Transfer of stable public clinic opioid dependent …...3. KIT1: Transfer of stable public clinic...

KIT1Transfer of stable public clinic opioid dependent patients to GP prescribers.

State-Wide Advisory Team (SWAT) Drug Health Shared Care

Written by Dr. Adam Winstock Dr. Jill Molan

2.

KIT1: Transfer of stable public clinic opioid dependent patients to GP prescribers.

Written by Dr. Adam Winstock and Dr. Jill Molan

AcknowledgementsWorking group participants

Mr Jerry Bacich Central Sydney Division of General Practice

Ms Wendy Campbell The Alliance of NSW Divisions

Mr Steve Childs Senior psychologist and NSW Allied Health representative

Mr Sione Crawford NSW Users and AIDS Association

Dr Mark Hardy GP prescriber and HMO Affiliate at St George Hospital, Kogarah

Dr David Helliwell Public prescriber (North Coast AHS)

Mr Denis Leahy The Pharmacy Guild of Australia (NSW Branch)

Ms Khin Win May The Pharmacy Guild of Australia (National Secretariat)

Ms Jane McPhail GP/pharmacy liaison officer (Northern Sydney/Central Coast AHS)

Dr Christopher Mitchell General practitioner

Dr Michael Moore Central Sydney Division of General Practice

Ms Tricia O’Riordan Mental Health and Drug & Alcohol Office, NSW Health

Ms Wendy Pierpoint Nursing Unit Manager (Greater Western AHS)

A/Prof Alison Ritter National Drug and Alcohol Research Centre (Facilitator)

Ms Suzanne Robinson NSW Users and AIDS Association

Ms Meriel Schultz Australian General Practice Network

Mr Marc Reynolds Mental Health and Drug & Alcohol Office, NSW Health

Ms Carlene Smith The Pharmacy Guild of Australia (NSW Branch)

Ms Carol Stubley Nursing Unit Manager (South Eastern Sydney/Illawarra AHS)

Ms Jane Westley Australian General Practice Network

Dr Ross White Public prescriber (Sydney West AHS)

Ms Katherine Wiggins Mental Health and Drug & Alcohol Office, NSW Health

The authors wish to express their sincere appreciation to the following people:

• Themembersofthe‘PatientJourney’workinggroupfortheircommitmentandexpertcontributions;

• AssociateProfessorAlisonRitterforfacilitatingthe‘PatientJourney’workshopheldinFebruary2007;

• ThePharmacyGuildofAustralia(NSWBranch)forhostingandprovidingadministrativesupportfortheworkshop.

In addition, the authors would like to thank Dr Vince Roche for his contribution to the information on bulk billing, andMsKananGandechaforheradviceonrequirementsforunaccreditedprescribers.

The authors also wish to acknowledge Sydney South West Area Health Service and NSW Health who provided funding forthePatientJourneyproject.

Thisworkiscopyright.Itmaybereproducedfreelyinwholeorinpartforuseinclinicalsettingsorpatientservicedeliveryareas.Itmaybereproducedinwholeorinpartforstudyortrainingpurposessubjecttotheinclusionofanacknowledgementofthesource.Itmaynotbereproducedforcommercialusageorsale.

©NSWHealth2007

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3.



IntroductionWhat is the Kit for?

The Patient Journey Kit 1 will support general practitioners (GPs) working with other professionals and users to develop combined care and business plans for the management of opioiddependentpatients.

Use of this Kit will maximise the appropriate utilisation of existing care and referral pathways andwilloptimiseboththequalityofcaredeliveredtopatientsandthefinancialremunerationobtainedbythosedeliveringcareinthecommunity,specificallyGPs,butalsopharmacistsandalliedhealthprofessionals.

Kit 1 is also suitable for use by all public health care workers involved in providing treatment to patients on the Opioid Treatment Program (OTP) in NSW, and to people receiving treatment for opioiddependenceonthisprogram.

Inaddition,thisKitidentifiesthatitistheresponsibilityofallinvolvedtoensurethatthepatienthasapivotalroleinthetreatmentprovided.Patientconsentisnecessaryforthedeliveryofhighqualitycarebutalsofortheinformedsharingofinformationbetweenprofessionals.TheKitprovidespatientswithagenuineopportunitytobeanactivepartnerintreatment.

Background

The core objective of the State-Wide Advisory Team (SWAT) project was to increase the capacity ofpublicandcommunityservicestoprovidecaretothosewithopioiddependence.Integratingthe care of patients into community based services, such as GPs and community pharmacies, is part of the NSW Health Drug and Alcohol Plan2006-2010.

Althoughtherehasbeenanincreaseoverthelastfivetosevenyearsinthenumberofpatientsdosed at community pharmacies, the engagement of GPs in opioid treatment has remained persistentlylow.ThePatientJourneyKit1hasbeendevelopedtoincreasetheparticipationofGPsintheNSWOpioidTreatmentProgram(OTP).

Support Services

For patients (NSW) AlcoholandDrugInformationService(ADIS)Sydney0293618000 orforcallersoutsideSydney1800422599

For health professionals NSWDrugandAlcoholSpecialistAdvisoryService(DASAS)Sydney0293618006 orforcallersoutsideSydney1800023687

For GPs GP Psych Support provides GPs with patient management advice from psychiatrists within 24hourshttp://www.psychsupport.com.au

Theterms‘client’and‘patient’havebeenusedinterchangeablyaccordingtothecontextinthisdocument.

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http://www.psychsupport.com.au

4.



ContentsACKNOWLEDGEMENTS 2

INTRODUCTION 3

IMPORTANT NOTICES 5

COMMONLY USED ABBREVIATIONS 6

WHO CAN USE KIT 1 AND WHY 7

ROLES AND RESPONSIBILITIES 8

PART 1 Summary steps in planning care for a patient with opioid dependence 9

Flowchart 1 Patient Transfer from Clinic to GP 10

Flowchart 2 GP plans and schedule of appointments and reviews 11

Using a GP Mental Health Care Plan (GPMHCP) 12

PART 2 Detailed steps in planning care for a patient with opioid dependence 17

Step 1 Initial discussions about transfer 17

Step2 GPassessesfortransferandinitiatesGPMentalHealthCarePlan(GPMHCP) 18

Step3 GPrequestsHomeMedicinesReview(HMR)ofpatientandreceivesfeedback 21

Step4 GPreviewspatientinoneweekandcompletestransfer 22

Step5 GPreferspatienttoamentalhealthalliedhealthprofessional 22

Step6 Regularreviewappointments(GPMHCPorGPMPorTCA) 23

Step7 Reviewofplan(GPMHCPorGPMPorTCA) 24

Step8 AdditionalstepsforthedevelopmentofaGPManagementPlan(GPMP) 25

Step9 TeamCareArrangement(TCA) 25

Step10 GPMPandTCAreferraltoalliedhealth 25

Steps11-12 AsforSteps6-7 25

Next (possible but unlikely) step for a GP: Returning your patients to clinic care when unstable 26

ATTACHMENTS 27

TransferringaPatient’sDosingfromaPublicClinictoaCommunityPharmacy 27

TimeFramesforCarePlanningandReviews 28

AnExampleofMedicareItemsandRebatesfirst12months 29

SampleLetterfromClinictoClient 30

SampleLetterfromClinictoGP 31

StabilityAssessmentFlowchart 32

ThePatient’sPrioritiesforCare 33

GP:AssessingRiskandComorbidity 34

GP:PrescriberGoalsSpecifictoOpioidDependentPatients 35

GP:ProvidingReducingScriptstoMaintenancePatients 36

GP:ReviewProformaforOpioidDependentPatients 37

PatientReviewForm(PharmacyGuild) 38

MonitoringStabilityinCommunityDosedOTPPatientsbyPharmacists 39

PrescriptionShoppingProgram 40

MedicareUrineDrugScreenItemNumbers 40

Driving 40

LinkstoResources 41

5.



Important Notices

What if I do not routinely bulk bill?

Approximately one third of all patients on methadone or buprenorphine receive their treatmentthroughpubliclyfundedclinics,atnocost.Forpatientsattendingaprivateprescriberandapharmacy,thecombinedcost($30-35perweekforpharmacydosing,plus a gap payment for a consultation) may be prohibitive, especially in the early stages of treatmentortransfer,whentwotothreevisitsaweekmaybeoptimal.

Atatimeinpatients’liveswhenthingsaregoingwell,suchfinancialhurdlesmayjeopardise their ability to start or continue in treatment, as it impacts on their basic living requirements—especiallyiftheyareonbenefits.Allthisatatimewhenweareurgingthemtoavoidhighriskactivitiespreviouslyadoptedbysometofinancetheirillicitdruguse.Isthere another way?

We would respectfully ask GPs or practices that would not usually consider bulk billing to view patients on methadone or buprenorphine as possible (and very infrequent) exceptions totheirusualpractice.Infrequent?Atpresent,lessthan5%ofallGPsinNSWprescribemethadoneorbuprenorphine;inmostcaseswewouldexpectnoGPtohavemorethanoneortwopatientsonmethadoneorbuprenorphine.Afewexceptionsareunlikelytobreachthe levee bank—and potentially could make the difference for those with the health care problemofopioiddependence.

The SWAT team suggest that where possible optimal use of the care plans within a bulk billingframeworkcouldhaveatrulysignificantpublichealthimpactandareworthadopting:

• GPMentalHealthCarePlanItem2710100%MedicareAustraliaRebate$150.00

• GPManagementPlanItem721100%MedicareAustraliaRebate$124.95

• TeamCareArrangementItem723100%MedicareAustraliaRebate$98.95(TeamCare Arrangement with dispensing pharmacist and local drug & alcohol worker would meet these requirements)

•HomeMedicinesReviewItem900100%MedicareAustraliaRebate$134.10

The additional remuneration obtained by utilising these care plans, Home Medicines Review and other related item numbers will offset to some degree any loss incurred through bulk billing—aswellasimprovingcareandhealthoutcomesinthispopulationandtheirfamilies.

Prepared with the assistance of Dr Vince Roche, GP prescriber.

NEW DVD A new DVD information resource Access All Areas has been developed to answer questions frominandoutoftreatmentdrugusers.Itwillbeavailabletowardstheendof2007 Contact [email protected].

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mailto:[email protected]

6.



Commonly used abbreviations in this KitADIS Alcohol and Drug Information Service

AGPN Australian General Practice Network (formerly ADGP)

AHS Area Health Service

BBV Blood-borne Viruses

BDI Beck Depression Inventory

CDM Chronic Disease Management

DASAS NSW Drug and Alcohol Specialist Advisory Service

DoHA Department of Health and Ageing

DMMR Domiciliary Medication Management Review

EPC Enhanced Primary Care

FPS Focused Psychological Strategies

GPMHCP GP Mental Health Care Plan

GPMP GP Management Plan

HMR Home Medicines Review

K10 KesslerPsychologicalDistressScale

MBS MedicareBenefitsSchedule

MMP Medication Management Plan

MSE Mental State Examination

NUM Nursing Unit Manager

OTP Opioid Treatment Program

PAC Pharmacotherapies Accreditation Course

PBS PharmaceuticalBenefitsScheme

PG The Pharmacy Guild of Australia

PPC Patient’s Priorities for Care

PSB Pharmaceutical Services Branch of NSW Health

PSIS Prescription Shopping Information Service

PTSD Post Traumatic Stress Disorder

SF12 MedicalOutcomesStudyShortForm12

TCA Team Care Arrangement

SWAT State-Wide Advisory Team

UDS Urine Drug Screen

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7.



General Practitioners | GotoSteps2-124

The Kit provides details on how all GPs can apply existing plans for managing mental health and chronic medical conditions tothecareofapatientonanOTP.ThisKitaddressestheappropriate and coordinated use of the Medicare Better Access to Mental Health Care initiative item numbers, the Chronic Disease Management item numbers and the pharmacy Home MedicinesReview(HMR)incaringforthispatientgroup.

