CHHS16/039

Canberra Hospital and Health ServicesOperational Guideline Step-Up Step-Down Residential ProgramsContents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Background........................................................................................................................... 2

Key Objective........................................................................................................................ 2

Scope........................................................................................................................................ 2

Section 1 – Referral Processes..................................................................................................2

Section 2 – Medication Alliance................................................................................................4

Section 3 – Considerations for people who are stepping up versus stepping down.................7

Section 4 –Self Management of Medication.............................................................................8

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.......................................................10

References.............................................................................................................................. 11

Search Terms.......................................................................................................................... 11

Attachments............................................................................................................................12

Attachment A – Referral form for ASUSD Program.............................................................13

Attachment B – Referral form for YSUSD Program.............................................................19

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Guideline Statement

BackgroundMental Health, Justice Health, Alcohol and Drug Services (MHJHADS) provides residential services to people who require a higher level of treatment, care and support than is otherwise available in their usual home environment.

The Step-Up Step-Down (SUSD) service is provided in partnership with Wellways which provides a stepped care (as a step down from hospital admission or a step up from the community setting) model.

Two residential programs form part of this model of care: Youth Step-up Step-Down (YSUSD), a six bed program for young people aged between

18 to 25 years Adult Step-up Step-Down (ASUSD), a five bed program for adults aged between 26 and

65 years (over 65 will be considered on an individual case basis).

Key ObjectiveThis guideline articulates the referral and triage pathways for both programs and also sets out the role of staff across both settings.

The document includes sections on medication for people in the program and guiding principles for the promotion of self-management of medication.

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Scope

This guideline outlines procedures for MHJHADS and Wellways staff.

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Section 1 – Referral Processes

Adult Step-up Step-DownClinical Managers or members of the treating team will complete the requisite referral (Attachment A) and scan and email to AdultSUSD-CNC@act.gov.au. It is important that relevant supporting documentation is attached as part of the referral, including a copy of the person’s recovery plan, outcome measures, Advance Agreement (if available) and Advance Consent Direction (if applicable).

Urgent referrals can be made by phoning the ASUSD Clinical Nurse Consultant (CNC) on Mobile: 0432 753 420.

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The role of the ASUSD CNC is to review referrals and ensure the person referred meets the minimum criteria for entry to the program. These criteria include: Multiple and simultaneous care needs including psychosocial, disability support and

clinical interventions High level care needs that cannot be met in the community and which do not require

the monitoring and management of an in-patient setting Ability to attend to activities of daily living with support from Wellways staff Residence within the ACT geographical catchment area Aged between 26 and 65 (over 65 considered on a case by case basis), Involvement of an assigned Clinical Manager from MHJHADS (prior to entry), and Capacity to comply with facility policy including the capacity to participate in therapeutic

programs and interact appropriately with other participants

The CNC will conduct a brief initial assessment of the person and/or a review of the clinical file. The CNC is able to accept a referral, in consultation with and on behalf of Wellways. Referrals will be discussed in an open and transparent way allowing for joint decision-making between agencies.

The CNC will make an entry on the person’s electronic clinical record (MaJICER) about the outcome of the referral and subsequent assessment for suitability.

Clinical Managers will be consulted when additional information about the referral is required.

The CNC will maintain a database for the program and provide regular monthly reports to senior management and other stakeholders. The CNC will also: Regularly review people for side effects of medication Assess the efficacy of the PRN (pro re nata – whenever necessary) medication Engage in educative and consultative activities with stakeholders.

Youth Step-up Step-DownInformation outlined above is also applicable to the youth program. The two exceptions are that Clinical Managers or members of the treating team will complete the requisite referral (Attachment B) and scan and email to the Youth CNC.

Urgent referrals can be made to the Youth CNC on mobile number: 0481 006 496

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Section 2 – Medication Alliance

There are two components to the Medication Alliance: monitoring of medication and the active promotion of self-management of medication.

Medication MonitoringGuiding principles for medication monitoringSUSD Staff are to follow the principle of the ‘5 Rights’ acknowledging that they oversee the person taking the medication from the Webster Pack or Dosette box, but they are not responsible for its administration.

1. Right Webster Pack/pill box2. Right Person3. Right use of the Webster Pack/pill box (i.e. the medication is taken from the correct bay

for the day and time)4. Right route (can only observe oral medication, including the person’s ability with taking

and swallowing medication, and noting any suspicion of person diverting medication)5. Right documentation.

