PHARMACOLOGICAL MANAGEMENT/AOD MEDICAL/SOMATIC SERVICE

Purpose

To codify the Mid-Ohio Psychological Services, Inc. policies concerning the delivery of Pharmacological Management Service/AOD Medical/Somatic Service and establish the responsibilities of both the clinical staff and support staff for the delivery of this service.  

Policy

It is the policy of Mid-Ohio Psychological Services, Inc. to provide the highest quality, cost effective, and timely Pharmacological Management Service/AOD Medical/Somatic Service (psychiatric services) available within this community.  Pharmacological Management Service/AOD Medical/Somatic Services are designed, through face-to-face contact, to provide medical interventions, including physical examination, prescription or supervision of medication, and medical interventions to address the physical health needs of this agency’s client population.  

This service is provided by qualified mental health practitioners (as defined by the Ohio Department of Mental Health code 5122-23-04--specifically, a licensed physician who is qualified to provide psychiatric services or nursing staff, including Registered Nurses and Licensed Practical Nurses under the supervision of a licensed physician) and supported by competent support staff, all of whom are sensitive to the needs of the consumer (including varied ethnic/cultural backgrounds, disabling conditions, and social/physical environments that affect the person’s functioning).  

It is the responsibility of the Medical Director, in direct consultation with the Clinical Director, Executive Director, and Administrative Coordinator, to oversee the delivery of Pharmacological Management Service/AOD Medical/Somatic Services.  The Medical Director is responsible, with the assistance of the Clinical Director, for codifying the procedures for this service and for ensuring compliance by all staff with the established procedures, reporting any discrepancies to the appropriate staff personnel and the Executive Director.  The Medical Director is responsible for developing policies and procedures regarding medical services and medical components of activities including research, service evaluation and quality assurance and supervise medical services of the agency including medications and medical examinations for persons served.  

It is the responsibility of all clinical staff and support staff to provide immediate feedback to the Medical Director when any problems arise in the delivery of this service or when any areas for improvement are identified.  

It is the responsibility of the Quality Assurance Committee to review the provision of this service through established procedures to ensure the thoroughness, appropriateness, and effectiveness of service delivery.  

Procedures

Admission

All admissions to the Mid-Ohio Psychological Services, Inc. must first enter through the Mental Health Assessment/AOD Assessment process before initiating Pharmacological Management Service/AOD Medical/Somatic Services.  The time period involved in initiating Pharmacological Management Service/AOD Medical/Somatic Services depends on the nature of the problem, scheduling limits, hours of operation, and client attendance. Pharmacological Management Service/AOD Medical/Somatic services should be provided within 30 days of the time the service is requested.  

Intake

Intake usually begins when a client calls with a presenting problem.  Support staff are to complete an Initial Telephone Contact Form or a referral source must complete a Referral to MOPS Form.  The Initial Telephone Contact Form and/or Referral to MOPS Form will be reviewed by the Clinical Director or their designee and the case will be assigned to a clinician for assessment according to established guidelines provided by the Clinical Director.  During the initial phone intake, every effort will be made to determine the existence of any special needs including assistance with language, physical challenges or the potential impediments to the completion of an assessment and every effort will be made to address these concerns at no cost to the client.

The receptionist will make arrangements for the individual to be seen by a counselor for their Mental Health Assessment/AOD Assessment session, setting the appointment with appropriate consideration to the person's work schedule, place of residence, availability of transportation, and other valid circumstances; however, it is requested that, when possible, the assessment be conducted within seven working days of the initial contact.  At this point, the client will be informed of relevant fees for service.  The client is given/mailed an appointment card indicating the time, date, and day of the session, as well as the name of the counselor the client is scheduled to see.  The Receptionist notes the client's name in the computer scheduler for the time, date, and type of session (Mental Health Assessment/AOD Assessment).  If the client is in acute distress and in need of emergency services, the client will be referred to the community Emergency Services program as established by the Mental Health Board.  