Providing the GP has access to specialist drug and alcohol support services, the GP may manage a small number (up to5)ofopioiddependentpatientswithoutcompletionofthePharmacotherapiesAccreditationCourse(PAC).Indoingthis, the GP will take on the role of the prescriber of opioid treatment as well as the provider of the patient’s primary healthcare.GPswhohavepracticenursesmayalsowishtoengage them in the development and implementation of managementplansforopioiddependentpatients.Inaddition,some GP practices may wish to employ a mental health nurse usingtheMentalHealthNursesIncentiveProgram.

Kit 1 will also guide GPs as to what they may expect from specialist drug and alcohol public clinic staff in terms of information processes and documentation for patient transfers, and in terms of ongoing support in caring for opioid dependent patients (see Returning your patient to clinic care when unstable).

Public Clinic Staff | Go to Step 14

Kit 1 will support public OTP clinic staff in identifying patients suitable for transfer to a GP and will provide guidance on working with patients to support and engage them in this process.Itwillalsoguidestaffastotheinformationexchangeprocesses needed, including the content and form of documentation,tofacilitatethetransfer.Theaimofthetransferis that the GP will take over prescribing from the public clinic prescriber,andalsotheplanningofcare.

Pharmacists | GotoStep34

Kit 1 will encourage community pharmacists to increase their level of involvement in the care delivered to patients receiving methadone, buprenorphine (Subutex®) or buprenorphine-naloxone(Suboxone®)attheirpharmacy.Thiswilloccurthrough the development of information exchange processes betweentheGP,thepharmacist,andthepatient.SpecificallyKit 1 provides details on how the Home Medicines Review can be utilised and appropriately integrated into GP care plans for thispatientgroup.ThroughtheHMRpharmacistscanprovideadditionalmonitoringandsupporttobothpatientandGP.A secondary outcome of Kit 1 may be the engagement of pharmacistsnotalreadyinvolvedinthedeliveryofOTP.

Consumers | GotoSteps1-124

Kit 1 informs patients of the nature of information to be exchanged between professionals involved in their care and it highlights how patientscanactivelycontributetotheirowncareplan.

Allied health | GotoStep54

Kit 1 provides information and guidance to a range of other health care workers, such as psychologists, social workers and occupational therapists who may be involved in the care of an OTPpatient.ProcessessupportingoptimalreferralfromGPstoalliedhealthworkersareidentifiedintheKit.

Other mental health professionals (nurses, Aboriginal Health Workers)

The Better Access initiative also makes provision for mental health nursesandAboriginalHealthWorkerstoparticipateasproviders.At the time of writing this Kit, details of provider numbers were underdevelopment.Inaddition,fromJuly2007,theMental Health Nurses Incentive Program will be available to eligible GPpracticeswhowishtoemployamentalhealthnurse.

The process by which an unaccredited prescriber such as a GP takes on the prescribing of methadone or buprenorphine to a patient who has been stabilised is as follows:

1) GP completes a yellow (methadone) or purple (buprenorphine and buprenorphine-naloxone) form and returns it to Pharmaceutical Services Branch (PSB) ofNSWHealth(phone0298795246orfax0298595170).

2)OntheformtheGPnominatestheiraccreditedpharmacotherapyprescribersupervisor(usuallyalocalspecialistorexperiencedGP). Aprescribersupervisormaybeaccessedthroughlocaldrugandalcoholservices.

3)PSBwillthencallthedoctorandconfirmtheyarefamiliarwiththeprocessesrequiredtotakeovertheprescribingforthepatient.

4)PSBwillthengiveapprovaltotheGP,permittingtheGPtocommenceprescribingatthattime.

5)PSBthenforwardstheapplicationandtheGP’sdetailsforratificationatthenextmeetingofthePrescriberCredentialingSubcommittee(PCS).

Underthisarrangement,theGPmaytakeuptofivepatients,seekingindividualapprovaltoprescribeforeachpatient.

IftheGPwishestotakeonmorethanfivepatients,theGPmustsuccessfullycompletethePrescribersPharmacotherapiesAccreditationCourse(PAC).ThiscourseisfreeofchargetoGPs,andisconductedregularlythroughoutNSW.Formoreinformationonthiscourse,goto

http://www.pac.med.usyd.edu.au/newpac/about.html Prepared with the assistance of Ms Kanan Gandecha, Deputy Chief Pharmacist, Pharmaceutical Services Branch, NSW Health

Who can use Kit 1 and why?

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http://www.primarymentalhealth.com.au/site/index.cfm?display=24625


http://www.pac.med.usyd.edu.au/newpac/about.html

8.



General Practitioners

• Behonestandtransparentwiththepatientoveranyclinicaldecisions you make

• Provideaccesstogoodqualityprimarycare

• Prescribemethadone/buprenorphine—safesensibleprescribing

• Reviewpatientregularlyandensuresafeprovisionoftakeaways

• Liaisewithcommunitypharmacyregularly(beforeeachscript)

• Supportthepatientinexplicitlycontributingtotheircareplanand achieving their goals

• ProvidefeedbackasrequiredtopharmaciesandtopatientsaspartofHMR

• UtiliseGPMHCPandGPMP/TCAtoprovidebetter access to additional medical and allied health services

• Giveacopyofanycareplanstothepatient

• Organisecoverforprescribingandreviewsifnecessarywhenyougo on leave or retire

Public Clinic Staff

• Behonestwiththepatientabouthowandwhythetransferis being offered

• Provideexcellentcaretothepatient

• Identifystablepatientssuitablefortransfer

• EngagethepatientinadiscussionabouttransferringtoaGP

• ProvideevidencetotheGPsupportiveofpatientstability

• ProvideclinicalsummariesinaformattosuitGPs

• ProvidetheGPwiththenameofaspecialistmedicaldoctor,other experienced prescriber or experienced nurse or case manager whom the GP can contact for advice

• ArrangethetransferofprescribingtotheGP

• Facilitate,whererequired,useofthecommunitypharmacyas a means of important feedback and support (HMR)

• SupporttheGPinthedevelopmentofcareplans (GPMHCP, GPMP or TCA)

• ProvideongoingsupporttotheGPasrequired

• AgreetoworkwiththeGPifthepatientbecomesunstable,andtake the patient back to the clinic, either temporarily or permanently, if indicated

Allied Health

• Behonestandtransparentwiththepatientoveranydecisions regarding treatment or feedback you make

• Supportthepatientinengagingwithyourservice

• ProvidefeedbackasrequiredtootherhealthprovidersespeciallytheGP

• SupportpatientcareplanningincollaborationwiththeGP

• Providetailoredtreatmentstosupportthepatientinattainingtheirgoal

Pharmacists

• Behonestwiththepatientshouldyouhaveanyconcerns

• Providesafedispensingofopioidmedications

• Adviseonsafestorageoftakeawaymedication

• Ensurescriptisadheredtobythepatienti.e.enhancecompliance

• NotifytheGPifapatientmisses3ormoredoses,divertsadoseor demonstrates other signs suggestive of instability

• ProvideroutinefeedbacktotheGPabouttheprogressofthepatient

• Provideadviceandotherhealthcaretothepatient

• Providesupportandadvicetothepatientifappropriate

• Beflexibleindeliveryoftreatmenttopatient

Roles and Responsiblities

Consumers

• Behonestwithhealthcareprovidersaboutsubstanceuseandrisky behaviours or other concerns

• Attendfordosingandotherhealthappointments

• Providefeedbacktothehealthcareprovidersaboutwhatyouwould like addressed in your treatment

• Beinvolvedinyourcareplan

• Askforhelporadviceifyouneedit

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9.



Kit 1 describes the referral pathways and required information exchange processes necessary to support the transfer of a patient fromapublicclinicprescribertoaGPprescriber(boldarrowB).Theinitialtransferofthepatientfrompublicdosingtopharmacydosing(arrowA)isassumedtohavealreadytakenplace(seeFlowchart1).RefertothesectiononTransfer to a pharmacy.

Summary steps in planning care for a patient with opioid dependence

Public Clinic Public Prescriber GP Prescriber

Pharmacy

A.

B.

Figure 1 Streamed Shared Care: Patient transfer from public to private services

Part 1

PART 1 contains:

Summary of the steps involved in the successful transfer of a patienttoaGPprescriber.

If you are familiar with Medicare care plans and drug use problemsyoumayonlyneedtoreviewthefirstsectionoftheKit.

PART 2 contains:

DetailsofeachstepsummarisedinPart1.

IfyouarelessfamiliarwithGPcareplansandthespecificissuesrelatedtodruguseproblemsthefirstandsecondpartsoftheKitsmaybeuseful.

Part 1 provides a summary, whilst Part 2 provides details of each step.

How to use this Kit

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10.



Flowchart 1: Patient Transfer from Clinic to GP

Patient commences treatment at public clinic

Clinic determines whetherpatient has existing GP

Does not have aGP for primary care

Clinic helps patient�nd GP for primary care

Already has GPfor primary care who is happy to

take on prescribing

Already has GPfor primary care

Clinic dosing until patient stable

Transfer to a communitypharmacy for dosing

Minimum 3 months remainsstable at pharmacy

Clinic sta� initiate discussion with patient re transfer to GP

Clinic sta� o�er to contact GP OR assist client with a letter to GP

Clinic exits patient the day before the GP’s authority commences

HMR referral and feedback from pharmacist

GP agrees to see patient. Clinic or patient makes �rst appointment with GP. Clinic faxes relevant documents (history, identi�cation, current script) to GP.

Patient keeps second appointment with GP one week after the �rst. GP con�rmsauthority, writes �rst prescription (for two weeks), and faxes it to the pharmacy.

GP and patient complete MMP. GP gives a copy of MMP to patient and to pharmacy.

Patient keeps �rst appointment. GP completes assessment and agrees toaccept patient. GP initiates GPMHCP with patient agreement. GP noti�es clinic

of intention to accept transfer. GP lodges application with PSB.Makes appointment for one week’s time. May initiate HMR.

A.

B.

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11.



Flowchart 2: GP plans and schedule of appointments and reviews

Initial appointmentRefer to Flowchart 1

Possible HMRreferral and

feedback frompharmacist

Appointment made forabout 1 week from�rst appointment

Appointment 2Refer to Flowchart 1

POSSIBLE REFERRALS TO:Psychologist, Social worker,Occupational therapist, eligible GP, Psychiatrist. Better Access item numbersfor Allied Health, GP and Psychiatrist .

Routine appointments at:

POSSIBLE REFERRALS TO:Specialists e.g. dietician,physiotherapist, dental (speci�cconditions). Chronic DiseaseManagement item numbersfor Allied Health

Some patients willneed both plans

With POSSIBLE Preparation of TCA

Item 723

GPMHCPItem 2710

GPMPItem 721

2 weeks - 2 weeks - 1 month - 1 monthGPMH Consultation Item 2713 OR Level B or Level C consultation

Further routine appointments at:1 month - 3 month - 3 months - 3 months

GPMH Consultation Item 2713 OR Level B or Level C consultation

Review Plan at 6 months or sooner if indicatedGPMHCP Item 2712 or GPMP Item 725

+/- TCA review Item 727

Prepare New Plan at 2 years or 1 year if indicatedGPMHCP Item 2710 or GPMP Item 721 or TCA Item 723

Steps 1-3

Steps 4-7 Steps 8-12

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12.



Using a GP Mental Health Care Plan (GPMHCP)

Step ProcessDocumentation and information exchange

Forms: •Paperbasedor•Electronic

For public clinic staff

Step 1.1 Public clinic talks to patient about having a GP for primary care with a view to future transfer to a GP forprescribing.

