Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 3.15 Psychotropic Medication: Prescribing and Monitoring

3.15.1 Introduction
3.15.2 Terms
3.15.3 Procedures
3.15.3-A. Basic requirements
3.15.3-B. Assessments
3.15.3-C. Informed consent
3.15.3-D. Youth and Psychotropic Medications
3.15.3-E. Psychotropic Medication Monitoring
3.15.3-F. Reporting requirements

3.15.3-G Complementary and alternative medicine (CAM)
3.15.4 References

3.15.1 Introduction
The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) has developed guidelines and minimum requirements designed to:

  • Promote the safety of persons taking psychotropic medications;
  • Reduce or prevent the occurrence of adverse side effects;
  • Promote positive clinical outcomes for behavioral health recipients who are taking psychotropic medications; restore and maintain optimal levels of functioning and achieve positive clinical outcomes;
  • Monitor the use of prescribed psychotropic medications to foster safe and effective use; and
  • To clarify that medication will not be used for the convenience of the staff, in a punitive manner, or as a substitute for other behavioral health services and shall be given in the least amount medically necessary with particular emphasis placed on minimizing side effects which otherwise would interfere with aspects of treatment, as stated in R9-21-207(C).

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3.15.2 Terms
Adverse Drug Event (ADE)

Adverse Drug Reaction

Behavioral Health Professional

Complementary and Alternative Medicine (CAM)

Cross-tapering

Medication Error

3.15.3 Procedures

3.15.3-A. Basic requirements
Medications may only be prescribed by T/RBHA credentialed and licensed physicians, licensed physician assistants, or licensed nurse practitioners. See Section 3.20, Credentialing and Recredentialing for more information regarding credentialing requirements.

Psychotropic medication will be prescribed by a licensed psychiatrist, psychiatric nurse practitioner, physician assistant, or other physician trained or experienced in the use of psychotropic medication. The prescribing clinician must have seen the client and is familiar with the client’s medical history or, in an emergency, the prescribing clinician is at least familiar with the client’s medical history.

When a client on psychotropic medication receives a yearly physical examination, the results of the examination will be reviewed by the physician prescribing the medication. The physician will note any adverse effects of the continued use of the prescribed psychotropic medication in the client’s record (see Section 4.2, Behavioral Health Medical Record Standards).

Whenever a prescription for medication is written or changed, a notation of the medication, dosage, frequency or administration, and the reason why the medication was ordered or changed will be entered in the client’s record (see Section 4.2, Behavioral Health Medical Record Standards).

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3.15.3-B: Assessments
Reasonable clinical judgment, supported by available assessment information, must guide the prescribing of psychotropic medications. To the extent possible, candidates for psychotropic medication use must be assessed prior to prescribing and providing psychotropic medications. Psychotropic medication assessments must be documented in the person’s comprehensive clinical record per Section 4.2, Behavioral Health Medical Record Standards and must be scheduled in a timely manner consistent with Section 3.2, Appointment Standards and Timeliness of Service. Behavioral Health Professionals (BHPs) can use assessment information that has already been collected by other sources and are not required to document existing assessment information that is part of the person’s comprehensive clinical record. At a minimum, assessments for psychotropic medications must include:

  • An adequately detailed medical and behavioral health history;;
  • A mental status examination;
  • A diagnosis;
  • Target symptoms;
  • A review of possible medication allergies;
  • A review of previously and currently prescribed psychotropic medications or other medications including any reported side effects and/or potential drug interactions and all medications (including medications prescribed by the PCP and medical specialists, OTC medications, and supplements) currently being taken for the appropriateness of the combination of the medications;
  • For sexually active females of childbearing age, a review of reproductive status (pregnancy);
  • For post-partum females, a review of breastfeeding status; and
  • A review of the recipient’s profile in the Arizona State Board of Pharmacy Controlled Substance Prescription Monitoring Program (CSPMP) database when initiating a controlled substance (i.e. amphetamines, opiates, benzodiazepines, etc.) that will be used on a regular basis or for short term addition of agents when the client is known to be receiving opioid pain medications or another controlled substance from a secondary prescriber.

Reassessments require the prescribing clinician of psychotropic medication to note in the client's record the following (see Section 4.2, Behavioral Health Medical Record Standards):

  • The reason for and the effectiveness of the medication;
  • The clinical appropriateness of the current dosage;
  • All medication (including medications prescribed by the PCP and medical specialists, OTC medications, and supplements) being taken and the appropriateness of the combination of the medications;
  • Any side effects such as weight gain and/or abnormal/involuntary movements if treated with an anti-psychotic medication; and
  • Minimum requirements as per 3.15.3-E;
  • Rationale for the use of two medications from the same pharmacological class;
  • Rationale for the use of more than three different psychotropic medications in adults; and
  • Rationale for the use of more than one psychotropic medication in the child and adolescent population.