Practical considerations for accessing, storing and dispensing medicationEach person in the program will have an individualised Webster Pack which clearly identifies their name, date of birth and the medication contained.

Circumstances may arise where a Dosette box will be used for a short period of time. The Dosette box will be clearly labelled with the person’s name and date of birth and the medication contained within it. In circumstances when a Dosette box is required, the CNC will be notified with a view for ensuring that the CHHS Medication Handling Policy is adhered to.

Examples of when a Dosette box may be needed are: If the person is having urgent or immediate adjustments to their medication regime Where the need exists to monitor use and access of PRN medication, which should be

made up into a Webster Pack as soon as practical.

The CNC will organise the Webster Pack and ensure the supply of this medication when the preferred chemist is used.

If an alternative chemist is used, the Clinical Manager (or other representative) is responsible for the supply and delivery of the Webster Packs to SUSD staff.

Medication that is stored on-site must be kept in a locked cabinet that only staff and the CNC have access to.

People who are self-managing their Webster Pack are to keep the Webster Pack in the locked cabinet in their room, which is to be locked at all times. Doc Number Version Issued Review Date Area Responsible PageCHHS16/039 1 29/02/2016 01/07/2018 MHJHADS 4 of 25

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If an unplanned exit occurs and staff have not been able to consult with the person’s Clinical Manager, CNC or other MHJHADS clinical staff; only one day of medication will be given to the person. The person’s Webster Pack will be delivered to the Adult Community Team or the Crisis Assessment Treatment Team (CATT) on the following day.

In some cases the pack will be given to a responsible adult (for example an individual aged 18 years or older who is the nominated person, partner, carer or guardian of the person within the SUSD program

Ongoing supply of the Webster PackPreferred Chemist used by ASUSD Program is Lyneham Capital Chemist Open Monday to Friday (9am to 5pm) and half day Saturday (10am to 3pm)Phone: (02) 6247 7004FAX: (02) 6249 8912Email: lyneham@capitalchemist.com.au Attention: Chemist in Charge

Preferred Chemist used by YSUSD Program is Capital Chemist WanniassaOpen Mon to Sun (9am till until 9 pm)Phone: (02) 6231 6446Fax: (02) 6231 9716Email: wanniassa@capitalchemist.com.au

At the Preferred Chemist: Wellways staff are able to assist the person when filling of prescriptions and accessing

the requisite Webster Pack as required The Clinical Manager will organise and provide prescriptions as needed All prescriptions are to be held at the chemist The CNC will advise the chemist of Webster Packs that are required on a weekly basis.

At all other chemists: The Clinical Manager is responsible for organising and supplying Webster Packs and

engaging in quality record keeping practices on the person’s electronic record (MaJICER).

Note:

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Medications that require refrigeration for storage cannot be held at either SUSD or YSUSD residential programs.

Liquid forms of medication cannot be monitored by community agency staff at either SUSD or YSUSD residential programs and are not advised for use there, if possible.

For any exceptions to the above the relevant CNC can be contacted for advice. Supply of Webster packs can vary depending on whether an individual is stepping up

(i.e. from a community setting) or stepping down (i.e. being discharged from hospital setting).

Changes in the medication regime to a Webster Pack while in useWhere possible, any changes in medication will be scheduled to take effect on the same day that the next Webster Pack is to be made up and are the responsibility of the person’s treating team.

Any urgent or immediate changes in medication are to be bought to the attention of the CNC via phone or email communication by the treating team.

Recommendations for PRN medication managementThe CNC or other Registered Nurse from MHJHADS is able to take a phone order for STAT (statim – at once/one off dose of medication) or PRN medication.

The use of PRN medication is to be kept to a minimum and a separate Webster Pack to be used whenever possible. The CNC will write on the PRN medication sheet the name of the medication and any directions for its use.

Staff can recommend to the person to take PRN medication once in a 24 hour period. For any further dose of the PRN medication staff will need to consult with the CNC, or Clinical Manager during business hours or the Crisis Assessment and Treatment Team (CATT) Team outside of business hours.

The Clinical Manager or representative is to review the person’s mental state and response to the PRN medication, unless negotiated otherwise with the CNC.