If the patient has a GP, clinic staff discuss with patient the possibility of thatGPbecomingtheprescriber.

If the patient does not have a GP, or does not want their primary care GP to become their prescriber, then clinic staff need to negotiate a place withanotherGP.

Public clinic or patient approaches GP to take over primary care / prescribing and gains agreement fromGP.

Letter from clinic to client Letter from Clinic to Client

Initial letter from clinic to GP Letter from Clinic to GP

Public clinic checks the GP’s registration at www.nswmb.org.au to ensure that the GP does not have anyrestrictionsonS8prescribing.

Summary assessment form or referral letter from clinic to GP outlining clinical history and medication.

Clinic summary – standard assessment transfer form (local format)

ConfirmationofstabilityprovidedtoGPbyclinic.

Stability Assessment Flowchart

Step 1.2 Public clinic prompts patient re issues they need to consider before firstmeetingwithGP.

Public clinic provides patient with checklist(PPC).

The Patient’s Priorities for Care (PPC)

For GPs

Step 2.1 PatientattendsGPforfirstassessment and GP decides whether to accept patient or not (andviceversa).

PPC may be provided or used in discussionwithGP.

GPdoesclinicalassessment.

GP lodges PSB authority to takeoverprescribing.

Reviewappointmentin1week.

PPC (optional) Appropriate PSB form (methadone, buprenorphine)

Step 2.2 GP initiates care plan in consultation with the patient

Most appropriate care plan is GP Mental Health Care Plan, however GP may decide to also initiate GP ManagementPlan(seeSteps8-12)

GP Mental Health Care Plan (GPMHCP)item2710 Sample standard GPMHCP form (scroll down website)

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http://www.nswmb.org.au

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-gp-mental-health-care-medicare

13.





Step 3 GP requests Home Medicines Review(HMR)(item900)fromdosing community pharmacy, with patientconsent.TheuseoftheHMRis valid in these cases because it involves medication with a narrow therapeuticindex.

HMR information (Department of Health and Ageing)

HMR information for GPs (The Pharmacy Guild)

GP explains HMR to patient and obtains consent for HMR frompatient.

GP should consider any risks for the pharmacist attending the patient’s home and communicate this to the pharmacy (although the pharmacist will conduct their own assessmentofrisk).

Patient Information Sheet

Consumer brochures

Translations

HMR referral from GP sent topharmacy.

HMR referral form

Software templates for HMR forms

Medicare requirements to claim item900HMR

For pharmacies

Step 3 cont.

Pharmacy conducts HMR in a location convenient to the patient (notnecessarilythehome).

Risk assessment prior to HMR bypharmacy.

Any child protection issues that arise during the visit must be appropriatelyaddressed.

Pharmacy provides written feedbacktoGP.

GP discusses feedback with pharmacist.

Pharmacy HMR Report (local format)

For GPs

Step 4 GP reviews patient in about oneweek.

GPMHCP and Medication Management Plan (based on HMR) arecompleted.

GPMHCP

HMR Medication Management Plan

GP discusses HMR report with patient and develops Medication ManagementPlan(MMP).

GP provides feedback to both patientandpharmacy.

Copy of GPMHCP and Medication Management Plan are offered to the patient.

Medication Management Plan is copiedtopharmacy.

GPprovidesfirstprescriptiondirecttopharmacyviafaxormail.(Neverprovide a script for methadone or buprenorphinetothepatient.)

Confirmstransferofcarewiththepatientandtheclinic.

PSBisnotifiedofchangeofprescriber.

PSB Contact details: Fax:0298595170 Tel:0298795246

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http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm

http://beta.guild.org.au/mmr/content.asp?id=421

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/patientinfo.pdf

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/homereview.pdf

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-dmmr-transl

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/dmmrreferral.pdf


http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/mbsdmmr2.pdf

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/mbsdmmr2.pdf

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/72874007E87EA090CA256F19001D0364/$File/medmngtform.pdf

14.





For allied health professionals

Step 5 GP refers to allied health professionals or registered GP as required for focussed psychological strategies (FPS) or to clinical psychologist for psychological therapyservices.

GP locates allied health professional who is

1.registeredwithMedicare;

2.hasapracticeorientationthatcaters to adults with drug and alcoholproblems;

3.hasthecurrentcapacitytoseethepatientinatimelyway.

The following links are not exhaustive.

Find a Mental Health Psychologist

Find a Mental Health Social Worker

Find a Mental Health Occupational Therapist

Standard GP referral processes, no specificforms

Feedback from allied health personnel (local format)

Client will sign Medicare form if allied health professional is bulk billing

GP refers patient to psychiatrist for assessment and management plan for GP to follow collaboratively with patient(item291)

Review of management plan (item293)

Initial consultation for psychiatrist tomanagepatient(item296)

Standard referral processes

For GPs

Step 6 Regular appointment review schedule, some of which may be as GP Mental Health Consultation, some as regular Level B or C consultations.

Suggest minimum of monthly reviewsforthefirst3months.

Enhanced Primary Care (EPC) CaseConferenceifrequired.

GP Review Proforma for Opioid Dependent Patients

Pharmacy Guild Review Form

Monitoring stability in community dosed OTP clients by pharmacists

Item2713GPMHCareConsultationOR Level B or C Consultation Case conference (under EPC item numbers)

Step 7 Review of GPMHCP Six monthly (orthreemonthlyifindicated).

Contact dosing pharmacist prior to reviewtomonitorstability.


GPMHCPReviewitem2712


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http://www.psychology.org.au/FindaPsychologist/Default.aspx?ID=1204

http://www.aasw.asn.au/about/prof_practice/mental.htm

http://www.ausot.com.au/inner.asp?pageid=143


15.



Using a GP Management Plan (GPMP)



For GPs

Step 8 Patient attends GP for review and assessment of chronic diseases identifiedasrequiringadditionalplan(e.g.hepatitisC).

PPC may be provided/used by patientindiscussionwithGP.

The Patient’s Priorities for Care (PPC)

GP develops additional care plan for the chronic disease (GPManagementPlan).

GP Management Plan (GPMP) item 721:Sample GPMP form (scroll down website)

GP decides whether a Team Care Arrangementisappropriate.

GP starts Team Care Arrangement for patients requiring multidisciplinary care.

GP undertakes health check for patientsaged45to49yrs.

45-49yroldHealthCheck item717

GP undertakes health check for Aboriginalpatients.

Aboriginal Health Checks items704-710

Step 9 GPreviewspatient. GPMPisprovidedtopatient.Team Care Arrangement (TCA) completed.

TCAitem723: Sample TCA form (scroll down website)

Step 10 GP refers to allied health professionals as required e.g.chiropractor,podiatrist,physiotherapist.

StandardGPreferralprocesses.

Various item numbers

Allied Health referral form under EPC

GPrefersfordentalcare–specificconditions.

Information about dental referrals Dental referrals Fact sheet.

NOTE: New Dental Care items will become available through Medicare on November 1st 2007.

Dental referral form under EPC

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http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease-forms

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-45check#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pacd-medicare-resource-kit#http://www.health.gov.au/internet/wcms/


http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-medicare-health_pro-gp-pdf-epcahs-cnt.htm

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-dental-cnt.htm

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-epcdc-cnt.htm

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Step 11 (as for Step 6)

Regular appointment review schedule

Suggest minimum of monthly reviewsforthefirst3months. Enhanced Primary Care (EPC) Case Conferenceifrequired.



Monitoring stability in community dosed OTP clients by pharmacists

Level B or level C consultations

CaseConferenceitems740,742,744,759,762,765

Step 12 (as for Step 7)

GPMP Review and TCA Review Six monthly (ormoreoftenifindicated).


GPMPReviewitem725

TCAReviewitem727

Next Step

Patient becomes unstable and GP seeks support from the specialist service.

In addition to local specialist service:

NSW Drug and Alcohol Specialist Advisory Service (DASAS) Tel:Sydney9361-8006 Or for callers outside Sydney 1800023687

GP Psych Support 1800200588or www.psychsupport.com.au

GPs should also give patients the Alcohol and Drug Information Service (ADIS) telephone number for out-of-hourssupport(0293618000or1800422599forcallers outsideSydney).

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http://www.psychsupport.com.au

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Step 1 Initial discussions about transfer

Step 1.1 Public clinic or patient approaches GP to take over primary care and / or prescribingProcess Step 1.1.1 Initial discussions with client and identifying a GP

All clients should be advised when commencing treatment at a public OTP clinic that the ultimate aim once they are stable is to gradually transfer their care to the community—initially with dosing at a community pharmacy, followed by a transfer of their treatment(prescribingandprimarycare)toaGP.

Clients should therefore be encouraged to develop a relationshipwithaGPasearlyintreatmentaspossible,firstofall to ensure their access to primary care, but also to ensure the future smooth transfer of opioid prescribing to a community based GP who is already familiar with them and their health care needs.Itmaybehelpfultoprovidetheclientwithaletterthatexplainsthebenefitsofthemeventuallytransferringtheircaretotheir GP (see Sample Letter from Clinic to Client).

In many cases, clients will have a GP who provides their primary care.Insuchcases,thisGPshouldbetheoneapproachedinthefirstinstanceeitherbytheclient,orbytheclinicwiththeclient’sagreement, to take over opioid prescribing at a time when the clientisstable.

When the client does not have a GP, the clinic needs to help themfindone.SettingupongoingsupportiverelationshipswithlocalGPsislikelytobehelpfultotheclinicinthisprocess.Information about local Divisions of General Practice may be located at the Divisions Directory.

Step 1.1.2 Approaching the GP The initial approach to the GP may be through a phone call or a writtenrequest.Theclinicmaydothis,ormayprovidetheclientwith a letter to take to the GP (see Sample Letter from Clinic to GP).Initialinformationprovidedabouttheclientshouldconfirmthe suitability of the client for transfer and the client’s willingness fortheGPtobecometheprescriber.

In order to engage GPs in areas that for many will sit a little outside their comfort zone, GPs need to be reassured that if a transferred client becomes unstable while in their care the client can be transferred back to the specialist service for restabilisation (see Returning your patient to clinic care when unstable).Otheroptions include the client’s temporary transfer back to the care oftheclinicorareturntoclinicdosing.Itisvitalthattheclinichas processes in place to ensure access for unstable clients to returnasrequired.

Documentation and Forms to GP Documentation to the GP should provide a basic clinical history, clinical treatment, most recent script and a Stability Assessment Flowchart.Thismaybeprovidedasanelectronicorhardcopy(faxed)aspreferredbytheGP.Manysuchclinicalsummaryformsareavailable already and as long as they highlight the key information requiredbytheGP,theirpreciseformatisnotimportant.

The assessment information that a GP will need about the prospective new client will include, apart from the client’s identificationdetails:

• currenttreatmentincludingdosinglocation;

• currentdruguseanddrugusehistory;

• currentmentalhealthandhistory;

• medicalhistoryincludingBBVsifknown;

• currentmedications;

• socialcircumstances(family,children(withages), employment,housing);

• othercareprovidersandcurrentsupports;

• anyongoingclinicalmanagementissues.

PART 2 Detailed steps in planning care for a patient with opioid dependence

Note: The GP can use information provided by the clinicas part of the GP Mental Health Care Plan (GPMHCP),GP Management Plan (GPMP) and the Team Care Arrangement(TCA).

Note: Regardless of how well an assessment is conducted, people and their problems are dynamic and there may always be crises or issues that arise in the client’s life which mayprecipitatethemintoinstability.

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http://www.agpn.com.au/site/index.cfm?module=DIVISION&state_code=NSW

18.