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3.15.3-C: Informed Consent
Informed consent must be obtained from the person and/or legal guardian for each psychotropic medication prescribed. When obtaining informed consent, the BMHP must communicate in a manner that the person and/or legal guardian can easily understand. It is preferred that the prescribing clinician provide information forming the basis of an informed consent decision. In specific situations in which this is not possible or practicable, information may be provided by another credentialed behavioral health medical practitioner or a registered nurse.

The comprehensive clinical record must include documentation of the essential elements for obtaining informed consent (see Section 4.2, Behavioral Health Medical Record Standards). Essential elements for obtaining informed consent for medication are contained within PM Form 3.15.1, Informed Consent for Psychotropic Medication Treatment. The use of PM Form 3.15.1 is recommended as a tool to review and document informed consent for psychotropic medications. If PM Form 3.15.1 is not used to document informed consent, the essential elements for obtaining informed consent must be documented in the person’s individual comprehensive clinical record in an alternative fashion (see Section 4.2, Behavioral Health Medical Record Standards).

For more information regarding informed consent, please see Section 3.11, General and Informed Consent to Treatment.

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3.15.3-D: Youth and Psychotropic Medications

  • Youth under the age of 18 are to be educated on options, allowed to provide input, and encouraged to assent to medication(s) being prescribed. Information is discussed with the youth in a clear and age-appropriate manner consistent with the developmental needs of the youth.
     
  • The information to be shared should be consistent with the information shared in obtaining informed consent from adults.
     
  • Discussion of the youth’s ability to give consent for medications at the age of 18 years old is begun no later than age 17 years old, especially for youth who are not in the custody of their parents.
     
  • There should be special attention to the effect of medications on the reproductive status and pregnancy, as well as long term effects on weight, abnormal involuntary movements and other health parameters.
     
  • Evidence of the youth’s consent to continue medications after his/her 18th birthday may be documented through use of PM Form 3.15.1, Informed Consent/Assent for Psychotropic Medication Treatment, a recommended tool to review and document informed consent for psychotropic medications.

3.15.3-E: Psychotropic Medication Monitoring
Per national guidelines and to address the monitoring of psychotropic medications and metabolic parameters, the T/RBHAs must establish policies and procedures for monitoring of lithium, valproic acid, carbamazepine, renal function, liver function, thyroid function, glucose metabolism, screening for metabolic syndrome and movement disorders.

Medications prescribed for youth must be monitored for efficacy, side effects and adverse events at each visit with a registered nurse, physician assistant, psychiatric nurse practitioner, or physician.

3.15.3-F. Reporting requirements
ADHS/DBHS requires that T/RBHAs establish a system for monitoring the following:

  • Adverse drug reactions;
  • Adverse drug event; and
  • Medication errors

The above referenced events must be identified, reported, tracked, reviewed and analyzed by the T/RBHA. Providers within the Gila River RBHA must report adverse drug reactions and medication errors to the RBHA within 7 days of each occurrence. The Gila River RBHA reviews, tracks and trends data at least quarterly with findings reported to the Gila River RBHA Quality Management Committee.

An incident report must be completed for any medication errors, adverse drug event and/or adverse drug reaction that result in harm and/or emergency medical intervention. See Section 7.4, Reporting of Incidents, Accidents and Deaths for more information.

3.15.3-G Complementary and alternative medicine (CAM)
Complementary and alternative medicine (CAM) is not AHCCCS reimbursable.

When a BHP uses Complementary and Alternative Medicine (CAM), (see The Arizona Medical Board’s Guidelines For Physicians Who Incorporate Or Use Complementary Or Alternative Medicine In Their Practice) informed consent must be obtained from the person or guardian, when applicable, for each CAM prescribed (See PM 3.16, Behavioral Health Drug List). When obtaining informed consent, behavioral health medical practitioners must communicate in a manner that the person and/or legal guardian can easily understand. The comprehensive clinical record must include documentation of the essential elements for obtaining informed consent (see Section 4.2, Behavioral Health Medical Record Standards). Essential elements for obtaining informed consent for medication are contained within PM Form 3.15.1, Informed Consent for Psychotropic Medication Treatment.

The use of PM Form 3.15.1 is recommended as a tool to document informed consent for CAM. If PM Form 3.15.1 is not used to document informed consent, the essential elements for obtaining informed consent must be documented in the person’s individual comprehensive clinical record (see Section 4.2, Behavioral Health Medical Record Standards) in an alternative fashion.

3.15.4 References
The following citations can serve as additional resources for this content area:

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3.15 Psychotropic Medication: Prescribing and Monitoring
Last Revised: 7/31/2015
Effective Date: 7/31/2015

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