuous months before progressing to every two weeks, and then monthly. Wood work. "Prior to May 12. 2005 values for WBC and ANC counts requiring interruption of therapy were WBC < 3000/mm3 and/or ANC < 1500/mrrr. After May 12, 2005 values for counts requiring increased monitoring frequency of therapy are WBC < 3500/ mm1 and/or ANC < 2000mm1. respectively. Following discontinuation of therapy for any reason, the patient should have WBC and ANC count monitoring once a week for a minimum of 4 weeks. If at the end of 4 weeks WBC < 3500/mnT1 and/or ANC < 2000/mm'. weekly monitoring should continue until WBC ^3500/mm1 and ANC 2 2000/mm3. Cloânf (cloâpme) use it associated with a substantial risk of seuure affected 1% to 2% of patients a; lew doses (below 300 mg/day). 3% ;c 4% at nocerate closes (300 mg/day to 600 mgAJay}. and 5% at high doses (600 Tig/day to 900 nig/day). Cloianf is contra ndicated in patients with paralyse ileus. In clinical if als. Clo£ar I was associated with a 1% r- 2% incidence of agranulocy:csis, a ootenîallv fatal blood disorder, which, if caught early, can te reversed. Mandatory monrtonng of WBC courts and ANC's and drug dispensing as per the requirements specif en m the package insert, provide an erf-dent means of determining develop ng agranulocytosis. Analysis of post-rrarke-ting safety databases suggests that Clo7anl is associated with an in-reassd risk of fatal myocarditis, especially dinng. but not limited 10. tho first mjnth o: iherany. OrthostcVic t-'yporsnsion may occur in some oatio'-is. especially curing the i^nal phases of treatmeni. and can. in raie cases (approx -nate incidence of 1/3000). be accompanied by collapse and/or cardiac, arrest. Analysis of clinical studies reveal that elderly pafienis with deme^tw-related psychosis treated with atypical dnt psychotic drugs are at ar increased ns.< ot death comoared ic placebo Patient;, with jn established diagnosis of c-iabetes mellrtus who are snarled on CLOZAHIL should be n-ontored regularly for worsening plucose control (e.g.. polydipsia. potyuria. potvpriagia, and weakness) Clozaril (clozapine) J '•^SSSr Table 1. Frequency of Monitoring based on Stage of Therapy or Results from WBC Count and ANC Monitoring Tests Situation Initiation of therapy 6 months - 12 months of therapy 12 months of therapy Immature forms present Discontinuation of Therapy Substantial drop in WBC or ANC Mild Leukopenia Mild Granulocytopenia Moderate Leukopenia Moderate Granulocytopenia Hematological Values for Monitoring WBC > 3500/mma ANC > 2000/mm3 Note: Do not initiate in patients with 1) history of myeloproliferative disorder or 2) Clozaril® (clozapine) induced agranulocytosis or granulocytopenia All results for WBC > 3500/mm3 and ANC >2000/mm3 All results for WBC > 3500/mm3 and ANC > 2000/mm3 N/A N/A Single Drop or cumulative drop within 3 weeks of WBC > 3000/mm3 or ANC> 1500/mm3 3500/mmJ > WBC > 3000/mmJ and/or 2000/mm3 > ANC > 1500/mm3 3000/mmJ > WBC > 2000/mmJ and/or 1500/mm3 > ANC >1000/mm3 Severe Granulocytopenia WBC < 2000/mmJ and/or ANC < 1000/mm3 Agranulocytosis ANC < 500/mm3 Severe Leukopenia Frequency of WBC and ANC Monitoring Weekly for 6 months Every 2 weeks for 6 months Every 4 weeks ad infmitum Repeat WBC and ANC Weekly for at least 4 weeks from day of discontinuation or until WBC > 3500/mm3 and ANC > 2000/mm3 1. Repeat WBC and ANC 2. If repeat values are 3000/mm3 < WBC < 3500/mm3 and ANC < 2000/mm3, then monitor twice weekly Twice-weekly until WBC > 3500/mmJ and ANC > 2000/mmJ then return to previous monitoring frequency 1. 2. 3. 4. 5. Interrupt therapy Daily until WBC > 3000/mm3 and ANC >1 500/mm3 Twice-weekly until WBC > 3500/mm3 and ANC > 2000/mm3 May rechallenge when WBC > 3500/mm3 and ANC > 2000/mm3 If rechallenged, monitor weekly for 1 year before returning to the usual monitoring schedule of every 2 weeks for 6 months and then every 4 weeks ad infmitum 1 . Discontinue treatment and do not rechallenge patient 2. Monitor until normal and for at least four weeks from day of discontinuation as follows: • Daily until WBC > 3000/mm3 and ANC > 1 500/mm3 • Twice weekly until WBC > 3500/mm3 and ANC > 2000/mm3 • Weekly after WBC > 3500/mm3 1 . Discontinue treatment and do not rechallenge patient 2. Monitor until normal and for at least four weeks from day of discontinuation as follows: • Daily until WBC > 3000/mm3 and ANC > 1 500/mm3 • Twice weekly until WBC > 3500/mm3 and ANC > 2000/mm3 • Weekly after WBC > 3500/mm3 *WBC=white blood cell count: ANC=absolute neutrophil count; CNR=Novartis CLOZARIL National Registry; G-CSF & GM-CSF=bone marrow colony-stimulating factor M. Medications for Behavior Management The Behavior Treatment Review Committee (BTRC) has developed the following policy: 1. Medication may be prescribed without approval of BTRC when use of medication is part of generally accepted medical practice for the diagnosed condition. In this instance, if the treatment team has concerns about behavior management implications of the medication treatment, referral to the BTRC for approval or advice would be acceptable. All other uses of psychotropic medications will be reviewed and approved by the Behavior Treatment Review Committee. 2. The Behavior Treatment Review Committee has its own Operation and Procedure Manual. In summary, the BTRC will review use of medications in order to determine the clinical appropriateness of medication versus a behavioral program for controlling behavior. The BTRC will not recommend specific medications or dosages once approval for medication use has been granted. Prohibited Abbreviations "Do Not Use List" Abbreviation Potential Problem(s) Preferred Term(s) A.S., A.D., A.U., O.S., O.D. and O.U. Mistake for each other Write "left ear", "right ear", "both ears"; "left eye", "right eye", or "both eyes" c.c. Mistaken for U (units) when poorly written U (for unit) Mistaken as zero, four or cc Mistaken as IV (intravenous or 10) Write "ml" for milliliters Write "unit" Write "international unit" Mistaken for Q.O.D., and Q.D. (Latin abbreviation for the period after the Q can be once daily) Write "daily" mistaken for an "I" i. Mistaken for Q.D. and the Q.O.D. (Latin abbreviation i . , . 7* _ , ji period after the Q can be for once every other day) _ „:£ Write "every other day" mistaken for an ! and the "O" can be mistaken for "I" Trailing Zero Never a zero by itself after a Decimal point is missed decimal pqintJX nig) _ Always use a zero before a Lack of Leading Zero Decimal point is missed decimal point (Q.X mg) Confused for MSO» and Write "morphine sulfate" MS MgSO4 Confused for MS and Write "magnesium sulfate" MSO4 MgjSO4_ Write "shartness~ofbreath" SOB Confused with an epithet T.I.W. Mistaken for three times a day or twice weekly, resulting in overdose Write "3 times weekly" or "three times weekly" 0. CONTROLLED MEDICATIONS 1. Controlled Substance Education/Contract a. When a prescription for a controlled substance is written by a CMH prescriber for a recipient responsible for self-administration of medication, or who will soon be responsible for self-administration of medication,, he or she will be required to sign the consent for that medication and the Controlled Substance Contract if one has not previously been signed. b. The parent of a minor child who is prescribed a controlled substance by a CMH prescriber will be required to sign the Controlled Substance Contract. c. A health professional will explain to the recipient, guardian or parent the Controlled Substance Education/Contract Form and "Controlled Substance Education" Brochure, reviewing the contents with the person(s) involved. d. A copy of the signed Controlled Substance Education/Contract will given to the consumer, along with the brochure to take home for reference and to read more thoroughly. e. The original of the Controlled Substance Education/Contract will be filed in the consumer's medical record, under the Consents Tab. 1) Controlled Substance Information Guidelines, Medical Records Form 101 Ml 2) Controlled Substance Education Brochure CONTROLLED SUBSTANCE INFORMATION GUIDELINES JL| Z Q O ^5 £fe ^ ^f tO •• ^j »^™ This information is being provided to make sure that you have a safe and effective treatment plan. CMHOC wants you to be aware that there are possible adverse reactions and conditions that may develop with the use of controlled substances. Controlled substance is a drug or chemical substance whose possession and use are controlled by law. Examples include: Ativan & Ritalin. Psychological dependence or addiction can occur with use, but the risk is low when the medications are used properly. You will be given a list of some of the possible complications of treatment with controlled substances and additional information can be found on the "Controlled Substance Education Sheet" and the information sheet that comes with the prescription. It is important to take the medication exactly as prescribed and exactly as instructed. If you run out of the medication too soon or stop it suddenly, you might experience withdrawal symptoms that could be uncomfortable or dangerous. If you have questions or concerns about the amount you are taking, or when you take them, please contact the Medication Clinic to speak to a nurse. Do not change the dose amounts or change the time schedule of taking the medications without first calling the medication clinic. (392-1873 in Holland and 842-5350 in Grand Haven) lf you become pregnant (if applicable), the baby may become addicted to the medication or experience other unknown risks. Please let us know if you