When the client initially comes into the agency, they are asked to complete the Physical Health Assessment (self report) form, Psycho-Social History (self report) form, MACSIS Residence Verification Form, appropriate Outcomes Form, and Billing Authorization Form and to review the Client Guidelines and Client Rights Statement.  The client must complete these forms and sign the Authorization for Services portion of the Client Guidelines form prior to receiving any services.  These materials may be mailed to the client prior to the client first arriving to the office, when time permits.  The client must sign a statement indicating that they have received and reviewed the Client Guidelines and Client Rights Statement.  If a client is a minor or is under legal guardianship, the parent/legal guardian must sign the Client Guidelines, Client Rights Statement, and Authorization for Billing forms to provide authorization for services.  Upon completion of these forms, the person is then registered with the agency and the case is entered into the Master Log where an individualized client number is assigned to the case.

Client case numbers are based on the current year, month, date, and numerical sequence (Example:  For a person who registered on April 6, 1991 and is the third client to register that day, their individualized client I.D.  number will be 91-04-06-03).  The Master Log will then serve as a tracking device that follows the client's involvement in the agency through termination of service(s).  The billing clerk then enters the client information into the practice management software.  An Individualized Client Record (ICR)  is then organized, into which all of that client's records are placed and maintained.  At this time, the ICR will have at least the Phone Intake (or Referral to MOPS Form), Physical Health Assessment (self report) form, Psycho-Social History (self report) form, and Authorization for Billing and the signed portion of the Client Guidelines (Authorization for Services) and Client Rights Statement.   The Records Clerk will then organize the file, arranging to established procedures.  The file will then be affixed an identification label with the client's last name, first name, and middle initial, as well as his/her individualized case number.  The file is to be stamped with "CONFIDENTIAL" on its front cover.        

Mental Health Assessment/AOD Assessment

All clients must receive a Mental Health Assessment/AOD Assessment prior to receiving Pharmacological Management/AOD Medical/Somatic Services.  The Mental Health Assessment/AOD Assessment is either conducted according to the policies and procedures of this agency or is obtained from another agency through the transfer of an Integrated Client Record.  After the first session, a Plan of Action or Treatment Plan must be completed.  The Mental Health Assessment/AOD Assessment is complete when an Individual Service Plan (ISP) has been established or when it has been determined that mental health services are not necessary at this time.  The ISP must be signed by the client, the participating clinicians, and the clinical supervisor.  Mental Health Assessment/AOD Assessments should be completed by the second session but must be completed within the first four sessions or 30 days, whichever comes first. 

During the Mental Health Assessment/AOD Assessment, all the materials in the ICR are to be reviewed, appropriate collateral material obtained (with signed release of information forms), appropriate testing conducted, a complete psycho-social history gathered, and a mental status examination administered.  The clinician must also complete the MACSIS Intake Form and the appropriate Outcome Measure (as appropriate).

Case note for Mental Health Assessment/ AOD Assessment sessions must include a section addressing clinical formulation.  This clinical formulation section to the case note must include supporting data, evidence of sign and symptoms, and reasoning for the diagnosis that is being provided.

Pharmacological Management Service/AOD Medical/Somatic Service

Once the intake process is completed, the Mental Health Assessment/AOD Assessment has been completed, and it has been determined that Pharmacological Management/AOD Medical/Somatic Services are warranted, the client will be scheduled to be seen by a psychiatrist within thirty days.  Once the psychiatrist has determined that Pharmacological Management/AOD Medical/Somatic Services are indicated, the psychiatrist or a registered nurse (RN) will provide education concerning the potential benefits, side-effects, and risks of taking medication and will monitor the side effects and adverse reactions of medication which has been prescribed.  All clients will receive, in writing, information concerning potential side-effects of medication, potential aversive reactions, and appropriate action if they encounter a medication crisis situation or need to discuss their medications.  The person served and the parent/guardian, as appropriate, shall receive written and oral information in a language and format that may be standardized and that is understandable to the person receiving it concerning the anticipated benefits and side effect of the medication(s), including the results of not taking the medication(s), and of alternatives to the medication(s).  Persons served shall be given the opportunity to ask questions, seek additional information and provide input before medications are prescribed, administered or dispensed to them.  Documentation shall be kept in the ICR regarding the person’s participation in this process.   

Only a physician qualified to provide psychiatric services will be granted privilege to prescribe medication services and supervise medical services.  An RN may respond to a physician’s orders, dispense medication under a physician’s orders, monitor side effects and aversive reactions of medications, or conduct medication groups or classes.  