Step 1.2 Public clinic prompts patient re issues to consider about transferring careProcess The transfer of care can be a time of uncertainty and anxiety for allpatientswithchronicconditions.Thepatient’scontributionto the transfer arrangements will be crucial to the successful establishmentofanewrelationshipwiththeGP.Thelossofexisting therapeutic relationships with their public clinic care providersneedstobeacknowledged.

To ensure a successful transfer, the patient may need some additional support until a sound therapeutic relationship is establishedwiththenewcareprovider.Inparticular,iffinancesare of concern to the client in relation to paying GP consultation costs, budgeting advice may be helpful to the patient and can be provided by clinic staff or the prescriber depending on their skillsandexperienceinthisarea.Whenrequired,theclient may be referred to one of the local community groups or non-governmentagencieswhichassistwithbudgetingadvice.

In addition, the transition period may also be a challenge for the GP, particularly for those with limited experience in the managementofopioiddependence.

Documentation and Forms Feedback from consumer organisations has suggested that it is not uncommon for patients to feel uneasy when meeting anewprescriber.Toassistpatientstoidentifykeyareasthatmay be usefully discussed with a new prescriber, a checklist The Patient’s Priorities for Care (PPC) has been developed in collaborationwithusergroups.Itactsasapromptforpatientsbefore and during their initial assessment with their new prescriber.

SpecificallythePPCpromptspatientstoconsiderconcernsoruncertainty around moving treatment, such as what can be donetoeasethetransition;anyissuesaroundcurrentpharmacydosingarrangements;currentdoseadequacy;currentdruguse;prescribedmedicationsincludinganysideeffectsorinteractions;generalhealthrelatedconcerns,includingteeth;involvementwithanyotherhealthcareproviders;theoptionofhavingasupportpersoninvolvedintheplan;anycommitmentsthat may affect the keeping of appointments, for example, work orstudy;goalsandatimeframeforachievingthem.

Patients are encouraged to consider these issues before presentingtoanewGP.Somepatientsmaywishtowritedownquestions or relevant history details and take these with them to theGPappointmenttohighlighttheirowntreatmentpriorities.

Information exchange should be encouraged in all cases and is most likely to flourish within the context of a healthy therapeutic relationship between the patient and their care providers.

A patient’s consent should always be sought when sharing information between service providers.

Step 2 GP assesses for transfer and initiates GP Mental Health Care Plan (GPMHCP)

Step 2.1 Patient attends GP for first assessment and GP decides whether to accept patient (and vice versa)Process The focus in this step is on the assessment and planning required, however if the GP has already been involved in the delivery of primary care to the patient, much of this will have alreadybeendiscussed.Ideallypatientswillhaveestablisheda relationship with a GP well in advance of the proposal to transfertheiropioidprescribingtothatGP.

IfthisisthefirstappointmentwiththisGP,anextendedconsultation(i.e.45minutes)shouldberequestedatthetimeofmakingthefirstappointmentsothatallissuescanbeadequatelyaddressed.Atthetimeoftheappointment,theGP will already have received the clinic referral with a clinical summary.TheGPreviewsthedocumentationprovided,andassessesandexaminesthepatient.

ThepatientmayfindithelpfultouseThe Patient’s Priorities for Careasapromptduringthediscussion.

With the patient’s agreement, the GP will provisionally accept thepatient(forprimarycareand/orprescribing).

At the end of the consultation the GP phones the clinic to confirmthatheorshewilltakeoverprescribingandsetsadateforcommencementofprescribing—usuallythefollowingweek.The clinic is then able to arrange the timely exit of the patient fromtheircurrentpublicprescriber(throughnotificationtothePSB)onthedaypriortotheGPcommencingprescribing.

The GP must complete a PSB authority form identifying the date of commencement of prescribing for that patient so that he or she is able to take over care of that patient the day after the patientisexitedfromthepublicclinic(PSBphone0298795246orfax0298595170).

All GPs newly commencing prescribing should understand their responsibilities in taking on the care of patients on an Opioid Treatment Program, especially in regard to organising cover when the GP is away, or is considering leavingorretiringfrompractice.

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19.



Assess risk and comorbidity Therearefourspecificareasforassessmentinopioiddependent patients, in addition to the usual examination and assessment.Followeachlinkformoredetailsonthese.

1.Medication stability

2.Drug use

3.Other health issues (may indicate need for GPMP)

4.Psychosocial

Diagnosis All patients must have a diagnosis of opioid dependence to be onanopioidtreatmentprogram.Inaddition,itiscommonforthis patient group to have hepatitis C (over seventy percent) and about one third will have a current psychiatric diagnosis (most commonly depression, anxiety, post-traumatic stress disorder (PTSD), personality disorder or another substance useproblem).Othercommondiagnosesincludechronicpain,hepatitisBanddentalcaries.

Outcome Measures There are no commonly used outcome tools that are in routine use within a primary care setting to monitor the progress of drugproblems.Nevertheless,thereareseveralgoodclinicalindicators that do provide information to help guide a clinician abouthowtheirpatientisgoing.Someoftheseareobjectivemeasures such as attendance for dosing, inspection of injection sites,andurinedrugscreens.Othersareserialassessmentsand data collection from the patient and third parties that help informtheclinicianastohowtreatmentisprogressing.Theseare compiled in the GP Review Proforma for Opioid Dependent Patients.Inaddition,forgeneralinformationonoutcomemeasures, see http://www.gpcare.org

Objective measures

• Urinedrugscreens(seeMedicareUrine Drug Screen items)

• Attendingforalldosesandappointments

• Compliancewithdosingprocedurei.e.nodiversion

• Noevidenceofrecentinjectingonexamination

• AlcoholBreathAnalysiswhereclinicallyindicated

• Psychiatricscreeninginstrumentsasappropriate

• BDI/K10/SF12

Self report

• Reducedhighriskactivitiesincludingdruguse,injecting, risky sexual practices, crime, violence

• Engagementinemploymentoreducationactivities

• Improvedfamilyrelationshipincludingparenting

Feedback from third parties

• Pharmacyinformationonpatientpresentation,missed doses, refused doses

• Feedbackfromotheragenciese.g.childprotection, probation and parole, employers, education providers

Step 2.2 GP initiates care plan/s in consultation with the patientDeciding on which care plan to use There are two potentially suitable care plans under Medicare which may be used by GPs for planning the management of opioid dependent patients: the GP Mental Health Care Plan (Medicareitem2710)andtheGPManagementPlan(Medicareitem271).Bothalsohaverelateditems.

The best initial plan is the GP Mental Health Care Plan (GPMHCP)whichincludes‘Drugusedisorders’asaprimaryindication for its use and which is therefore suitable for all opioiddependentpatients.TheGPManagementPlan(GPMP)issuited for a narrower group of patients whose drug use disorder is associated with chronic physical conditions (such as hepatitis C) requiring treatment, or who have an additional independent chronicphysicalcondition(suchasdiabetes).

• Steps2to7willdetailthewaysinwhichtheGPMHCPand related items can be used in the care of opioid dependent patients

• Steps8to12willdetailtheadditionalwaysinwhichthe GPMP and related items can also be used in the management of some opioid dependent patients

Assessment (as part of a GPMHCP) The GP will develop an initial care plan, a GPMHCP (see Sample GPMHCP).Since‘Drugusedisorder’isaprimaryindicationtouse this item, the use of a GPMHCP initially will enable access to the Medicare Better Access initiative mental health item numbers for a mental health consultation, plan and review (see Flowchart for the three components of the Better Access initiative) with the possibility of onward referral to allied health care specialists suchaspsychologistsforcounselling.Forcomprehensiveinformation, go to Better Access to Mental Health Care initiative then go to the Better AccessOrientationManual.

The steps detailed below are required in the assessment process in order to claim the Medicare GPMHCP item.

Patient’s agreement The patient’s agreement is required for the service, recorded in thepatient’sfile,asforalltreatmentandinformationexchange.

Relevant history The clinical summary provided by the clinic will supplement the GP’sownassessment.

Mental State Examination (MSE) AnMSEisconductedasforanypatient.Astabledoseofmethadone/buprenorphine should in no way impact upon a MSEandthisshouldbeapproachedasforanyotherpatient.(see the Can Do initiative: Managing Mental Health and Substance Use in General PracticeontheAGPNwebsite).

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http://www.gpcare.org



http://www.primarymentalhealth.com.au/client_images/74978.pdf


http://www.primarymentalhealth.com.au/site/index.cfm?display=18157#http://www.primarymentalhealth.com.au/s



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Provision of psychoeducation The GP must provide some psychoeducation relating to the patient’sdiagnoses.ForpatientswithopioiddependenceonanOTP, this education includes avoiding overdose and engaging inrelapsepreventionstrategies.Forfurtherinformation,seehttp://www.gpcare.org/(select‘PsychologicalInterventions’thenclickon‘Psychoeducation’).

Crisis intervention and/or relapse prevention plan

Crisis All patients should be provided with information on what to do intheeventofacrisis.Shouldthepatientbeinneedofurgentadvice, they should be directed to either phone the GP surgery orthepublicclinicfromwhichtheyweretransferred.

In addition, all patients must be given the Alcohol and Drug Information Service (ADIS) telephone number for out-of-hours support(0293618000or1800422599forcallersoutsideSydney).

Should patients be concerned about their physical or mental health out-of-hours they are advised to go to Emergency Department and request any discharge information be copied totheGP.

Patients should also be aware that doctors and nurses across NSWcanaccess24hourdrugandalcoholspecialistsupportthrough contacting the NSW Drug and Alcohol Specialist AdvisoryService(DASAS)line(0293618006).Patientsmayadvisecliniciansunawareofthisserviceofitsexistence.

Relapse prevention Patients who have successfully completed a planned gradual reduction off maintenance treatment should be offered relapse preventionandaccesstoongoingcounselling.Theymustalsobe advised of the risk of fatal overdose on return to opioid use becauseoflowtolerance.Relapsepreventionshouldfocusontheidentificationoftriggersandhighrisksituationsandexplorecopingstrategiestomanage‘craving-richsituations’(people,placesandthings)andtechniquesto‘surfthecraving’(cravings come and go like a wave, use distraction until it passes,havealistofdistractionsready).Referraltospecialistdrug and alcohol services or psychologists may be helpful in suchcases.Thesepatientsshouldbeenencouragedtore-present as soon as possible to the prescriber or local clinic in ordertoreturntotreatment.Formoreinformationgotohttp://www.gpcare.org/,select‘PsychologicalInterventions’,thenclickon‘RelapsePrevention’.

Referrals Under the GPMHCP, the GP may refer patients for a range of servicesfromotherprofessionals.Thesereferralroutesaresetout at Patient Pathways.Formoredetail,gotoStep 5.

Documentation There is a sample GP Mental Health Care Plan (GPMHCP) which canbemodifiedforuseforpatientswithopioiddependence/drugandalcoholproblems.Appropriatedocumentationmaybe developed by the GP for their own use, or may involve the use of existing materials such as RACGP templates or the use ofsoftwareprogramssuchasMedicalDirectororBestPractice.Specificclinicalissuesrelatedtothemanagementofthoseonprescribed opioids for the treatment of opioid dependence can beaddedtotheplan.

Developing a Plan as part of GPMHCP

Feedback on assessment findings to the patient The GP discusses the assessment with the patient, including the mentalhealthandsubstanceuseformulationanddiagnoses.

Discuss referral and treatment options The GP discusses with the patient the options for treatment, including referrals to allied health professionals (such as for counselling).SeeStep 5.

Agreeing goals with the patient Below are some suggestions regarding goals that may be suitable for opioid dependent patients, for the prescriber and forthepatient.TheGPcandrawonthesetoreachagreementwiththepatientonthegoalstobeincludedintheGPMHCP.