become pregnant or think you may be pregnant. It is dangerous to get controlled substance medications from more than one doctor. Please tell us if other doctors are prescribing these medications for you and we will coordinate our recommendations with them. Your confidentiality is important and we will ask you to sign a release of information giving us permission to consult with your health care providers and with your pharmacy about the use of these medications. Please select one pharmacy to obtain all of your medications. < Pharmacy Name: Pharmacy Address: Pharmacy Telephone Number: Prescriptions can only be filled during regular CHMOC working hours: Monday through Friday, 8:00 am to 5:00 pm. No controlled substances will be refilled after hours, on weekends or holidays. Keep track of how much medication you have left and please allow 7 days for a prescription to be filled. It is very important that you allow adequate time to refill your medication. We can only accept telephone requests for controlled substance medication refills from you (or parent/guardian, if applicable). If you are too disabled or sick to come in, the decision to allow another person to pick up your prescription will be determined at CMHOC's discretion. Minors cannot pick up prescriptions and we can only give prescriptions to people for whom we have a signed valid release of information form. Please let us know immediately about any medication-related side effects. If any significant side effects occur during regular working hours, call the medication clinic. If they occur after hours or on weekends or holidays, please call the Helpline at 1-866-512-HELP and ask to speak to the on-call worker. If you need immediate medical attention, please go to the nearest emergency room. CMHOC cannot continue to prescribe controlled substances if they are not adequately monitored. You will be scheduled for medication reviews as often as your doctor feels is necessary and it is important that you keep these appointments. If you cannot make your scheduled appointment, please notify us a minimum of 24 hours in advance. For your safety, it is a federal offense to alter a prescription in any way and to transfer a controlled substance to another person. We are required by law to report these incidents and legal action could result. Protect yourself and others; don't let other people use your medication. CMHOC - Controlled Substance Information Guidelines - 03/5 - 101 Ml - 10/24/07 Case Number: CONTROLLED SUBSTANCE INFORMATION GUIDELINES IBB mm D O I * < ^( |_ CMHOC cannot renew prescriptions before they expire and cannot replace prescriptions for you. This includes lost or destroyed prescriptions or lost, damaged, or stolen medications. If your CMHOC health care provider has concerns about your well-being, they may ask you to submit to a random urine or blood sample for drug screens. The results of these tests will be fully explained to you, as well as any recommendations for possible changes in your treatment. For stimulant medications only: • • • Prescriptions can only be handwritten; we cannot call in or fax stimulant prescriptions Refills cannot be listed on a prescription Prescriptions must be picked up and cannot be mailed Your signature below indicates that this information has been fully explained to you and that any questions or concerns have been fully addressed. Consumer's Name DOB_ Consumer's/Guardian Signature IL O X < CMHOC - Controlled Substance Information Guidelines - 03/5 - 101 Ml - 10/24/07 Case Number. Conditions That May Develop with Controlled Substance Use Consumer Education Physical Dependence - after stopping the medication you can have withdrawal symptoms. These may include: ID nausea/vomiting ID sweating ID shaking ID general bad feeling or anxiety The activities and programs of this agency are brought to you by the members of the Ottawa County Board of Commissioners. The Michigan Department of Community Health provides financial support to this agency. CONTROLLED SUBSTANCE USE ID runny nose ID diarrhea and/or abdominal cramping Community Mental Health of Ottawa County has been accredited by CARF for twelve of its programs. ID soreness or aches Psychological Dependence or addiction - the risk is low when you follow directions on how to take the medication. After stopping the medication, you may go through withdrawal this is related to physical dependence. If your body feels like, or you think you have become dependent on medication, then you may act like you are addicted to drugs. Administrative Offices 12265 James Street Holland, Ml 49424 Customer Service Phone: (616)494-5545 Toll-free 1-866-710-SERV (7378) Consumer Education Rev. 08-2008 COMMUNITY M E N T A L H E A L T H O T T A W A C O U N T Y /Consumer Education on 1 Controlled Substance Use You have been prescribed a controlled substance by your health care provider. This medication will be used to treat your mental health concerns. For this treatment to work, you should follow all of these important instructions: Z) Please keep all of your appointments. Z> Be careful with your prescriptions and medications. We will not replace lost, destroyed, damaged, or stolen prescriptions or medication. ID Keep track of how much medication you have left and call for refills during office hours only. Possible Adverse Reactions (Side Effects) There are possible adverse reactions and conditions that may develop with the use of controlled substances. We have listed a few of these for your information. Please refer to your medication teaching sheet for a more complete list and let us know if any of the following occur: In the event of overdose, call the Regional Poison Control Center: 1-800-222-1222 Possible Side Effects Z> Allergy Z> Overdose (can cause problems with breathing and/or death) Z> Constipation Z> Itching Z> Difficulty with urination Z> Nausea or vomiting Z) Change in mental status or thinking ability ID Increased sleepiness Z) Problems with balance or feeling clumsy (use caution when operating a motor vehicle or dangerous equipment) Z) Problems having sex Z) Other less common side effects are possible Z> Children born to mothers on controlled substances (narcotics) are usually physically dependent at birth Z) Suddenly stopping the use of medication may cause seizures For Medication Refills or to cancel or reschedule an appointment: Holland (616) 392-1873 Grand Haven .... (616) 842-5350 Hudsonville (616) 669-6160 COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY OPERATIONAL GUIDELINE TITLE: ADHD Protocol EFFECTIVE DATE: 5/19/10 REVIEW DATES: AUTHORED BY: Muskegon County CMH SUBJECT: ADHD Protocol SCOPE: This guideline applies to all CMH employees and contract providers. PURPOSE: To enable the Agency to provide consistent and effective treatment of individuals diagnosed with ADHD. PROTOCOL: Adult ADHD: 1. Assessment a. Anyone can initiate a request for an assessment of adult ADHD by contacting CMHS staff. This may include the individual receiving services, family, friends, medical, or mental health care staff (case manager, therapist, psychologist, nurse, physician, physician assistant, etc.). b. The following data will be gathered in making diagnosis of ADHD in adults: 1. Childhood/school records will be obtained by the primary worker prior to treatment, if possible. 2. An Adult Rating Scale will be completed by the parent(s) and/or spouse, when possible, and obtained by the primary worker prior to treatment. 3. The Brown Adult ADD Scales/Conner's Adult ADHD Rating Scale procured from a supports coordinator will be completed by the individual and obtained by the primary worker prior to psychiatric evaluation. 4. A developmental history and assessment of comorbid conditions will be obtained by the Psychiatrist/Physician's Assistance/Nurse Practitioner during a psychiatric evaluation. A diagnosis of ADHD in an adult will me be made after consideration of the above information. 5. For borderline ADHD cases, the Psychiatrist/Physician's Assistant/Nurse Practitioner may request additional testing using such instruments as the CPT, WAIS-IV, or achievement measures. 6. When an adult individual comes to Ottawa County Community Mental Health with an existing diagnosis of ADHD, the Psychiatrist/Physician's Assistant/Nurse Practitioner will verify the diagnosis and request supportive documentation data when indicated. 2. Treatment a. Pharmacological Intervention The decision to medication should be based on persistent target symptoms sufficiently severe to cause functional impairment. 1. Medications used to treat ADHD include methylphenidate preparations, amphetamines, alpha 2 Adrenergic agonists, Strattera, Modafanil, NDRIs/Antidepressants 2. Any adult with a history of substance abuse will be prescribed nonstimulant medications as first choice and/or long-acting stimulant medication as a second choice. If there is a less than an adequate response or no response to this documented intervention, then shortacting stimulant Medications may be prescribed provided the individual is also involved in substance abuse treatment. 3. Whenever possible, for the sake of differential diagnosis, pharmacological treatment of comorbid DSM-IV conditions should be initiated and evaluated prior to the initiation of stimulant medication for ADHD symptoms. 