Face-to-face contact between the person served and a licensed physician shall be required prior to prescribing medication.  Any client who has been prescribed medication must be scheduled to be seen within sixty days for follow-up care.  No client will be seen on a crisis basis unless the physician is immediately available.  Any client in crisis will be referred to Emergency Services.  Telephone medical orders will not be accepted by a physician.  The Medical Director will be responsible for ensuring on-call coverage at all times.  All clients will be provided, a phone number for Emergency Services in order to contact the hospital to address their medication needs.  

As part of the Mental Health Assessment/AOD Assessment, every client will have a Physical Health Assessment completed.  The physician will communicate with the client’s case manager or other appropriate persons regarding pertinent aspects of the person’s physical health assessment, medication and somatic care, including but not limited to new prescriptions of medication, changes in medication, or dosage or administration schedule, and efforts to ensure on-going attention to medical or health concerns.  All medication information will be recorded on the Medication Summary Form in compliance with ODMH rule 5122-27-06 and the rationale for the medication decision will be recorded in a case note to be located in the ICR.  

Laboratory tests shall be performed, as applicable, for any person receiving a medication with potentially toxic or dangerous side effects, and generally recognized as requiring laboratory testing.  The results of such laboratory tests and monitoring shall be communicated to the person served and shall be recorded in the ICR. 

If it is concluded that a person is not capable of self-administering prescribed medication, the basis for this conclusion shall be recorded in the ICR.  This decision shall be reviewed in the ninety day ISP review process and a plan shall be developed to improve the person’s ability to self-administer medication.  A physician’s order shall be required for children and adolescents to self-administer medication.  Children for whom self-administration of medication is considered inappropriate shall have medication administer by an adult, including a parent, guardian, teacher.  Agency staff are not permitted to handle any medication for clients.  Assistance in self-administration of medication shall be limited to the following:

1)                  Taking medication from a locked storage area and handing it to the person;

2)                  Reading the label of the medication to the person served;

3)                  Opening or aiding with opening a container of medicine in the person is unable to do so;

4)                  Observation of persons as they self-administer medication to ensure the person follows directions on the container; and

5)                  Reminding the person of the schedule for medication.  

Individuals prescribing medication or providing information or education about the use of medication shall be educated regarding medication issues for persons such as children, elderly, minority populations, and persons with a severe mental disability or serious emotional disturbance.

Medication will be prescribed and pre-authorized in accordance with payer requirements whenever possible.  Vouchers for medications may be provided if available.  The use of vouchers will specifically be targeted in situations where generic medications are not available.

Mid-Ohio will not order, receive, or store medications on agency premises.

Termination

While the client  remains active in treatment/assessment, it is the responsibility of the assigned counselor to ensure the maintenance of the file and to report on the client's involvement to the referral source (when appropriate).  If  a client fails to appear for a session or fails to reschedule an appointment, it is the responsibility of the support staff to initiate the following procedures:  

1.                  Notify the clinician of the situation.

2.                  Attempt to contact the client to clarify their intentions and document said attempt.  This attempt should include at least one attempt to phone and one attempt to send a Missed Appointment Notification form.

3.                  Initiate a Termination Summary form, filling in the appropriate sections including # of sessions, name, attempts to reinitiate, etc. 

4.                  Have the counselor complete the Termination Summary form, MACSIS--Case Closure Form and have the clinical supervisor sign off.   

5.                  Place the ICR in the temporary inactive file.

6.                  After a reasonable amount of time, place the ICR in the file archives.  

Re-Admission

Any client who has not been in counseling contact with the program without prior notification for over six months will be required to be re-evaluated.  The type of re-evaluation will be determined by the counselor conducting the initial interview.  It may involve re-administering an evaluation device or may simply be a screening session.  The client will not pick up where he/she left off in treatment as had been outlined on the Individual Service Plan or Plan of Action.  Consequently, the client's case will be re-staffed by the counselor conducting the re-evaluation, and the appropriate recommendations will be made by the clinical staff relative to the results of the evaluation.  It is also possible that the initial diagnostic impression may be upgraded as a result of new or additional information.

In the event of a client applying for readmission after his/her case had been terminated the same case number will be maintained in the computer practice management system, however, the client will be assigned a new treatment episode/file number utilizing the same numbering system used to assign case numbers.

Any previous records that had not been destroyed (less than 10 years old) may be copied and placed in the new chart.  The old chart is to be maintained intact as an independent clinical chart.  

rev.5/2004

Last modified: December 20, 2007