GP prescriber goals specific to opioid dependent patients

1. Medication stability

2. Drug use stability

3. Health improvement

4. Psychosocial support

Some patient specific goals of treatment

• Cessation/reductioninheroinuse

• Improvedlevelofstabilityindaytodaylife

• Improvedaccesstootherhealthcare

• Reducedlevelsofsupervisionandincreasedaccess to takeaways

• Quickestwaytosafelycomeofftreatment

• Parentingsupport

Actions to achieve set goals

• Identifyoptimaldoseandtypeofmedicationforthepatient

• Safelystoringmethadonetakeaways

• Addresssideeffectsandconcernsovermedication

• Adviseyourpatienthowtogetthemostoutoftreatment

• Focusonengagingandaddressingothergoalsof the patient

• Betransparentabouttheneedforandtherangeof monitoring processes, including the frequency of reviews and the requirement for drug screening

• UsetheStabilityAssessmentFlowchartandcompletionof other proformas to track progress

• Regularreviews

• Provisionofurinefordrugscreen

• Referraltospecialistprovidersfortreatmentincluding community nursing or allied health professionals

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21.



These forms can be augmented in the case of managing those with opioid dependence with Stability Assessment Flowcharts and clinical assessment proformas which are consistent with current best practice in determining stability in injecting drug users and theirsuitabilitytoreceivetakeawaysdosesofmedication.AllshouldbebasedoncurrentMedicarerequirements.

Finally, give a copy of the care plan to the patient.

Step 3 GP requests Home Medicines Review (HMR) of patient and receives feedbackHMR is also known as Domiciliary Medication Management Review (DMMR)

Process Although most GPs will be familiar with the use of Home Medicines Review (HMR) for a range of medication related issues, they may not be aware that patients on methadone, buprenorphine or buprenorphine-naloxone are also eligible for an HMR under the DoHA criteria for HMR (see Medicareitem900, pointA.26.4.).

Thesemedicationsfallunderthecategoryof‘medicationwithanarrow therapeutic index or medications requiring therapeutic monitoring’.HMRcanbeundertakenonceperpatientperyearormoreoftenifmedicationsorotherfactorschangesignificantly.Full guidelines for the use of the HMR service can be found on the DoHA website at HMR Guidelines.

The information exchange that occurs through the HMR is a potentially powerful source of support for GPs in working with their patient to develop a treatment plan, whether a GP Mental Health CarePlan,aGPManagementPlanoraTeamCareArrangement.

Step 3.1 Starting the HMR• PatientcanbeidentifiedbytheGPorpracticestafforany care provider

• GPobtainsinformedconsentfromthepatientfortheHMRservice

The HMR is an optional component of care, and patient consent isrequired,andmustberecorded.Inthesediscussionswiththepatient, the GP may use the Patient Information Sheet and Consumer brochures (and Translations)availableontheDoHAwebsite.

ThebenefitofanHMRtothepatientisthatitprovidesanopportunity to have a period of uninterrupted time with a pharmacist to address a range of health care and medication relatedneedsandconcerns.AnHMRcanalsoprovideinformationon the optimal management of side effects (for both prescription and over-the-counter medication) and other issues such as complianceandstorage.Otherpotentialbenefitsincludethedetection of health care conditions for which the patient is not currently being treated and the experience of having a health care providerfocusonissuesotherthandruguseordepression.

Step 3.2 GP initiates HMR referral to a community pharmacyThe pharmacy should be of the patient’s choice, ideally their dosingpharmacywheretheyareknown.Withthepatient’sagreement, the HMR referral should include the following

information:presentingproblems;diagnosis;medications;currentpathology;medicalandsurgicalhistory;andclinicalmonitoring.Thebettertheinformationonreferral,thebetterthepharmacist’sreport.

Step 3.3 Pharmacist conducts an interview with the patientThe GP or pharmacist should determine the most appropriate locationtoconducttheHMRindiscussionwiththepatient.Itisnot mandatory that the HMR interview be done in the patient’s home, as long as it is in a location in which the patient and the pharmacist are both comfortable, and the patient’s privacy is protected.Inpart,anacceptablelocationwillbedeterminedbyfactorssuchasconvenienceandpatientpreference.

In cases where the pharmacist is considering conducting such a review in the patient’s home, a risk assessment should be undertaken by the pharmacist regarding such factors as the presence in the home of persons with a history of violence and pets,particularlydogs,inthehome.Also,anychildprotectionissuesthatarisemustbeappropriatelyaddressed.

Step 3.4 Pharmacist writes a report to the GPThereportcontains‘findings’orwhatthepharmacistfoundattheinterview;and‘recommendations’asaresultofthosefindings.ThepharmacyHMRreportprovidedbacktotheGPwilladdress a range of issues relevant to patient management such as:doseadequacy;othermedicationstaken(includingover-the-counter(OTC)andherbal);compliance;sideeffects;safestorage;interactions;contraindications;potentialformisuseandprescriptionshopping.

Step 3.5 Patient agreement to Medication Management PlanAtthenextappointment(seeStep4),andincollaborationwith the patient, the GP will incorporate the pharmacy HMR reportintoaMedicationManagementPlan.TheMedicationManagement Plan contributes to the development of the patient’s overall treatment plan, and this discussion ensures that thepatientisconsultedabouthowthisfeedbackisused.

Copiesoftheplanareprovidedtothepatientandtothepharmacy.

Step 3.6 GP submits item 900 claimDocumentation and Forms Information exchange between the patient, the referring GP andthepharmacycanbeconductedusingexistingdocuments.The DoHA website includes links to a GP Fact Sheet and Process Chart, an HMR Referral Form, and a Medication Management Plan Form.Inaddition,ThePharmacyGuildofAustraliaprovidesa page of detailed information on Home Medicines Review, includinglinkstosoftwaretemplatesforGPs.

The GP must provide a copy of the Medication Management Plan to the pharmacy as part of the requirements of Medicare item900.Thisfacilitatesthesupportthatthepharmacycanofferthepatient.

GPs should also provide a copy of the Medication Management Plan tothepatienttoensurethepatienthasongoingaccesstotheplan.

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http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/mbsdmmr2.pdf#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/dmmrguidelines.pdf#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/patientinfo.pdf#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/homereview.pdf#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/homereview.pdf#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-dmmr-transl#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/dmmrfactsheet.pdf#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/dmmrreferral.pdf#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/72874007E87EA090CA256F19001D0364/$File/medmngtform.pdf#http://www.health.gov.au/internet/wcms/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/72874007E87EA090CA256F19001D0364/$File/medmngtform.pdf#http://www.health.gov.au/internet/wcms/

http://beta.guild.org.au/mmr/#http://beta.guild.org.au/mmr/

22.



Step 4 GP reviews patient in one week and completes transferProcess ThepatientneedstoattendtheGPfortheirfirstprescriptionsome days before the new authority to prescribe comes into effect.AlthoughtheGPMHCP,(ortheGPMPandtheTCA)couldhavebeencompletedattheinitialappointment(i.e.Step2),itispreferable for the GP to make an appointment for the patient to returnthefollowingweek.Duringthistime,anyconcernsandtreatment delivery issues can be resolved, including the transfer of‘authoritytoprescribe’throughPSBandfinalisationoftheHMRreportbythepharmacy.

If the GP has received the HMR report from the pharmacy, then the Medication Management Plan can be completed at this appointmentindiscussionwiththepatient(seeStep3.5).TheGPwillprovidetheplantothepatientandtothepharmacy.Thisplanwillthencontributetotheoverallmanagementplan/s.The GP should then complete all plan/s (GPMHCP, GPMP, TCA) commencedattheinitialappointment.

TheGPshouldconfirmtransferofauthoritytoprescribewithPSBas requested the previous week, to commence from the next day (bothfaxandphonenumbersontheapplicationform).Thefirstprescription will then be written at this appointment and faxed directtothepharmacy.Theoriginalscriptwillthenbemailedtothepharmacy.

Thefirstprescriptionshouldgenerallynotbeformorethan2weeks(4weeksmaximum).Prescriptionsarenevertobeprovideddirectly to the patient and must always be faxed (and then posted) tothepharmacy.Prescribersareadvisedtoroutinelycontactthepharmacy prior to providing any prescription to ensure that the patient has not missed any doses, been refused any doses or been intoxicatedatpresentation(seeStep6).

Documentation The DoHA website includes templates which can be adapted for useforpatientswithopioiddependence.See Sample GPMHCP and Sample GPMP and TCA.

Step 5 GP refers patient to an allied health professionalProcess Under the GPMHCP, the GP may refer patients for a range of servicesprovidedbyotherprofessionals.Referralroutesandservices are set out at Patient Pathways and include referral to a clinical psychologist for psychological therapy services or referral to a registered GP, a psychologist, social worker or occupational therapistforfocussedpsychologicalstrategies(FPS).Theseservices will in future also be provided by mental health nurses andAboriginalHealthWorkerswithappropriatequalificationsandexperience.

These health care workers must be registered with Medicare tobeeligibletoclaimfortheavailablerebates.Forcontactdetails of registered professionals, refer to Finding a Mental Health Allied Health Professional.Inadditiontotheseservices,the GP may refer the patient directly to a psychiatrist for initial consultation(item296);assessmentanddevelopmentofamanagementplan(item291);reviewofamanagementplan(item293).Forfurtherinformationonfeesandrebates,refertoBetter Access Medicare items.

Patientsmayreceiveupto12individualand/orgroupmentalhealthalliedhealthservicespercalendaryear.Afterthefirstsix sessions, the allied health professional is required to report backtothereferringGP.Ifindicatedbyareviewofthepatient’sneeds,theGPmayreferforafurthersixsessions.Inexceptionalcircumstances an additional third set of six services is available per patientpercalendaryear.

To make a referral to a mental health allied health professional under the Better Accessinitiative,theGPfollowsthesesteps.

1. LocateanalliedhealthprofessionalregisteredwithMedicare: Find a Mental Health Psychologist;FindaMental Health Social Worker;FindaMental Health Occupational Therapist.

2. Ensurethatthepractitionerhasapracticeorientation thatcaterstoadultswithdrugandalcoholproblems.Some practitioners may specialise in child and family services, for example,andnotadultswithdrugandalcoholproblems. Psychologists practice orientation is available for some professionals, however it may be useful for the GP to establish an ongoing understanding with some local professionals for the purpose of referring patients with drug andalcoholproblems.

3. Checkthattheprofessionalhasthecurrentcapacitytosee the patient in an appropriate time (depending on the patient’sneeds).

Inaddition,GPswillfindinformationforconsumersaboutpsychologists at Consumer information.

Patientsshouldbemadeawarepriortoattendingthefirstappointment with an allied health professional that some will bulk bill, while others will not and the payment will need to be madeatthetimeoftheconsultationandclaimedbythepatient.

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http://www.psychology.org.au/medicare/




http://www.psychology.org.au/FindaPsychologist/Default.aspx?ID=1204

http://www.psychology.org.au/Assets/Files/Medicare_Fact_Sheet1.pdf

23.



Theremaybeagapwhichthepatientmustpaythemselves.Itis essential that the professional indicates what the cost will be whenthepatientmakesthefirstappointment.Professionalswho do not bulk bill may be reluctant to take on some patients, believing that attendance at appointments may be erratic or thatpaymentisnotguaranteed.

Documentation While referrals to allied health do not require a special form, in order for the professional to be paid by Medicare, the referral must include (in addition to relevant patient details), the name of the referring doctor, the provider number, the date, and a requestforpsychologicaltreatment.

Step 6 Regular review appointments (GPMHCP or GPMP or TCA)Process and Documentation Afterthefirstweek,theGPandpatientneedtoagreeonanappointmentscheduleforroutinereviews.Initiallymorefrequent appointments may work well for both patient and prescriber, particularly in order to establish their therapeutic relationship (though cost may mean that some patients are less keenonthisthantheirdoctor,evenifthedoctorisbulkbilling).