4. The prescribing Psychiatrist/Physician's Assistant/Nurse Practitioner shall be responsible for assuring there are no contraindications for stimulant medication; and if needed, request the individual to obtain necessary lab work or a physical exam, or consultation with specialists (e.g. cardiologist). b. Psychosocial, Behavioral, and Environmental Intervention The individual receiving services should be provided information regarding the availability of adjunct treatment modalities for ADHD, including: 1. 2. 3. 4. Education using a biopsychosocial model. Accommodations to help foster attention skills. Behavioral supports. Individual counseling/Community Support Group (CHADD) if available. 3. Follow-up Periodically, the Brown Adult ADD Scales/Conners Adult ADHD Rating Scale should be administered by the primary worker and reported to the prescriber. For those individuals with a history of substance abuse, a lab screen sensitive to the medication being prescribed for ADHD as well as illicit substances may be ordered prior to the appointment date for issuing a subsequent prescription for the prescribed ADHD medication. Child ADHD 1. Assessment a. Anyone can initiate a request for an assessment of child ADHD by contact CMH staff. This may include the individual receiving services, family, friends, medical, or mental health care staff (case manager, therapist, psychologist, nurse, physician, physician assistant, etc.). b. The following data will be gathered in making a diagnosis of ADHD in children: ADHD Protocol Page 2 of4 1. Childhood/school records will be obtained by the primary worker prior to treatment. 2. A Parent and Teacher Rating Scale will be completed, (Achenback or Conners), and obtained by the primary worker prior to psychiatric evaluation. 3. A developmental history, physical exam, and assessment of comorbid conditions will be obtained by the Psychiatrist/Physician's Assistant/Nurse Practitioner during a psychiatric evaluation. A diagnosis of ADHD in a child will be made after consideration of the above information. 4. For borderline ADHD cases, the Psychiatrist/Physician's Assistant/Nurse Practitioner may request additional testing using such instruments as the CPT, WISC-IV, or achievement measures. 5. When a child individual comes to CMH with an existing diagnosis of ADHD, the Psychiatrist/Physician's Assistant/Nurse Practitioner will verify the diagnosis and request supporting documentation data when indicated. 2. Treatment a. Pharmacological Intervention The decision to medicate should be based on persistent target symptoms sufficiently severe to cause functional impairment. 1. Medications used to treat ADHD include methylphenidate preparations, amphetamines, alpha 2 adrenergic agonists, Strattera, Modafanil, and NDRIs/Antidepressants. 2. Any child with a history of substance abuse will be prescribed non-stimulant medications as first choice and/or long-acting stimulant medication as a second choice. If there is a less than adequate reason or no response to this documented intervention, then short-acting stimulant medication may be prescribed provided the individual is also involved in substance abuse treatment. 3. Whenever possible, for the sake of differential diagnosis, pharmacological treatment of comorbid DSM-IV conditions should be initiated and evaluated prior to the initiation of stimulant medication for ADHD symptoms. 4. The prescribing Psychiatrist/Physician's Assistant/Nurse Practitioner shall be responsible for assuring there are no contraindications for stimulant medication; and, if needed, request the individual to obtain necessary lab work or a physical exam or consultation with specialists (e.g. cardiologist). b. Psychosocial, Behavioral, and Environmental Intervention The parent and/or individual receiving services should be provided information regarding the availability of adjunct treatment modalities for ADHD including: 1. Education using a biopsychosocial model. 2. Accommodations to help foster attention skills. ADHD Protocol Page 3 of4 3. Behavioral supports. 4. Individual counseling/Community Support Group (CHADD) if available. 3. Follow-up The Conners Parent and Child Rating Scales should be administered by the primary worker and reported to the prescriber. For those individuals with a history of substance abuse, a lab screen sensitive to the medication being prescribed for ADHD as well as illicit substances may be ordered prior to the appointment date for issuing a subsequent prescription for the prescribed ADHD medication. REFERENCES American Academy of Child and Adolescent Psychiatry: Practice parameters for the use of stimulant medication in the treatment of children, adolescents, and adults with Attention Deficit Hyperactivity Disorder. J. Am Academy of Child and Adolescent Psychiatry 2002; 41 (2suppl): 265-495 Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD) ADHD Protocol Page 4 of4 COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY OPERATIONAL GUIDELINE Pagel of 3 TITLE: MEDICATION PRACTICE GUIDELINES AND CONTROLLED MEDICATION PRESCRIBING EXCEPTIONS EFFECTIVE DATE: 12/01/2010 REVIEW DATES: AUTHORED BY: Denise Wiswell, Ph.D, Bruce Walters, M.D., Barb Sychowski, BSN SUBJECT: SCOPE: PURPOSE: MEDICATION PRACTICE GUIDELINES AND CONTROLLED MEDICATION PRESCRIBING EXCEPTIONS Psychiatrists, Nurse Practitioners and Physician Assistants employed or contracted by Community Mental Health of County (CMHOC). To provide a consistent prescribing philosophy and procedure for CMHOC consumers who require controlled medications. To decrease opportunities for consumers with substance use disorders to obtain controlled medications. To minimize unintended consumer addiction to controlled medications. To support safe, effective and optimum guidelines for individuals receiving psychiatric services from CMHOC who have or have a history of substance abuse. DEFINITION: Any medication containing a chemical classified by the Department of Justice, Drug Enforcement Agency (DEA), Office of Diversion Control to be a Schedule I, II, III, IV or V Controlled Substance. MEDICATION PRACTICE GUIDELINES: 1. Prescribers will prescribe a reasonable trial of one or more non-addictive medications before any controlled substance (addictive medication) is prescribed (regardless of patient's history elsewhere). 2. If controlled substances are prescribed they will be time limited as indicated in the medication dosage and duration table. Consumers who are tried on several medications will still be subject to the overall time limits. 3. Consumers using controlled substances will be encouraged to actively participate in a holistic recovery program which may include individual, group or other services as recommended by their treatment team. 4. Controlled substances will not be replaced if lost or stolen. 5. Controlled substances will not be refilled early. 6. Controlled substances may or may not be prescribed to individuals receiving controlled substances from other prescribers. This will be determined by the CMH prescriber in consultation with the medical and/or treatment team and the other prescriber if indicated. 7. Medications with opposing effects or those with potential additive effects may not be prescribed at the same time (i.e. sleep medication or anti-anxiety medication for someone taking a stimulant; or anti-anxiety medication and pain medications or others with tranquilizing effects). 8. Verification of a history of ADHD or ADD may be required before stimulants are prescribed. This may include getting releases of information from school records or from other reliable sources. ADHD treatment protocol will be followed (ADHD is treated after the consumer is treated for substance abuse, mood disorder, or an anxiety disorder). 9. Functional need for stimulants should be detailed by the prescriber or the treatment team before this type of medication is prescribed, (e.g., consumer is working and work supervisor verifies they have difficulty staying on task; consumer has a verified school history of ADHD and now wishes to take classes as an adult). 10. Periodic drug screens may be requested if a consumer is being prescribed a controlled substance. 11. Dosages of controlled substances will not be increased unless it is part of the existing (titration) plan without being seen by the prescriber. 12. The Controlled Substance Contract is required for consumers on a controlled substance. 13. A release of information to the consumer's PCP is required before any controlled substance is prescribed. Consumers must have a PCP (within 3 months) if CMHOC is to prescribe medications. 14. Prescribers will seek consultation from the medical team prior to prescribing medications in a manner that departs from the above stated guidelines. 15. Prescribers will notify the treatment team if prescribing in a manner other than consistent with the guidelines. 16. Treatment team members will notify prescribers if they receive information that might negatively affect a consumer's health or treatment (e.g., consumer reports street drug use, has new medications from another prescriber, is refusing other recommended treatment options, etc). EXCEPTION PROTOCOL: The Prescriber requesting an exception to CMHOC Practice Guidelines for Controlled Medication will: 1. Complete a Request for Exception to Practice Guidelines for Controlled Medications form. (Attachment) 2. Discuss issue at Team Meeting, obtaining feedback from other team members. 3. Team Supervisor will record a summary of team feedback on form. 4. The prescriber requesting 'exception' will e-mail a request to the Medical Director to place a review of exception on the agenda of the next Medical Staff Meeting. 5. Prescriber will bring the exception request form to the Medical Staff Meeting and present case to peers. 