If continual use of PRN medication is occurring, the person may need to be reviewed by their treating doctor within 5 working days - the Clinical Manager or representative is responsible for organising this review.

Monitoring response to medicationMonitoring the medical status of a person is a core part of the holistic care provided in the SUSD service.

Wellways staff, in collaboration with clinical managers and the CNC, will facilitate a person’s regular contact with general practitioners (GPs) and any other appointments required to maintain good physical health.

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Pathology tests may be required for the prescribing of some medications (ie. mood stabilisers and clozapine) or for routine investigation (ie. diabetes or other health issues) or for other screening purposes. The community treating team is responsible for coordinating this activity.

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Section 3 – Considerations for people who are stepping up versus stepping down

Step-Down - Being discharged from an adult inpatient setting

Note – Transfers to the ASUSD program occur between 1000 and 1500 Mon-Fri (excluding PH), unless negotiated otherwise with the CNC.

Prior to discharging the person, Adult Mental Health Unit (AMHU) staff will:

Supply one Webster Pack from the hospital pharmacy or

Fax a copy of the discharge medication to the Preferred Chemist and work collaboratively with the CNC to advise the person of expected costs for establishment of the Webster Pack or

If the patient is using their own chemist, staff will fax a copy of the Discharge Medication to their Nominated Chemist, and advise the patient of the potential cost.

Supply at least one month of outside prescriptions for ALL discharge medication (ie prescriptions that can be used in the community)

Inpatient Team to update the medication tab on MaJICER (AMHU will decide who in their team is best placed to do this)

Provide a copy of the person’s discharge medication sheet to the program (this can be done by handing it to the CNC or ASUSD worker on transfer/pick up of the person; or scanning and emailing to the CNC)

Prior to discharging the person, Calvary 2N will:

Work collaboratively with the CNC to advise the person of expected costs for the establishment of the Webster Pack

Fax a copy of the discharge medication to the Preferred Chemist or

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If the patient is using their own chemist, fax a copy of the Discharge Medication to their Nominated Chemist, and advise the patient of the potential cost.

Supply at least one month of outside prescriptions for ALL discharge medication (ie prescriptions that can be used in the community)

Update the medication tab on MaJICER (2N will decide who in their team is best placed to do this)

Provide a copy of the person’s discharge medication sheet to the program (this can be done by handing it to the CNC or ASUSD worker on transfer/pick up of the person; or scanning and emailing to the CNC)

Protocols for other facilities will be negotiated between the CNC and the Inpatient Ward or Facility, recognising the above guidelines.

Step-Up - Being Stepped up from a Community Setting

The Clinical Manger or representative will:

Organise the Webster Pack prior to or on entry to the program (note - if the person arrives without a Webster Pack the program may not be able to accept them).

When organising the first Webster Pack at the preferred chemist, the Clinical Manager will advise the chemist if the Webster Pack is needed that day. The Webster Pack will usually be available that afternoon or the next day (dependent on when the call is made and relevant urgency).

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Section 4 –Self Management of Medication

Promotion of Medication Self-Management The aim is to empower and foster independence and the person’s capacity to self-manage their medication.

Wellways staff will work collaboratively with the CNC to support this recovery oriented practice in the program by embedding routines and prompts that sustain an individual’s sense of mastery.

The first step in the process is to assess a person’s suitability for self-management of their medication (see Attachment D.a). Consideration also needs to be given to any barriers to medication adherence (see Attachment D.b).

Developing a routine of for self-management of medication

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As much as possible any routines developed in the program will be sustainable and realistic for the person when they return home.

Administration times will be documented on the first medication chart and general principles are as follows: Morning medication is to be taken by 8.00 am – 9.00am (i.e. with breakfast) Midday medication is to be taken between 12.00pm – 2.00pm Evening medication is to be taken at the evening meal between 5.00pm – 8.00pm

(usually with the evening meal) Night medication is to be taken between 6.00pm-10.00pm (linking the medication in

with a bed time routine)

Factors to Consider when Assessing for Suitability for Self- Management of Medication

Has the person been self-managing medication prior to entry to the SUSD service? Have any Medication Alliance issues already been identified by the community team?

Has the person been having overnight leave or weekend leave from the inpatient facility? Have any Medication Alliance issues been identified by the inpatient team?

Are there any risk issues or vulnerabilities among other people in the program that may be escalated if the person is encouraged to manage their own medication?