A suggested appointment schedule following the initial GP plan is at:

• 2weeks

• 4weeks

• 8weeks

• 12weeksandthen

• aminimumofthreemonthly.

• Patientsshouldbeadvisedbytheclinicthatthesearethe maximum intervals and the GP may insist on more frequentvisits.

• PatientsshouldbeadvisedbyclinicstaffandtheGPthat non-attendance at the GP for scheduled appointments may jeopardise their script provision and may result in a loss of takeaways if the GP is no longer able to obtain sufficientinformationtosupporttheirongoingprovision.

Scripts should not usually be provided for more than one monthduringthefirst3monthsoftreatment.Afterthefirst3months,scriptscanbeprovidedforamaximumof3months.This schedule ensures that the prescriber reviews the patient atleast6timesduringthefirst12monthsoftransfer.Theseareroutine reviews (such as Level B or C consultations) and not a fullreviewofthecareplan(seeStep7),howevertheycanonoccasions qualify for a routine mental health care consultation (item2713).

Should a patient who has already been receiving takeaway doses from a community pharmacy be transferred to a new prescriber(i.e.theGP),thepatientshouldbeawarethattheirnew prescriber has a responsibility to ensure that it is still

appropriate for the patient to continue to receive takeaways ontheexistingschedule.Theassessmentsupportingtheprovision of ongoing takeaways needs to be documented (suchasbyusingtheStabilityAssessmentFlowchart).Wherethere is evidence to support the patient’s continued stability, in most cases it will be appropriate to continue with the inherited prescription,keepingthetakeawayprovisionasitwas.

For further guidance on prescribing unsupervised doses see the current New South Wales Opioid Treatment Program Clinical Guidelines for Methadone and Buprenorphine Treatment of Opioid Dependence(NSWHealth2006)andtheAustralasianChapter of Addiction Medicine Clinical Guidelines: Assessing Suitability for Unsupervised Medication Doses in the Treatment of Opioid Dependency(2006).

Each time the GP provides a prescription they must ensure that itreflectstheneedsandstabilityoftheirpatient,specificallythedose,anyflexibilitywithregardtoincreasesordecreasesindoseandthattheprovisionoftakeawayshasbeenconsidered.Thusbefore giving a patient a prescription, the GP should address the following areas:

• medicationstability;

• drugusestability;

• psychosocialstability;and

• anyunmethealthcareneeds.

To assist in this process, GPs may choose to use the Stability Assessment Flowchart or the GP Review Proforma for Opioid Dependent Patients.Thecompletionofthelattercouldusefullyformpartofthe6monthlyreview.

In addition, information must be obtained from the dosing site priortotheprovisionofanyprescription.Thismaybesupportedby the use of pharmacy monitoring feedback forms. Key areas to be enquired about are:

• Anymisseddoses?

• Anyrefuseddoses?

• Anyintoxicatedpresentations?

• Isthepatientpaidup-to-date?

• Anyotherconcerns?

Local arrangements may need to be developed to ensure that the pharmacist knows when the review date is—though usually thiswillbeaweekorsobeforethescriptexpires.

If the GP is using a GPMP, the GP may decide to organise a Team Care Arrangement (TCA) at any point where collaboration withotherhealthprofessionalswouldsupportthepatient.Inaddition, under the Enhanced Primary Care item numbers, a CommunityCaseConferencemaybeorganisedifindicated.TheGPmayeitherparticipatein(items740,742,744)orbetheorganiserofaCommunityCaseConference(items759,762,765).

At six months, unless indicated earlier, the GP may conduct a ReviewoftheGPMHCPorGPMP(seeStep7).

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http://www.health.nsw.gov.au/policies/gl/2006/pdf/GL2006_019.pdf



http://www.racp.edu.au/index.cfm?objectId=1A4852EF-FF7C-429D-B7D38051518D41CF



24.



Consideration for rural and remote areas. Rural isolation may place limitations on some patients’ abilitytotravel.Theimpactofthesehurdlesneedstoberecognised, especially early in treatment where they may actasadisincentivetoremainingintreatment.Intermsoffrequency of appointments, both clinics and GPs need to ensure a balance between what is reasonable to expect from a patient in terms of travel (cost, time, presence of public transport),otherresponsibilitiesandtheirclinicalneeds.

In some circumstances, scripts may need to be provided for periodsinexcessoftherecommended3monthmaximumperiod.Wherethisoccurs,everyeffortshouldbemadetoensurethatthescriptisflexibletomeetthepatient’sneedswhilenotcompromisingsafetyorpromotingdestabilisation.

Where community drug and alcohol workers are available the GP may request that they review the patient to ensure that they are on a stable dose and not in receipt ofinappropriatetakeawaydoses.Inaddition,appropriatereporting mechanisms should be in place between the pharmacy and the prescriber to ensure that in between reviews,shouldproblemsemerge,thesecanbeidentifiedearly.Suchcontactshouldbeatleast3monthly.

In rural areas, isolated practitioners or pharmacies with few support staff may feel vulnerable should they encounter episodesofaggressionfrompatients.Itmaybethatadditional work is required within rural and remote areas to engage and retain both GPs and community pharmacies who may have an negative opinion of the work involved in deliveringopioidtreatment.

Additionally local services will need to work collaboratively to incorporate rural doctors into routine prescribing, to achievemanageabilityinsupportofthepatients.Thisisanarea the clinic NUMs can manage by providing community supportandliaison.

Contracts covering pharmacies and public sites should also extend to doctors’ consulting rooms to ensure the patient is aware that expectations of reasonable behaviour are not limitedtodosingsites.

Click here for details on Providing Reducing Scripts to Maintenance Patients.

Step 7 Review of plan (GPMHCP or GPMP or TCA)Process and Documentation Reviewconducted4weeksto6monthsafterinitialplan.

The review date should be set and documented at the time ofplanpreparation.Thereviewshouldcovereachaspectoftheoriginalplan,sothateachitemcanbetickedoff.Patientconsent is required, and a further review date is to be set at theconclusionofeachreview.Therequirementsofthereviewinclude the patient’s agreement and a record of progress against goals,withmodificationoftheplanifrequired.Anyoutcometoolsusedintheinitialassessmentmustbereadministered.

Formal review of the GPMHCP (or GPMP) is recommended six monthly, but it may be done more frequently if indicated by a changeinthepatient’slevelofstability.

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25.



Step 8 Additional steps for the development of a GP Management Plan (GPMP)Process AGPManagementPlan(GPMP)(item721)andrelateditemsmay be used in addition to a GPMHCP when a patient has a chronic physical problem, such as hepatitis C, requiring treatment.Theplanmustbedevelopedbythepatient’s‘usual’GPforaconditionthathas,orwill,lastformorethansixmonths.A GPMP may be completed in addition to a GPMHCP, and may nowbedoneonthesameday.

The patient’s consent must be obtained for the development of the GPMP, and an explanation given to the patient of the steps involved.Theplanmustbeacomprehensivedocumentthatsetsout and enables evidence-based management of the patient’s healthandcareneeds.

A large part of the information obtained to complete the GPMHCP can appropriately be utilised in the development of aGPMP.Additionalinformationregardingthespecificchronicmedicalconditionswillneedtobeexploredasrequired.

It is recommended that the following items be included in the GPMP:

• thepatient’shealthcareneeds,healthproblemsand relevantconditions;

• managementgoalswithwhichthepatientagrees;

• actionstobetakenbythepatient;

• treatmentsandservicesthepatientislikelytoneed;

• arrangementsforprovidingthetreatmentandservices;and

• areviewdatefortheGPMP.

The GPMP and the patient’s agreement must be documented in thepatient’sfile.

Uponcompletion,acopyoftheplanshouldbeofferedtothepatient.

In addition, the GP may decide it is appropriate to conduct a 45Year Old Health Check(item717)oranAboriginal Health Check (items704-710).

Documentation A checklist and GPMP sample form are available at the DoHAwebsite.

Step 9 Team Care Arrangement (TCA)Process Under the Enhanced Primary Care Program (EPC) Chronic Disease Management (CDM) item numbers, if a GPMP is in place, the GP may also institute a Team Care Arrangement (TCA)(item723).ATCAisappropriateforpatientswhorequireongoing care from a multidisciplinary team of at least three healthcareproviders(includingtheGP).Werecommendinthe case of those with opioid dependence that a TCA also be developedaswellasaGPMP.TheGPcanusetheinformationprovided by the OTP clinic and the HMR report from the pharmacytocompleteaTCA.

The patient’s consent must be obtained for the development of a TCA, and an explanation given to the patient of the stepsinvolved.TheGPshoulddiscusswiththepatientthecollaborating providers who would contribute to and provide treatmentandservicestothepatient.

A TCA requires preparation of a document that describes:

• thetreatmentandservicegoalsforthepatient;

• thetreatmentandservicesthatcollaboratingproviders wouldprovidetothepatient;

• actionstobetakenbythepatient;and

• areviewdatefortheTCA.

The TCA and the patient’s agreement to it must be documented inthepatient’sfile.

Upon completion, a copy of the TCA should be offered to the patient and relevant parts of the TCA given to the collaborating providers.

Documentation A checklist and sample TCA formareavailableattheDoHAwebsite.

Step 10 GPMP and TCA referral to allied health Process and Documentation Under the GPMP, when a TCA is in place, the GP may refer to a range of eligible allied health professionals (including physiotherapists, dieticians, podiatrists and others) for a limited numberofsessionsperyear.

In addition, dental referrals may be made for a limited range of conditions when a dental problem is impacting on other healthproblems.ADental Care Factsheet is available which detailstheseconditions.CurrentReferral form for Dental Care is availableforusewiththeGPMPandTCA.

NOTE: New Dental Care items will become available through Medicare on November 1st 2007

Steps 11-12 as for Steps 6-7

Additional Steps

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http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pacd-medicare-resource-kit#http://www.health.gov.au/internet/wcms/



http://www.health.gov.au/internet/wcms/publishing.nsf/Content/Allied+Health+and+Dental+Care+initiative

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-dental-cnt.htm


26.



Patientstransferredtoyourcareunderthe‘patientjourney’aresupportedbyaguarantee,sothatshouldaGPfindtheyarenolonger able to prescribe because of concerns about the patient’s well-being, they are able to return the patient to the care of the clinic, for either short term or long term care by clinic staff and specialistprescriber.

For urgent professional support, ring the NSW Drug and Alcohol SpecialistAdvisoryService(DASAS)(Sydney0293618006orforcallersoutsideSydney1800023687).DASASisa24hourtelephone service for the clinical management of patients with alcoholandotherdrugrelatedproblems.

In addition, GP Psych Support is a free service available in all States and Territories which provides GPs with patient managementadvicefrompsychiatristswithin24hoursandnowincludesadviceonsubstanceuse(1800200588or www.psychsupport.com.au,asecureandpasswordprotectedwebsite).

The following steps should be taken should you wish your patient to be reviewed by or returned to the clinic or to the specialistprescriber.

1. Anyconcernsyouhaveaboutthepatient’sstabilityshouldbe addressedassoonaspossible.

2. Yourconcernsshouldbediscussedwiththepatient.

3. Intheabsenceofavailablelocalspecialistadvice (perhaps out of hours) the GP can contact the DASAS (numbersabove).

4. Assoonaspossible,theclinicshouldbecontacted, specificallyeithertheNUMorthespecialistorthepatient’s previouscasemanager.

5. Thenatureofyourproblem/concern/requestshould bemadeclear.

6. Theclinic’sresponseshouldwithoutfuss,delayorprevarication betorespondinapositivemannertoyourrequest.

7. Discusstheclinic’sresponsewiththepatient.

8. Appropriateresponsesbytheclinicwillbedetermined by the nature of the request and may include the following scenarios:

8.1 Theclinicarrangesurgentclinicalreviewbya staffmember.

8.2 TheGPcontinuestoprescribebutthepatientreturnsto the public clinic for dosing in the short term until stabilityisregained.Thiswillrequirecancellingofthe existing script with the pharmacy and a new script by theGPforclinicdosing.TheGPmustnotifythe pharmacy of the change in dosing site and cancellation ofthescript.