6. Following presentation at the Medical Staff Meeting, all Prescribers present, and Registered Nurse assigned to the consumer will record their suggestions, comments and approval or disproval of continuation of this controlled medication for the individual. Controlled Substance Guidelines 7. Prescriber who requested exception will follow the recommended group consensus. In instances when a clear group recommendation is not reached, Medical Director will make the final determination. 8. Medical Director will track review date if applicable, and be responsible for including review on future agenda of the Medical Staff Meeting. 9. Support staff will scan completed signed Exception to Practice Guidelines For Controlled Medications form in consumers EMR. Controlled Substance Guidelines Controlled Substance Practice Guideline List of Meds Affected and Dosages Benzodiazepine anxiolytics Generic name Class Brand name Alprazolam IV Xanax IV Alprazolam XR Xanax XR IV Librium Chlordiazepoxide IV Chlorazepate Tranxene IV Clonazepam Klonopin Diazepam IV Valium Lorazepam IV Ativan Usual maximum 1-10 mg/day 1-10 mg/day 300 mg/day 60 mg/day 20 mg/day 40 mg/day 8 mg/day Review after 6 months 6 months 6 months 6 months 6 months 6 months 6 months Typical dosing 5-20 mg BID 10 mg/day 10 mg/day 10-70 mg/day 5-20 mg BID 10-20mgAM 20 mg/day 20 mg/day 18-54 mg/day 30 mg/9hr Usual maximum 40-60 mg/day 20 mg/day 20 mg day 70 mg/day 60 mg/day 60 mg/day 60 mg/day 60 mg/day 72 mg/day NTE 2 mg/kg 30 mg/9hr Review after 2 years, then indefinite 2 years, then indefinite 2 years, then indefinite 2 years, then indefinite 2 years, then indefinite 2 years, then indefinite 2 years, then indefinite 2 years, then indefinite 2 years, then indefinite Wakefulness medications Generic name Class Brand name Armodafinil Nuvigil IV IV Provigil Modafinil Typical dosing 150-250 mg/am 100-200 mg/day Usual maximum 250 mg/am 400 mg/day Review after 2 years, then indefinite 2 years, then indefinite Anticonvulsants Generic name Pregabalin Typical dosing 150mgBID/TID Usual maximum 600 mg/day None (not for psych use) Typical dosing 3-6 mg/day 3-6 mg/day 10-25mgTID/QID 10-25 nig TID/QID l-2mgBID/QID 2-10mgBID/QID 2-6 mg/day Psychos tim u la nts Generic name Amphetamine combo Dexmethylphenidate Dexmethylphenidate XR Lisdexamfetamine Methylphenidate Methylphenidate LA Methylphenidate SR Methylphenidate ER Methylphenidate CR Methylphenidate patch Class II II II II II II II II II II Class V Brand name Adderall Focalin Focalin XR Vyvanse Ritalin, Methylin Ritalin LA Ritalin SR Metadate CD/ER Concerta Daytrana Brand name Lyrica Maximum duration Hypnotics Generic name Chloral hydrate Eszopiclone Flurazepam Temazepam Triazolam Zaleplon Zolpidem Zolpidem CR Class IV IV IV IV IV IV IV IV Brand name Noctec Lunesta Dalmane Restoril Halcion Sonata Ambien Ambien CR Typical dosing 500 mg HS 2mgHS 7.5-30 mg/HS 7.5-30 mg/HS 0.25 mg/HS 5-20 mg/HS 5-10 mg/HS 12.5 mg/HS Usual maximum 1 gmHS 3mgHS 30 mg/HS 30 mg HS 0.25 mg/HS 20 mg/HS 10 mg/HS 12.5 mg/HS Maximum duration41 3 months 3 months 3 months 3 months 3 months 3 months 3 months 3 months [*Does not include occasional use in DD population if only used prior to medical or dental procedures] Opioid dependence therapy Generic name Class Buprenorphone/Naloxone III Brand name Suboxone Typical dosing <12mg/day Usual maximum 16mg/day Maximum duration111 6 months REQUEST FOR EXCEPTION TO PRACTICE GUIDELINES FOR CONTROLLED MEDICATION z Requested by: u Consumer Name: Date: D O I < Applicable CMHOC Practice Guidelines: O Ik O D Prescriber will prescribe a reasonable trial of one or more non-addictive medications before any controlled substance is prescribed regardless of patient's history elsewhere. D If controlled substances are prescribed; they will be time-limited, as indicated in the medication dosage and duration table. Consumers who are tried on several medications will still be subject to the overall time limits. Consumers using controlled substances must be actively engaged in treatment; including groups, individual or other services (including engagement, if pre-contemplative) as recommended by their treatment team. D Controlled substances will not be replaced if lost of stolen, nor refilled early. D Medications with opposing effect, or those with potential additive effects, many not be prescribed at the same time (i.e. sleep medications or anti-anxiety medication for someone taking a stimulant; or anti-anxiety medication and pain medication, or others with tranquilizing effects). n Consumers must have a Primary Care Physician within 3 months of initiating medication services, if CMHOC prescribes medication. Medication information: z 3 2 5 O O Name and dosage of medication for which exception is requested: Date started: (Circle: actual/estimated) Started by: at Continued by requesting prescriber since: Relevant diagnoses: CMHOC - Exception for Controlled Medication - 03/5 -101 - Ml- 07/16/11 Case Number: REQUEST FOR EXCEPTION TO PRACTICE GUIDELINES FOR CONTROLLED MEDICATION Check all that apply to this individual: 3 O u O Has a history of substance abuse O Has used illegal substances within the past year O Has requested early refills of controlled medications within the past year O Has reported "lost" or "stolen" controlled meds within the past year? H] Has history or known attempt to seek controlled medication from different prescriber while receiving them from CMHOC. CD Is currently receiving controlled medications from another prescriber. I Other options tried: HU Alternate medications 0 Alternate individual treatment (i.e. individual therapies) 1 I Alternate group supports (i.e. Dual Diagnosis Group, AA, NA, etc) O U. Please comment on the above, including approximate dates, span of treatment and response. Include attempts to wean or discontinue above medication. O X H In the space below, please give detailed rationale for continuing this prescription as written: Treatment team comments/recommendations summary (to be completed by Team Supervisor). ill 2 Following presentation of case at Medical Staff Meeting, CMHOC prescribing staff will record their comments, suggestions and recommendations with date and signature below. MEDICAL STAFF RESPONSE Signature:, Date: D Approve n Disapprove O Comments: O CMHOC - Exception for Controlled Medication - 03/5 -101 - Ml- 07/16/11 Case Number: REQUEST FOR EXCEPTION TO PRACTICE GUIDELINES FOR CONTROLLED MEDICATION \: 2 "• D Approve ] Disapprove ** Comments: U ^ Signature: Date: ^f D Approve n Disapprove ^m Comments: O IL W Signature: Date: ^m D Approve D Disapprove •• Comments: u X I Signature: ^" H Date: Team Nurse n Approve n Disapprove Comments: S Lm ^^ Signature: Date: Medical Director D Approve n Disapprove Comments: O u CMHOC - Exception for Controlled Medication - 03/5 -101 - Ml- 07/16/11 Case Number: REQUEST FOR EXCEPTION TO PRACTICE GUIDELINES FOR CONTROLLED MEDICATION > I" Z D SUMMARY OF CONSENSUS AGREEMENT (completed by Medical Director) O O I RE-EVALUATE CONSUMER'S USE OF THIS MEDICATION ON: IL O K < Z O O CMHOC - Exception for Controlled Medication - 03/5 -101 - Ml- 07/16/11 Case Number: 6. Letter to Consumers Regarding Controlled Medications a. The letter below is printed on CMHOC letterhead paper and given to consumers eligible for psychiatric services at CMHOC by Access Clinican completing assessment interview. b. The information provided in the letter will also be discussed by assigned MDT Therapist during pretreatment planning sessions and other team members when appropriate. Dear Consumers: Community Mental Health of Ottawa County has recently implemented a new set of Practice Guidelines for our medication practices. The guidelines were developed to add consistency in our medication prescribing, to be more consistent with Psychiatric Best Practices, and to better address our philosophy of treatment. The medications that will be effected by these guidelines are controlled substances and include: stimulants, benzodiazepines, hypnotics (for sleep), and other medications that may foster dependence. A list of some of these medications includes: Xanax Xanax XR Librium Tranxene Halcion Adderall Focalin Focalin XR Vyvanse Ritalin LA Lunesta Concerta Seconal Restoril Ritalin SR Valium Dalmane Ativan Klonopin Ambien Ambien CR Ritalin Provigil Other medications may also be affected but not listed above. Your prescriber will discuss your individual situation with you at your medication review appointment. If you are prescribed medical medications such as pain pills or muscle relaxers this may also impact the medications you will receive from us. Guidelines from both state and federal mental health sites note that short term use of these medications may be helpful but long term use is not recommended. The reasons for this are that the medications are not as effective after a few months and the potential for becoming dependent on them greatly increases. If an individual is taking the types of medications mentioned above and is actively using substances, such as: alcohol, street drugs, or certain pain medications, the potential for serious medical problems greatly increases. National and State guidelines are clear that for individuals with a substance abuse history use of these medications is not recommended. Your prescriber will be following recommended guidelines for dosages of these medications and will be limiting the length of time for these prescriptions. Other medications known to be effective but not addictive will be made available to you. In addition to medication we will encourage active