Possible Barriers to Medication Adherence co-morbidity with alcohol and/or illicit drugs insight into their mental illness Complex dosing regimens or monitoring systems Inadequate understanding of their medications Poorly tolerated side-effects of medications Homelessness, inadequate security with on-going accommodation or lack of adequate

support in their accommodation Depressed mood, cognitive impairment or gross disorganisation

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Implementation

This guideline will be provided to all MHJHADS staff and is available on the ACT Health Policy Register for access at any time.

Copy of guidelines will be presented at Partnership Meeting and given to the relevant community organisations.

Current referrals forms will be sent out to all areas twice a year.

CNC will attend weekly at AMHU.

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90% of referrals are given to the appropriate SUSD program within 2 business days after being received by the CNC

Databases are up to date weekly to produce a monthly report A balance is maintained between Step-Up consumers and Step-Down consumers Utilisation of SUSD programs is at least 86% per calendar month (internal bench mark).

Method The CNC keeps a ‘minimal database’ that identifies entry and exit dates; age and gender;

bed days (for residential programs); current vacancies; Step-Up Step-Down ratio; legal status of the consumer; and admission rate to inpatient facilities from the individual programs

Documentation in the MHAGIC file of referrals received (both programs), outcome of the referral (residential program), and outcome of any individual assessment conducted by the CNC

CNC has appropriate professional consultation and supervision to review referrals and assessments as needed

Record keeping of weekly attendance and outcomes at referral review meetings with each SUSD Program

Submission of monthly and quarterly report to MHJHADS Weekly e-mail to the Patient Flow Nurse MHJHADS re: occupancy for the residential

program and current vacancies for the non residential program.

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Related Policies, Procedures, Guidelines and Legislation

PoliciesACT Health Child Protection Policy ACT Health Consent to Treatment PolicyCHHS Medication Handling Policy MHJHADS Smoke Free Environment Policy

ProceduresCHHS Clinical Handover ProcedureCHHS Consent to TreatmentMHJHADS Clinical Guidelines for Nicotine DependenceMHJHADS Significant Incidents ReportingMHJHADS Suicidal Behaviour – Risk Assessment, Treatment and Care of ConsumersTreatment Guidelines for the Initiation, Administration and Monitoring of Consumers on Olanzapine Long-Acting Injection (LAI) (SOP)Treatment Guidelines for the Initiation, Maintenance and Monitoring of Consumers on Clozapine (SOP).

Guidelines National Safety and Quality in Health Service Standards 2012National Standards for Mental Health Services (2010)Doc Number Version Issued Review Date Area Responsible PageCHHS16/039 1 29/02/2016 01/07/2018 MHJHADS 10 of 25

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LegislationMental Health Act 2015Work Health and Safety Act 2011Privacy Act 1988Discrimination Act 1991Children and Young People Act 2008Human Rights Act 2004Health Records (Privacy and Access) Act 1997

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References

Julius R, Novitsky M, Dublin W. Medication Adherence: A Review of the Literature. J of Psychiatric Practice 2009 Jan 15:1 34-44

Ascher-Svanum H, Ahu B, Faries D, et al. A prospective Study of Risk Factors for Nonadherence With Antipsychotic Medication in the Treatment of Schizophrenia. J clin Psychiatry 2006 July 67:7 1114-1123

Grunebaum M, Weiden P, Ofson M. Medication Supervision and Adherence of Persons With Psychotic Disorders in Residential Treatment Settings: A Pilot Study. J clin Psychiatry 2001 May 62:5 394-401

Wilk J, Marcus S, West J et al. Substance Abuse and the Management of Medication Nonadherence in Schizophrenia. The J of Nervous and Mental Disease 2006 June 194:6 454-457

Judson T, Owen R, Thrush C, et al. A Pilot Study of Barriers to Medication Adherence in Schizophrenia. 2004 Feb J clin Psychiatry 65:2 211-216

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Search Terms

SUSD, Step Up, Step Down, ASUSD, YSUSD, ACMHS, CAHMS, Wellways

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Attachments

Attachment A – Referral form for ASUSD ProgramAttachment B – Referral form for YSUSD Program

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Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval

This document supersedes the following: Document Number Document Name

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Attachment A – Referral form for ASUSD Program

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Attachment B – Referral form for YSUSD Program

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