8.3 Temporaryrespiteprescribingtakenoverbythe specialist prescriber until the patient has restabilised, in additiontothechangeindosingsite.Insuchcases the GP needs to notify the pharmacy of the change in dosing site, cancel the existing script and notify the PSB that another doctor will be acting as a locum prescriber ontheirbehalfforthispatient.Thespecialistprescriber willprovideascriptforclinicdosing.

8.4 Fullreturnofthepatient’sprescribingtothepublic prescriber,inadditiontothechangeindosingsite.In such cases the GP needs to notify the pharmacy of the change in dosing site and cancel the existing script with thepharmacy.

The GP also needs to notify PSB that another prescriber istakingoverprescribingforthispatient.Thisinvolves submittinganExitFormtoPSB.TheExitFormshouldbe dated to match with the date the specialist prescriber will commence prescribing, and will require liaising with the clinic to ensure the smooth transfer of authority toprescribe.

8.5 TheGPneednotbediscouragedandshouldtakeon anotherstablepatientassoonaspractical.

Next (possible but unlikely) step for a GP Returning your patients to clinic care when unstable

3Return to Introduction 3Return to Summary Table 3Return to Step 1

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27.



Transferring a Patient’s Dosing from a Public Clinic to a Community Pharmacy

Typicallythefirststepintransferringapatient’scarefromspecialistclinictocommunitycareistotransferthepatient’sdosingtoacommunitypharmacy.AperiodofmaintainedstabilityatacommunitypharmacyfollowingtransferisagoodindicationthatthepatienthascontinuedtodowellandwillbesuitablefortransfertoaGPforprescribing.

For many patients there will be budgetary issues associated with the cost of dosing at a community pharmacy (and paying GP consultationcosts),andthesecanbediscussedbetweenthepatientandtheclinic.Budgetingadvicemaybehelpfultothepatientandcanbeprovidedbyclinicstaffdependingontheirskillsandexperienceinthisarea.Whenrequired,thepatientmaybereferredtooneofthelocalcommunitygroupsornon-governmentagencieswhichassistwithbudgetingadvice.

Transferofpatientsfromapublicclinicdosingsitetoacommunitypharmacydosingsiteallowsgreaterflexibilityindosinghours,andprovidesthepatientgreatercontrolinorganisingtheirdailylives.Thepatientwillhaveusuallybeenstableforaminimumofthreemonthsatapublicclinictobeeligibleforthistransfer(thismaybeless,especiallyforthoseonbuprenorphine).Prescribingandcareplanningremainwiththeclinicatthisstage.

The Stability Assessment Flowchart is recommended for use by either the clinic staff or the prescriber to assess patient suitability fortransfer.Theflowchartisdesignedtobecompletedinconsultationwiththepatient.Itcanthen,with the patient’s informed consent, befaxedtothepharmacistwiththepatient’sidentificationdetailsandprescription.Thiswillassistthepharmacisttoknowwhat assessment has been conducted at the clinic, and it will also provide a list of items for the pharmacist to consider in providing routinefeedbacktotheclinic(suchasattendanceandoverallpresentation)attimeofprescriptionreviews.

Attachments

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28.



Time Frames for Care Planning and Reviews*

*DetailsandrebatescurrentatJune2007.Forupdates,gotohttp://www9.health.gov.au/mbs/search.cfm.

1. GPMHCP & review

Name Better Access Item Item No Rebate $

Recommended frequency

Minimum Claiming Period*

Preparation of a GPMHCP

2710 150.00 2yearly 12months*

Mental health care consultation

2713 66.00 3monthly 12months*

Review of a GPMHCP 2712 100.00 6monthly 3months*

2. GPMP, Review, TCA, Review

Name Chronic Disease Management item Item No Rebate $

Recommended frequency


Preparation of a GP Management Plan


Preparation of Team Care Arrangements


Review of a GP Management Plan


Coordination of Review of Team Care Arrangements


Contribution to a multidisciplinary care plan or Team Care Arrangements


*These services can also be provided more frequently in ’exceptional circumstances’—where there has been a significant change in the patient’s clinical condition or care circumstances (such as development of comorbidities or complications, deteriorating condition, illness/death of carer etc) that require a new GPMHCP or review , a new GPMP, TCA or review service.

3. Other

Item Name Item No Rebate $Recommended frequency


Aboriginal Health Check

704-710 167.45–236.85 Annuallyforunder15andover55;onceevery18monthsfor others

45YearOldHealthCheck

717 100.00 Once between ages 45-49

Once only

The Medicare Benefits Schedule book contains all the requirements of a GPMP, TCA and GPMHCP and it is essential you check these details yourself before billing these items.

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http://www9.health.gov.au/mbs/search.cfm

29.



An Example of Medicare Items and Rebates first 12 months*

*DetailsandrebatescurrentatJune2007.Forupdates,gotohttp://www9.health.gov.au/mbs/search.cfm.

Patient flow – first six weeks…

1stConsAdmission;Needsassessment

GP Mental Health Care Consultation

Item2713+/-23,10990 $66.00+/-$37.40

2nd ConsGPMHCP

GP Mental Health Care Plan Item2710+/-23,10990 $150.00+/-$37.40

3rd ConsGPMP

GP Management Plan Item721+/-23,10990 $124.95+/-$37.40

4th ConsTCA

Team Care Arrangement Item723+/-23,10990 $98.95+/-$37.40

5th ConsContinuing care

Level B Item23 $32.10+/-$5.30

6th ConsultationPossible HMR

HMR Item900+/-23,10990 $134.10+/-$37.40

Totals $509.40—$657.25

Patient flow - the next three months…

7thConsWk8OngoingCare Level B Item23 $32.10+/-$5.30

8thConsWk10Ongoing Care

Level B Item23 $32.10+/-$5.30

9thConsWk12Case Conference

Case Conference 15-30minutes

Item740+/-23,10990 $83.75+/-$37.40

10thConsWk14GP Plan Review

GP Mental Health Care Plan Review

Item2712+/-23,10990 $100.00+/-$37.40

11thConsWk16GP Management Plan Review*

GP Management Plan Review*

Item725+/-23,10990 $62.50+/-$37.40

12thConsWk18TCA ReviewOngoing Care

TCA Review Item727+/-23,10990 $62.50+/-$37.40

Totals $372.95—$554.35

Patient flow - Ongoing yearly cashflow

Week0—6 $509.40—$657.25

Week7—18 $372.95—$554.35

Week19—30 $372.95—$554.35

Week30—52 $372.95—$554.35

Total $1628.25—$2320.30

The Medicare Benefits Schedule book contains all the requirements of a GPMP, TCA and GPMHCP and it is essential you check these details yourself before billing these items.

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30.



<CLINIC NAME AND ADDRESS>

<DATE>

Dear client

Youhavebeenreceivingtreatmentatthisclinicfor……months/years.Wehavebeenveryhappywithyourprogressandatthispointwewouldlikeyoutoconsidertransferringyourcare(includingprescribingyouropioidtreatment)toaGPofyourchoice.

The advantages of having a GP become your prescriber are:

1. integrationofallyourhealthcarewithonedoctor;

2. accesstoahostofMedicareservicesthatcanbeveryusefultoyou,suchaspsychology,dental,andoccupationaltherapy;

3. increasedflexibilityofyourtreatment;

4. nothavingtocometothisclinic!

Should you ever require a specialist review of your problem your GP always has access to us (and of course you can always pick up thephoneandcallusifyouneedto).

We want to move stable patients on so that our specialist doctors can look after other patients such as those with multiple problems whomayneedtreatmenturgently,especiallythosewhohavenotreceivedtreatmentbefore,andwhowillbenefitfromtheskillsofthespecialistdoctors.

FinallyweunderstandthatforsomeofyouamovetoaGPwillmeanadditionalcosts.WehopethatmostGPswillbebulkbillingandwehaveprocessesinplacetohelptheminmaximisingtheincometheycangeneratebyprovidingyouropioidtreatmentcare.

Finally, when you move to a new prescriber there is often the requirement to see them more frequently initially than you would havebeenseeingyourpublicprescriber.Thisisbecausetheywillwanttogettoknowyou(andyouthem)andgetcomfortablewithprescribing,especiallywhentakeawaysareinvolved.Italsomeansthattheycanplanothertreatmentsorreferralsyoumayneed.IfaccessingyourGPmorefrequentlyisaproblem,pleasediscussthiswithusoryourGP.

InordertohelpyouaccessaGPaboutthisissuewehavedevelopedaletterforyoutotaketothemwhichyoucanhaveonrequest.

Ifyouhaveanyquestions,askus.

<INSERT NAME AND POSITION – NUM, CASE MANAGER ETC>

Sample Letter from Clinic to Client 3Return to Summary GPMHCP 3Return to Step 1.1

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31.



<INSERT LETTERHEAD>

<INSERT GP NAME & ADDRESS IF KNOWN>

<INSERT DATE>

Dear GP

Your patient…<INSERT PATIENT NAME>…hasbeenintreatmentasaclientofourserviceforthelast……years.Wecanconfirmthattheclientisdoingverywell,thatis,isstable(astabledoseofmedication,asignificantreductionorcessationofinjectingheroinorotherdrugs,goodattendance,nodoserefusalordiversion,noriskofoverdose,noacutephysicalormentalhealthproblems).Inourassessmentthisclientcouldappropriatelybemanagedinprimarycare.AttheclinicwearekeentoencouragestableclientstoconsiderhavingtheirownGPbecometheirprescriber,inadditiontobeingtheirprimarycareprovider.

Whiletheadvantagesofholisticandintegratedcarefortheclientareobvious,thebenefitsalsoextendtothewiderlocalpopulation.Thisclinicwillbeabletooffertreatmenttonewclientsandthosewithspecialistneedsasstableclientstransfertoprimarycare.Patients of primary care providers are able to access a wider range of community based health care services through the use of Medicarecareplansandrebates.

Don’tworryifyouhaveneverprescribedbefore!Evenifyouarenotanaccreditedprescriber,youarestillabletoprescribeforuptofive(5)patientsunderthesupervisionofanaccreditedprescriber(usuallyaspecialistoranexperiencedGP).

The clinic staff would be able to support you by providing the following:

1. Aclinicalsummaryoftheclient’shistoryandassessmentofstability.

2. Guidanceonprescribingsafely.

3. AdviceonusingthecommunitypharmacytoconductaHomeMedicinesReview(HMR).

4. AguidetomaximisingboththecareyouprovideandtheremunerationyoucanobtainthroughtheuseofexistingGPcareplan rebatessuchastheGPMHCP,GPMP,TCAandrelateditems.

5. Anassuranceofongoingsupporttoyou,andpatientreviewshouldthisberequired.

We have discussed this with your patient, and we were hoping that you might be interested in taking over the prescribing of <INSERT NAMEOFMEDICATIONMethadone/Buprenorphine>.

The patient is currently prescribed……mg /day <SPECIFY IF ALTERNATE DAY BUPRENORPHINE>, receives……takeaways each week, and is dosed at <INSERT NAME AND PHONE NUMBER OF PHARMACY>.Atpresentthepatientisseenbyourprescriberevery……weeks.

Should you have any issues or concerns regarding the stability of your patient or the most appropriate management, we are very happytosupportandadviseyouasrequired.Ifrequested,theservice/specialistwillreviewthepatientandifnecessary,bringthepatientbacktotheclinicforaperiodtotimetoallowrestabilisation.