participation in our therapy program. Everyone experiences uncomfortable or painful feelings at times and often people believe the medications will take those feelings away. However, medications are not intended to remove normal painful feelings. Medications are meant to help the person feel the painful feelings more accurately, and to facilitate the process of developing healthy coping skills. Our therapy program will help you develop coping skills and better manage your feelings. Sincerely, CMHOC Staff Community Mental Health Ottawa County Dr. Michael Brashears, Executive Director Dear Consumers: Community Mental Health of Ottawa County has recently implemented a new set of Practice Guidelines for our medication practices. The guidelines were developed to add consistency in our medication prescribing, to be more consistent with Psychiatric Best Practices, and to better address our philosophy of treatment. The medications that will be effected by these guidelines are controlled substances and include: stimulants, benzodiazepines, hypnotics (for sleep), and other medications that may foster dependence. A list of some of these medications includes: Xanax Xanax XR Librium Tranxene Halcion Adderall Focalin Focalin XR Vyvanse Ritalin LA Lunesta Concerta Seconal Restoril Ritalin SR Valium Dalmane Ativan Klonopin Ambien Ambien CR Ritalin Provigil Other medications may also be affected but not listed above. Your prescriber will discuss your individual situation with you at your medication review appointment. If you are prescribed medical medications such as pain pills or muscle relaxers this may also impact the medications you will receive from us. Guidelines from both state and federal mental health sites note that short term use of these medications may be helpful but long term use is not recommended. The reasons for this are that the medications are not as effective after a few months and the potential for becoming dependent on them greatly increases. If an individual is taking the types of medications mentioned above and is actively using substances, such as: alcohol, street drugs, or certain pain medications, the potential for serious medical problems greatly increases. National and State guidelines are clear that for individuals with a substance abuse history use of these medications is not recommended. Your prescriber will be following recommended guidelines for dosages of these medications and will be limiting the length of time for these prescriptions. Other medications known to be effective but not addictive will be made available to you. In addition to medication we will encourage active participation in our therapy program. Everyone experiences uncomfortable or painful feelings at times and often people believe the medications will take those feelings away. However, medications are not intended to remove normal painful feelings. Medications are meant to help the person feel the painful feelings more accurately, and to facilitate the process of developing healthy coping skills. Our therapy program will help you develop coping skills and better manage your feelings. Sincerely, CMHOC Staff 12265 James Street, Holland, MI 49424 (616)392-1873 • Fax (616) 393-5687 Qt Controlled Substance Guidelines Consumer Reactions <& CMHOC Recommended Resonses 1) Refusing to see a particular prescriber and/or demands to change prescribers. a. Staff explains there is (usually) only one prescriber option per team. b. Reinforce to consumer that all prescribers operate from same practice guidelines. c. Consumer's holder of record brings issue to next Team Meeting to get input from team regarding rationale and recommendation to change prescribers. i. Coordinate the transfer to an "alternate but equal" CMHOC MDT, if available, and consumer is agreeable to receive all CAAH services from alternate site. ii. Consumer has the option of finding a new community prescriber (at his expense) to prescribe his psychotropic medications Page two 2) Consumer demands controlled meds from prescribe!*. a. Prescriber calmly explains CMHOC Practice Guidelines, rationale <& plan for slow tapering to consumer. b. Prescriber stands firm in response to consumer demands. c. Prescriber may choose to do a MAPS search to check for the possibility of multiple controlled med prescribers. d. Consumer has option of making a complaint to Recipient Rights Officer, if desired. e. Consumer has option of finding a new community prescriber (at his expense) for psycho tropic medications. f. Prescriber utilizes "panic button" if consumer refuses to leave office. Page three 3) Consumer is adamant about wanting to continue controlled meds, but has no interest in stopping admitted substance abuse. a. Prescriber calmly explains rationale, but remains firm in only prescribing medications that safe with use of illegal substances. b. Prescriber may link prescribing practices to results of regular or irregular urine drug screens. c. Consumer has option of making a formal complaint to CMHOC Recipient Rights Officer. d. Consumer has option of finding a new community prescriber (at his expense) for psycho tropic medications. Page four 4) Consumer makes threats, either prospectively or retrospectively, that planned or actual decreases in controlled medications will (or have) resulted in increased substance abuse, suicide attempt, etc. a. Prescriber stands firm in only prescribing medications that are safe with the use of illegal substances. b. Prescriber may link prescribing practices to the results of regular, or irregular, urine drug screens. c. Therapist, Case Manager and Prescriber reinforce that each consumer has a right to make his own choices. Coach consumer in proper steps to take if that choice causes him/her serious problems, i.e. Call 911, go the hospital ER, etc. P. Medications Not Related to Mental Health 1. Only psychotropic medications to be prescribed: Prescribing professionals employed by or under contract with CMHOC shall not routinely prescribe medications except those specifically involved in the treatment of psychiatric disorders and side effects 2. Anti-Epileptic Drugs: Anti-epileptic medications will not routinely be prescribed, except when used for psychiatric diagnosis and/or for behavioral management. Anti-epileptic medications, when used for non-psychiatric convulsive disorders, will be referred to a neurologist or other physician. 3. Non-psychotropic medication may only be prescribed temporarily in situations where: a. The consumer is already using the medication b. Interruption of the medication might be potentially harmful c. No other source for obtaining the medication is readily available d. Medications are prescribed to treat a side effect (document rationale). Q. Substance Abuse 1. Alcohol and Other Drugs of Abuse Treatment, CMHOC Policy 4.23 2. Handling of Drugs, Weapons and Medications, CMHOC Policy 4.39 3. CMHOC Suboxone Procedure a. CMHOC Suboxone Treatment Contract b. Suboxone Patient Assistance Medication Log c. Suboxone Reimbursement COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY INDIVIDUAL CARE TO CONSUMERS CHAPTER: 4 SECTION: 21 Page 1 of 3 SUBJECT: INDIVIDUAL CARE TO CONSUMERS TITLE: ALCOHOL AND OTHER DRUGS OF ABUSE TREATMENT REVISED DATE: EFFECTIVE DATE: 12/15/95 11/28/01, 10/19/04, 12/7/04, 8/16/05, 8/7/07, 8/2/10 ISSUED AND APPROVED BY: vfltMwJl $wLt<4 ' -#sfcy. j) l EXECUTIVE DIRECTOR I. PURPOSE: In providing quality mental health care to consumers with developmental disabilities and/or mental or emotional disorders, a substance-related disorder is recognized as a limiting factor in achieving self-sufficiency and self-reliance. Therefore, Community Mental Health of Ottawa County (CMHOC) seeks to assess consumers for the presence of a substance-related disorder and to address the problem as needed. II. APPLICATION: To all CMHOC providers. III. DEFINITIONS: Substance abuse - Individual has never met the criteria for substance dependence and has a maladaptive pattern of substance use leading to significant impairment or distress, as manifested by one or more of the following, occurring within a 12 month period: a) recurrent substance use resulting in a failure to fulfill major obligation; and/or b) recurrent substance use in situations in which it is physically hazardous; and/or c) recurrent substance-related legal problems; and/or d) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of a substance Substance dependence - Individual has a maladaptive pattern of substance use leading to significant impairment or distress, as manifested by three or more of the following, occurring within a 12 month period: a) tolerance, b) withdrawal, c) the substance is taken in larger amounts or over longer period than was intended; d) there is a persistent desire or unsuccessful efforts to cut down or control substance use; e) a great deal of time is spent in activities necessary to obtain the substance; f) important social, occupational, or recreational activities are given up or reduced because of substance use; Substance Abuse 4.21 COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY INDIVIDUAL CARE TO CONSUMERS Page 2 of 3 g) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance IV. POLICY: It is the policy of CMHOC to maintain a cohort of staff who are properly credentialed as providers of treatment for persons with mental illness and co-occurring substance use disorders, and to be a provider of treatment for persons with mental illness and cooccurring substance use disorders. CMHOC embraces the notion that dual diagnosis is an expectation and not an exception, that CMHOC is the preferred provider of service for persons with serious mental illness and co-occurring substance abuse, that integrated treatment for mental illness and substance abuse is the preferred mode of service delivery, that both disorders should be considered primary, that both disorders should be treated within a philosophical disease and recovery framework, that there is no single correct intervention for individuals with co-occurring disorders, and that clinical outcomes for individuals with co-occurring disorders must be individualized and based on stages of change and phase of recovery. V. PROCEDURE: 1. CMHOC will strive to assure that all employees are welcoming of individuals with co-occurring disorders, and that staff who are providing services for individuals with co-occurring disorders will display an empathic and hopeful orientation with the individual. 2. At the time of request for CMHOC services, persons who are eligible for services based on their mental illness will be welcomed regardless of their alcohol or drug abuse or dependence. If a substance-related disorder is reported to be the primary reason for service in the absence of a co-occurring mental illness/emotional disturbance/developmental disability, a referral will be made to a community provider of treatment for substance use disorders. 3. At the time of the initial psychosocial assessment, individuals will be screened and assessed for substance use disorders. Service recommendations will be in accordance with the individual's stage of change and phase of recovery. 4. Individual and group services for persons with co-occurring disorders will employ motivational interviewing strategies, substance abuse counseling, and dual recovery support groups as appropriate to the individual's stage of change and phase of recovery. Substance Abuse 4.21 COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY INDIVIDUAL CARE TO CONSUMERS Page 3 of 3 5. Every crisis assessment will include an evaluation of the individual's current and past substance use and treatment history. A determination will be made as to whether there is evidence of substance abuse at the time of the assessment, and whether substance abuse impacts the individual's psychiatric condition. When substance abuse impacts the individual's psychiatric condition, the emergency worker will make recommendations for treatment that are in keeping with the individual's stage of change and phase of recovery. Inpatient detoxification will be recommended when the individual's substance use puts them at serious medical risk. 6. Psychiatric services: Medications for the treatment of substance-related disorders (e.g., Disulfiram, Methadone, Buprenorphine, Naltrexone) may be prescribed by Agency prescribers when privileged to do so. Consumers with an identified substance abuse history or current use may be referred for a substance use lab screen as indicated by the prescriber. Provision of necessary non-addictive medication for treatment of psychotic illness and other known serious mental illness will be initiated or maintained regardless of continuing substance use. Individuals whose substance use appears to be significantly risky will warrant closer monitoring or supervision, not treatment discontinuation. 7. Referrals to CMHOC by community substance abuse treatment providers will be accepted for mental health and/or integrated mental health and substance abuse treatment when it is determined that the individual meets eligibility criteria for CMHOC services. VI. ATTACHMENT: Revised Controlled Substance Education document VII. REFERENCE: The Michigan Department of Community Health Standards for Mental Health Services, and DCH Administrative Rules. Substance Abuse 4.21 COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY INDIVIDUAL CARE TO CONSUMERS CHAPTER: 4 SECTION: 39 Page 1 of 2 SUBJECT: INDIVIDUAL CARE TO CONSUMERS TITLE: HANDLING OF DRUGS,WEAPONS, AND MEDICATIONS REVISED DATE: EFFECTIVE DATE: 9/4/07,1/27/10,12/16/11 6-7-05 ISSUED AND APPROVED BY: Mt^wJ. ^J^LQ -^J) ' ' EXECUTIVE DIRECTOR I. PURPOSE: To establish policy and procedure that addresses the handling of items brought into CMHOC's program by the persons served and personnel. II. APPLICATION: To all Community Mental Health of Ottawa County (CMHOC) programs. III. DEFINITIONS: Legal Drug - A substance used in the diagnosis, treatment, or prevention of a disease or as a component of a medication that has been recognized or defined by the U.S. Food, Drug, and Cosmetic Act. Typically these are most commonly available to the general public and referred to as: 1. "over the counter" (OTC) medications 2. prescription medications (those prescribed by an authorized professional 3. Alcohol: The use of Alcohol in this country is legal. There are aspects of alcohol use (such as drinking alcohol before driving and public order offences involving alcohol) which are controlled by law, but generally the legal controls focus on the sale of alcohol to others. It is not against the law to produce alcohol in the form of beer or wine, but distillation is illegal. Illegal Drugs - are those drugs whose use is considered illegal by any individual in the United States (e.g. cocaine, crystal meth,) or prescription medications that have not been prescribed to the individual (e.g. narcotics prescribed to someone else). Weapons - are described as guns, knives, and any other implement brought to and/or used on the premises with intent to threaten or inflict harm on someone or something, or which can be viewed as threatening or harmful to someone or something. IV. POLICY: It is the policy of CMHOC to maintain a safe environment, in conformance with the law. V. PROCEDURE: 1. Consumers and staff who have a need to bring legal medications (with the exception of alcohol) onto the premises of any CMHOC program must have those medications in the original container. These medications must be held by the Handling of Drugs, Weapons, and Medications 4.39 COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY INDIVIDUAL CARE TO CONSUMERS Page 2 of 2 consumer or staff to whom they are prescribed, or in keeping with guidelines contained in the Medication Committee Manual. These medications may not be distributed to anyone else (consumers or staff). 2. Illegal drugs are not permitted on the premises of any CMHOC program. 3. Alcohol is not permitted on the premises of any CMHOC program. 4. Weapons are not permitted on the premises of any CMHOC program. The only allowable exception is for on duty police officers who may carry firearms and/or other weapons in order to protect and serve the public. 5. Should any of the procedures 1-4 be violated, the appropriate incident report must be completed by any individual that has knowledge. 6. Failure to comply with any of the procedures 1-4 may result in: a. Suspension or termination of service to the consumer, and/or b. Disciplinary action for staff, and/or c. Report to law enforcement if harm or threat of harm is present. VI. ATTACHMENT: None applicable. VII. REFERENCE: CARF Standards; Ottawa County Personnel Policy and Procedure 40.000, CMHOC Medication Manual Handling of Drugs, Weapons, and Medications 4.39 3. CMHOC Suboxone Procedure A. Prescribing Staff 1. Prescribers require special certification. 2. Two physicians should share on-call duties for these patients. 3. Other opiates (e.g. Vicodin) cannot be prescribed for the treatment of opiate withdrawal. 4. Activity Code = H0033 (oral medication administration, direct observation) B. Patient Eligibility 1. Suboxone treatment is a planned component to a comprehensive treatment plan that includes substance use counseling. Suboxone treatment is not available to a Meds-Only patient. The individual receiving Suboxone treatment should be receiving services in the CMHOC IDDT program. Psychosocial recovery is essential in addition to Suboxone medication. 2. Office-based induction should be available to those with mild to moderate withdrawal symptoms as measured by the COW Scale. 3. Withdrawal symptoms measured as greater than moderate (i.e. when a person becomes "dope sick") requires facility-based sub acute detox (refer to Shoreline for Medicaid and uninsured, or Pine Rest for insured). 4. One contingency for non-compliance is discontinuing the prescription ("give one chance to screw up"). 5. Relapse is to be expected as a normal part of recovery. 6. Hand select the first patients for Suboxone treatment for better outcomes (i.e. persons in the action stage of change). 7. Provide Suboxone for those not necessarily in the action stage, but who are in crisis and likely to be receptive to intervention (strike when the iron is hot, window of opportunity). 3. CMHOC Suboxone Procedure (Cont.) C. Cost and Funding 1. Local Holland K-Mart, Walgreens and Wal-Mart stores plan to carry Suboxone tablets. 2. Private insurance may cover the cost of Suboxone ($150-$300/month). 3. Lakeshore Coordinating Council will pay for counseling. 4. Suboxone requires prior approval for Medicaid to cover the cost. Access the prior approval form at www.michigan.fhsc.com. When completed, fax to number indicated on the form. If the individual has Medicaid but prior approval was not achieved, Medicaid will not pay for this medication. If, however, the individual received Medicaid coverage subsequent to the initiation of Suboxone treatment, Medicaid will pay retroactively. 5. The initial Medicaid authorization will be for 3 months. A secondary request can be made for an additional 2 months. It's meant to be a 5 month process for Medicaid consumers. If more than 5 months is requested, MDCH will be involved in the decision to authorize. 6. This is a fee-for-service arrangement, i.e. Medicaid will be billed directly for the cost versus coming out of capitated Medicaid dollars. 7. Prior approval requires that the individual be involved in formal substance abuse counseling. This can be through the prescribing psychiatrist, CMH or another substance abuse agency. 8. If discharged from the hospital on Suboxone, seek Medicaid approval if on Medicaid, or apply for patient assistance in conjunction with RESAT if uninsured. 3. CMHOC Suboxone Policy and Procedure (cont.) D. Induction and Maintenance Procedure 1. Service will be provided at the James Street CMHOC location only. 2. Induction will take approximate 1-1/2 hours. 3. Utilize family therapy room for induction period. 4. Show DVD on Suboxone to patient prior to induction. 5. Medical Procedure: a. Perform History & Physical b. Write prescription for Suboxone c. Send patient to pharmacy to obtain Suboxone d. Administer the COW Scale e. Instruct patient to drink water. f. Physician to administer drug sublingually g. Team Nurse to monitor B/P, Pulse & Respirations every 30 minutes after administration. h. Physician to continue administration of additional Suboxone until patient if "feeling good", usually a total of 8-12mgs. i. No eating, drinking or talking for the first 30 minutes after medication is given. j. Physician to see patient back for med checks on following days, up to one month later. Suboxone (cont.) k. Physician to provide script for interim period. Less than 2mg/day may result in cravings. I. Constipation is the most typical side effect. OD is almost impossible. 6. The longer the taper (i.e. 6-12 months) the better. 7. Transition out to community physicians those patients who have no mental health treatment needs once Suboxone has been successful. Community Mental Health of Ottawa County 12265 James Street Holland, MI 49424 393-5600 Fax: 616-393-5657 SUBOXONE TREATMENT CONTRACT Consumer Name Date As a participant in Suboxone® treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment contract as follows: 1. I agree to keep and be on time to all my scheduled appointments. 2. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and could result in my treatment being without any recourse for appeal. 3. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor's office. 4. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my Suboxone® filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without any recourse for appeal. 5. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit. 6.1 agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost. 7. I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating physician. 8. I understand that mixing Suboxone® with other medications, especially benzodiazepines ®« ®t ®t (for example, Valium , Klonopin , or Xanax ), can be dangerous. I also recognize that several deaths have occurred among persons mixing Suboxone® and benzodiazepines (especially if taken outside the care of a physician, using routes of administration other than sublingual or in higher than recommended therapeutic doses). 9.1 understand that medication alone is not sufficient treatment for my condition, and 1 agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan. 10. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances (excepting nicotine). 11. I agree to provide random urine samples and have my blood alcohol level tested. 12. I understand that violations of the above may be grounds for termination of treatment. Date Consumer Signature t Valium ^ a registered trademark of Roche Products Inc. Klonopin is a registered trademark of Roche Laboratories Inc. ® Xanax is a registered trademark of Pharmacia & Upjohn Company SUBOXONE PATIENT ASSISTANCE MEDICATION LOG SBATE PRESCRIBED FOR MEDICATION STRENGTH LOT NO. RECEIVED DISPENSED TOTAL INITIALS , Suboxone Reimbursement Consumer with Medicare, Part D Insurance Determine detailed information regarding Medicare, Part D policy, policy number Contact fax and/or phone numbers for insurance carrier Do they contract with an outside agency to do prior authorizations? Consult with CMH provider to determine diagnosis and other clinical evidence to make a case for Suboxone therapy Complete PA request form and fax to appropriate source. Allow a minimum of one week to obtain written response regarding coverage of Suboxone. Allow 2-5 additional days for pharmacy to order & receive Suboxone. This pharmacy order lead time may be needed for each refill of script. Consumer with Medicaid Insurance Determine detail information regarding Medicaid Policy Policy number Do they belong to a Medicaid HMO? Contact fax and/or phone numbers for insurance carrier Do they contract with an outside agency to do prior authorizations? Consult with CMH provider to determine diagnosis and other clinical evidence to make a case for Suboxone therapy. Utilize Michigan Dept of Community Health Pharmacy Program form (Suboxone specific) if have straight Medicaid. Complete PA request form and fax information to appropriate source. Allow a minimum of one week to obtain written response regarding coverage of Suboxone. Allow 2-5 additional days for pharmacy to order & receive Suboxone. This pharmacy order lead time may be needed for each refill of script. Suboxone Reimbursement (cont.) Consumer with Medicaid & Medicare, Part D Insurance Determine detailed information regarding both policies Policy numbers Do they belong to a Medicaid or Medicare HMO? Contact fax and/or phone numbers for each insurance carrier Do insurance carriers contract with an outside agency for prior authorizations? Consult with CMH provider to determine diagnosis and other clinical evidence to make a case for Suboxone therapy. Utilize Michigan Dept. of Community Health Pharmacy Program form (Suboxone specific) if have straight Medicaid. Complete PA request form and fax information to appropriate source(s). Submit request for prior authorization to Medicare, Part D carrier first. If Suboxone coverage is denied, then submit to Medicaid insurance carrier. Allow a minimum of two weeks for final determination by both carriers. Allow 2-5 additional days for pharmacy to order & receive Suboxone. This pharmacy order lead time may be needed for each refill of script. Consumer with Adult Benefit Wavier Determine policy number and demographic information Consult with CMH provider to determine diagnosis and other clinical evidence to make a case for Suboxone therapy. Complete Michigan Dept. of Community Health Pharmacy Program PA authorization form (Suboxone specific) and fax to First Health Services. Allow a minimum of one week for final determination of coverage. Allow 2-5 additional days for pharmacy to order & receive Suboxone. This pharmacy order lead time may be needed for each refill of script. Suboxone Reimbursement fcont.) Consumers Without Insurance Consumer may purchase the medication from pharmacy from own funds. o Allow 2-5 days for pharmacy to order & receive Suboxone. o This pharmacy order lead time may be needed for each refill of the script. Consumer may complete application and submit all required documentation for Reckitt Benckiser's Patient Assistance Program. o Team Nurse or CMA, will coordinate and submit completed applications package to Reckitt Benckiser. o Allow a minimum of four weeks after submitting all required information before we receive medication (if accepted on their program). o Each qualifying patient's physician will receive a monthly supply of Suboxone for up to 12 months (available as a 2mg or 8mg formulation) delivered directly to their DEA-registered office location. o It will be necessary for consumers to reapply six months following original application to see if they remain eligible for this program for an additional six month period. o See attached forms & information for additional details. R. Over-the-Counter (OTC) Medications 1. Over-the-Counter (OTC) Medications include vitamins, herbal products and many other drugs or medications that can be purchased without a prescription. 2. In residential settings and Community Based Education settings, OTC medications require a written prescription from a MD, DO, PA-C or NP licensed professional for staff to administer to residents/consumers. 3. OTC medications must be listed on InfoScriber, and included in the Medication Review or Psychiatric Evaluation report. It is required to include the drug name, strength, route, dosing instructions and the name of the prescriber. This is the responsibility of the prescriber. S. Prescriber Documentation 1. Psychiatric Evaluation a. All consumers will be requested to bring the original containers of all over-the-counter and prescription medications they receive from any prescriber, or take without prescriber approval, to their Psychiatric Evaluation appointment. b. Prescriber documentation will be completed utilizing the AVATAR CWS Psychiatric Evaluation format for the initial appointment with a new consumer. c. Prescriber will also complete a Psychiatric Evaluation if a consumer's case is reopened, and the previous Psychiatric Evaluation was completed more than one year prior. d. Psychiatric Evaluations for children and adolescents will be scheduled for 90 minutes. e. Psychiatric Evaluations for individuals over the age of 18 will be scheduled for 60 minutes. Psychiatric Evaluations The Psychiatric Evaluation is a stand-alone document reflecting a thorough assessment and description of the consumer's current and historical circumstances as they relate to his/her mental illness, medical conditions and significant psychosocial factors. It should reflect a high degree of professionalism. It will include presenting problem with current signs and symptoms, medical history, family history, treatment history, results of a mental status exam and document any medication side effects that are currently present or have resulted in problems in the past. A diagnosis of Axis I-V will be documented, as well as rationale for all treatment recommendations and psychotropic medications prescribed. • • • • • • • • • Psychiatric Evaluations must be finalized within 14 days of the face-to-face contact. All sections of the Psychiatric Evaluation template must be completed. If the section does not apply to the consumer, indicate "Assessed, none noted" or a similar statement. All narrative sections must include a complete statement that summarizes the consumer's current condition. A statement that the evaluation is a face-to-face meeting shall be included. Use full sentences. Use spell check. Use correct grammar (e.g. if pronouns are used, ensure that the reader knows to whom you are referring). Include a listing of all OTC medications/herbals and prescriptions medications ordered by other medical health professionals, including the name, dose, directions and name of the prescribing professional (InfoScriber). Ensure that adequate medication refills are authorized to last until the consumer's next psychiatric appointment (InfoScriber). Communicate to the consumer and document when the next psychiatric appointment should be scheduled. Obtain consumer's signature on Medication Consent form and provide adequate education for all prescribed medications. Sign & complete all appropriate blank spaces on form. Obtain consumer's signature on Controlled Substance Contract when required. Order lab work as needed to assess the consumer's response and assure safety of prescribed medications. Answer all "Yes - No" questions. PSYCHIATRIC EVALUATION CLIENT NAME >• z 3 O O < Date: Start Time: CASE COORDINATOR Stop Time: IDENTIFYING INFORMATION / DIAGNOSTIC RATIONALE / SIGNS AND SYMPTOMS PRESENTING PROBLEM MEDICAL HISTORY I FAMILY HISTORY MENTAL STATUS EXAM SIDE EFFECTS o u. O X H < UJ DIAGNOSIS Axis I Axis II Axis III Axis IV Axis V TREATMENT RECOMMENDATIONS CURRENT PSYCHOTROPICS CONTINUATIONS X < EFFECTIVE DATE CHANGES DOSAGE # REFILLS DOSAGE # REFILLS UJ 5 Ez 3 5 OTHER MEDICATIONS (Including non-psychiatric medications, herbs, over the counter, etc.) Is notification to the primary care physician and/or other service provider required as part of this status report or goal? yes no nsumer/family advised of potential suicide risks with antidepressant and/or anticonvulsant medication therapy. O yes Q no Q n/a RETURN VISIT O O Signature/Credentials: CMHOC - Psychiatric Evaluation- 03/7 - 046 - MI/DD - 04/22/09 Date: Case Number: 2. Medication Review a. After a Psychiatric Evaluation is completed, following appointments with a prescriber will be documented utilizing the AVATAR CWS Medication Review template. b. Medication Review for both children and adults will be scheduled for 30 minutes. Medication Reviews The Medication Review document should provide a thorough picture of the consumer's current mental status and response to treatment. It should reflect a high degree of professionalism. Documentation of the following should be included. • All sections of the Medication Review template must be completed. If the section does not apply to the consumer, indicate "Assessed, none noted" or a similar statement. • All narrative sections must include a complete statement that summarizes the consumer's current condition. • Document whether the consumer is taking all medications as prescribed. If not, summarize current medication adherence & consumer's reported rationale. • Document that the medication review was a face-to-face meeting. • Document whether the consumer is having any current medication side effects. If so, describe symptoms and indicate which medication(s) may be associated. • If the consumer is taking antipsychotic medications (other than Clozaril only), document that AIMS testing was completed at least every three months. • Review any lab work results with consumer/guardian that were received since last psychiatric appointment. Document this action and any recommendations. • Review all Axis diagnoses, making changes when needed & including the rationale. • Document all psychotropic medication changes & rationale. • Document all consumer reported medication changes by other medical professionals (InfoScriber). Ensure that adequate medication refills are authorized to last until the consumer's next psychiatric appointment (InfoScriber). Update & complete Medication Consent form as needed. Order lab work, when necessary. Provide and document any medication-related or other education given to consumer/guardian when applicable. Answer all "Yes-No" questions. MEDICATIONREVIEW I CLIENT NAME CASE COORDINATOR I Date: Site of Service: z Start Time: Sjtpp Time: REVIEW OF PROGRESS/DIAGNOSTIC RATIONALE/SIGNS AND SYMPTOMS D o u MENTAL STATUS EXAM SIDE EFFECTS LABORATORY TEST REVIEW SIGNS AND SYMPTOMS OFTARDIVE DYSKINESIA (AIMS) •_ O l_ O JDIAGNOSIS Axis I Axis II Axis III/ Allergies "Axislv" Axis V CURRENT PSYCHOTROPICS CONTINUATIONS EFFECTIVE DATE CHANGES DOSAGE # REFILLS DOSAGE # REFILLS uj 5 OTHER MEDICATIONS (Including non-psychiatric medications, herbs, over the counter, etc.) Is notification to the primary care physician and/or other service provider required as part of this report ? Q yes D no Does face sheet need to be updated? D Yes Q No (e.g. Change in diagnosis, address, guardianship status, advanced directives) Consumer/family advised of potential suicide risks with antidepressant and/or anticonvulsant medication therapy. D yes D no D n/a PLAN: RETURN VISIT: Prescriber's Signature: CMHOC - Medication Review- 03/6 - 041- MI/DD - 04/22/09 Date: Case Number: 3. InfoScriber a. The prescriber is responsible for documenting the name, strength, route & dose of all medications prescribed by CMHOC. b. The prescriber is also responsible for documenting the name of the prescriber, medication name, strength, route & dose for any overthe-counter medications, as well as prescription medications prescribed to the consumer by other individuals. c. Team nurses will also update the InfoScriber allergy, pharmacy and listing of over-the-counter and non-CMH prescribed medications when identified through Nursing Assessments and/or communication with primary care providers. d. During the Psychiatric Evaluation appointment, is also the prescriber's responsibility to document on InfoScriber the consumer's Axis I & II diagnosis, allergies, CMHOC medication prescribed and the individual's chosen pharmacy. e. During follow-up Medication Review appointments, the prescriber will document all CMHOC medication changes, changes in diagnosis, changes in preferred pharmacy, new allergies and any changes in overthe-counter or prescription medications prescribed by others. COMMUNITY MENTAL HEALTH OF OTTAWA COUNTY OPERATIONAL GUIDELINE TITLE: RN Medication Review Appointments EFFECTIVE DATE: REVIEW DATES: AUTHORED BY: Barb Sychowski, RN BSN SUBJECT: Protocol for medication review appointments with a licensed professional nurse (RN) SCOPE: Consumers determined to have currently stable mental illness symptoms by a CMHOC psychiatrist, nurse practitioner or physician assistant assigned prescriber PURPOSE: Preserve limited Psychiatrist/NP/PA-C appointments for consumers dealing with unstable mental illness symptoms and/or medication related issues. Reduce agency cost of providing medication review appointments at CMHOC while maintaining quality of reviews. PROCEDURE: Prescriber identifies consumer as appropriate for RN Medication Review appointment. Prescriber discusses with consumer the plan for follow-up appointment with Treatment Team RN at conclusion of current appointment. Prescriber emails Treatment Team RN to communicate the plan for RN Med Review and recommendation of interval when consumer should next be scheduled. Prescriber includes in Plan portion of documented Med Review that consumer will schedule next appointment for RN Med Review. Plan will include any recommendations for titration or tapering of prescribed medication, plan to alternate prescriber and RN med reviews vs. one time only appointment, any plan to refer consumer to primary care provider, any plan for routine seasonal medication changes or other appropriate orders. RN Medication Review appointments may be for one time only or alternate with Prescriber Med Review appointments. No successive RN Med Review appointments will be scheduled. Team Support Staff will assist consumer to schedule a 30 minute appointment in the appropriate nurse's Lotus Notes calendar at the interval requested by the Prescriber. RN will utilize current AVATAR CWS Medication Review screens to document details of appointment and bill for services via Client Charge Input for applicable number of face to face minutes utilizing code T1002. RN will initiate a CWS Medication Request progress note, forwarded to referring prescriber, advising of completed RN Med Review, requesting any medication refills needed and/or communicating any concerns/issues regarding the consumer.

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Download CHAPTER VII. VII. Prescribing Psychotropic drugs