ThespecialistdoctorwhowouldbeyoursupportisDr………………………………………………………………………………..

The Caseworker is ………………………………………………………………………………………………………………………

TheNurseUnitManageris……………………………………………………………………………………………………………....

If you think you would be interested in taking over the management of this client’s opioid treatment, please let your patient know andwewillcontactyousowecancommencethetransferprocess.

Ifyouwouldliketodiscussthisfurtherpleasecallmeon……………………………………………………………………………...

………………………………………………<NUM>

………………………………………………<CLINIC CONTACT DETAILS>

Sample Letter from Clinic to GP 3Return to Summary GPMHCP 3Return to Step 1.1 3Return to Flowchart 2

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32.



Stability Assessment Flowchart 3Return to Summary GPMHCP 3Return to Step 1.1 3Return to Step 6

Contraindicationstotransfertocommunitypharmacy:(behaviourlast4-8weeks)

Anyoftheseshouldbeseenasacontraindicationtocommunitytransfer.

Parameter Comment

Medication stability

Recent diversion

Erratic / threatening behaviour

Irregular attendance for pick up

Episodes of refused dosing / presenting intoxicated

Regular problematic injecting drug use

Urine drug screen results

Unstable / risky substance use

Recent attempts at self harm / overdose

Acutesignificantmentalhealthproblems

Acutesignificantphysicalhealthissues

Unstable accommodation

Budgeting concerns

Child risk or protection issues

The client should remain at the clinic and in discussion with their case manger/prescriber causes for current instability should be identifiedandaddressedinarevisedcare.Transfershouldberevisitedin8weeks.

Parameter Comment

Attends regularly / good presentation

Budgeting capacity

No recent diversion

Urinesandexaminationshowsignificantlyreduced/niluse

No dependence upon benzodiazepines / alcohol

Employment / carer requirements

Stable accommodation / social situation

Education commitments

No refused doses

No recent / regular / IV use / overdose

No current mental health issues

Patient does not want to be dosed at public clinic

Indicationstosupporttransfer.Ifnocontraindications,thenconsiderfortransfer.

Find pharmacy

Arrange prescriber review

Arrange transfer

Remind re safe storage of medications

Maximumof4weekscriptsforfirst3months.

No or very limited takeaway

Regular feedback /contact with dosingpharmacy.

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33.



The Patient’s Priorities for Care

3Return to Summary GPMHCP 3Return to Summary GPMP 3Return to Step 1.2

Patient name & date

How do I feel about having to move my treatment? What can be done to ease this transition?

Do I have any problems at the pharmacy?

Am I on enough methadone or buprenorphine? Am I hanging out before dosing? Do I feel like using? Do I go on the nod?

Is my use of drugs or alcohol causing me worry, problems or putting me or others at risk?

Am I taking any over the counter or prescribed medications that I need to tell my doctor about?

Any side effects of medication I want to talk about? e.g.headache,constipation,sweating,sexualproblems,nausea, sedation

Am I seeing any other doctors, health care workers, or support people from child protection, probation and parole, Centrelink?

Do I have any health concerns I’d like to address over the next few months? For example hepatitis C, my teeth?

Would I like somebody close to me to be involved in my care as a support person?

Are there commitments that may affect me keeping appointments, for example, work, study, that I need to tell my GP about?

Is there anything I ever wanted to know about treatment but was afraid to ask?

Do I want a copy of my care plan?

Where do I want to be in six months time? Twelve months time? Five years time?

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34.



GP: Assessing Risk and Comorbidity 3Return to Assessment

Therearefourspecificareasforassessmentinopioiddependentpatients,inadditiontotheusualexaminationandassessment.

1. Medication stability

The following questions are useful for assessing the patient’s medication stability:

• Isyourpatientfreefromwithdrawalsymptomsforthefullinter-dosingperiod?

• Dotheycraveforheroin?

• Dotheyuseheroinontopoftheirmedication?

• Iftheydoinject,dotheyobtainasignificantpositiveeffect?

• Iftheyexperiencewithdrawalbeforedosingaretheycontinuingtocraveoraretheyusingheroin? (Wherethepatientis‘hangingout’beforedosingorwhen‘on-top’heroinuseispositivelyreinforcing,thepatientshouldbe encouragedtoincreasetheirdose).

• Dotheyexperienceanysideeffectssuchassexualdysfunction,sweatingorconstipationthatyoumaybeabletohelpwith?

• Dotheyexperiencepeakdosesedationandsleepduringtheday,makingsleepatnightdifficult?

• Dotheymixtheirmethadoneorbuprenorphinewithothersedativedrugsoralcohol?

• Dotheydrinkexcessiveamountsofcaffeine-containingdrinks?

• Dotheyneedsleephygieneinterventions?

• Dotheyevermissdoses?

• Doesthedosingsitehaveanyconcernsabouttheirpresentationorthepossibilityofdiversion?

• Iftakeawaydosesareprovided,aretheystoredsafelyandoutofreachofchildren?

2. Drug use

• DotheyuseotherdrugsespeciallyCNSdepressantsthatmayputthematriskofoverdose?

• Dotheyprescription-shopforbenzodiazepines?(seePrescriptionShoppingProgram)

• DoyouneedtogetthemtosignaMedicare‘prescriptionshopping’(formerlyknownas‘doctorshopping’)form?

• Iftheyuseanyothersubstances,whatistherouteofadministration?Iftheyarestillinjecting(evenifrarely),dotheyshare equipment? Have they been advised of the risks of sharing, and where to get clean needles? Do they dispose of used needles safely?

3. Other health issues (may indicate need for GPMP)

• Hasthepatientbeenscreenedforhepatitis?

• Dotheyneedorwantareferralfortreatmentorvaccination?

• Dotheyhaveanyotherchronicmedicalconditionsyoucanhelpwith?

• Isthereacurrentmentalillnessthatneedstreating?

• Aretheyonpsychiatricmedication?Dotheytakeit?

• Canthepharmacistdispensepsychiatricmedicationormedicationswithamisusepotentialinsmallerquantitieswithan increasedfrequencyofpickup?(Thismayincreasecomplianceandreducetheriskofdiversion.)Ifso,atwhatcost?

• Isthepatientatriskofoverdoseorselfharm?

4. Psychosocial

• Arethereissuesrelatingtoparenting,work,education,accommodation,driving,orcriminaljusticethatyouneedto address with the patient?

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35.



Medication stability

• Cessationorasignificantreductionininjectingopioiduse

• Cessationorasignificantreductioninotherinjectingdruguse

• Freefromwithdrawalforthefullinterdosingperiod

• Freefromseveresideeffectsortoxicity

Drug use stability

• Cessationorasignificantreductioninuseofalcohol/benzodiazepines

• Cessationofbingepolydruguseandalcohol

• Reductioninriskofoverdose

• ReductioninriskofBBVtransmission

Health improvement

• Mentalhealth

• Tobaccocessation

• Dietandexercise

• Sleephygiene

• Reduction/managementofmedicationrelatedsideeffects

• Dentalsupport

• ImprovedmanagementofhepatitisCvirus

• VaccinationforhepatitisB

• Improvedsexualhealthandfamilyplanning

Psychosocial support

• Parentingsupportandchildriskreduction

• Employmentandeducation

GP: Prescriber Goals Specific to Opioid Dependent Patients 3Return to Goals

3Return to Contents

36.



3 Return to Step 6

Patientsshouldbesupportedtoreducetheirdoseiftheyrequestit.Howeverthisshouldonlybedonewhensuchareductionisunlikelytoprecipitatedestabilisation.Theprocessofgradualwithdrawalisofteninterruptedbysetbacksandthusrequirescarefulmonitoring.Itisforthisreasonthatreducingscriptsshouldspecifyadosetowhichthepatientmayreducebeforerequiringanotherprescriberreview.Forexampleifapatientison80mg(16mls)methadonedaily,thepatientmayreduceby2.5mg-5mg,(½-1ml)every1-2weeksatpatientrequesttoaminimumof60mg(12mls)dailybeforenextreview.Thatis,ifthepatientwantstoreducebelow60mgtheyneedtoseeyoutheprescriber.

Equivalentdosereductionsforthoseonbuprenorphinemaintenancearetypically2mgevery1-2weeksastoleratedbythepatient.Inmonitoringthoseonareducingscript,considerationshouldbegiventorisksforareturntoillicitopioiduse.Thesemayincludesocial factors such as the return of an opioid using partner or the loss of a loved one, or an increase in craving for opioids if the patientweretoexperiencewithdrawalasthedosewasreduced.Whentheprescriberordersareducingscript,itisimportantthatthepharmacyactsatthepatient’srequest,withinthescript.Anyconcernsofthepharmacistinprovidingreducingdosesshouldbediscusseddirectlywiththeprescriber.

Should a patient return to injecting drug use during a period of a gradual withdrawal from treatment, they should be advised to stop theirreductionandrequesturgentreviewwiththeprescriber.Inmostcasesanincreaseindosewouldberequiredtorestabilisethepatient.Youmaychoosetodiscusssuchcaseswithanotherprescriberoryoursupportspecialistatthepublicclinic.

GP: Providing Reducing Scripts to Maintenance Patients

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37.



GP: Review Proforma for Opioid Dependent Patients

3Return to Summary GPMHCP 3Return to Summary GPMP 3Return to Step 2.2 3Return to Step 6

Medication stability – adequacy of prescribed dose Yes No Comments

Does the patient experience any withdrawal between doses?

Doesthepatientgo‘onthenod’afterdosing(peakdosesedation)?

Is the patient still experiencing craving for heroin?

Ifthepatientisusingheroindotheygetasignificanteffect(induction of tolerance)?

Does the patient experience any problematic adverse effects?

Is the patient on other prescribed medications?

Are any changes to current script required?

Drug Use Present Absent Comments/Change treatment

Is there evidence of recent injection on examination?

Are you having problems obtaining urines from the patient?

Is there evidence of drug use from the urine screen?

Is there any evidence from the pharmacy that suggests instability such as missed doses/ intoxicated presentations/refused doses etc?

Is the patient reporting ongoing drug use?

Psychosocial Stability Present Absent Comments

DNA at prescriber reviews

DNA at case manager reviews

Behaviour concerns-violence/aggression

Employment/education concerns

Child risk issues

Significantmentalhealth/selfharmrisk

Significantactivephysicalhealthissues

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38.



Patient Review Form (Pharmacy Guild)

CONFIDENTIAL

Thisfacsimile/ReviewFormcontainsconfidentialinformation,whichisintendedonlyforusebytheaddressee.Ifyouhavereceivedthisfacsimile/Review Form in error you are advised that any copying, distribution, disclosure or the taking of any action based on the contents of this information isstrictlyprohibited.Ifyouarenottheintendedrecipientcouldyoupleasenotifyusimmediately.

PATIENT REVIEW FORM - COMMUNITY PHARMACY BUPRENORPHINE / METHADONE TREATMENT

PATIENT’S NAME:

_____________________________________________

DOB:

_____________________________________________

ADDRESS: ____________________________________

_____________________________________________

PRESCRIBER’S NAME:

___________________________________________________________

PHARMACIST’S NAME:

___________________________________________________________

CASE MANAGER’S NAME:

___________________________________________________________

Treatment with:Methadone Buprenorphine (sublingual technique checked)

Current dose: ___________T/A per week______________Client is aware of the correct storage of T/A doses Yes No Current medications which may interact with or affect the metabolism of methadone or buprenorphine: ____________________________________________________________________________________________________________

Number of occasions the patient presented intoxicated in last month:______________

Does the pharmacist or staff have concerns about patient behaviour:______________

Number of missed doses in last month: ____________

Are takeaway doses safely stored:

Yes No

Has the patient presented with any of the following Clinical symptoms? (Indicate by circling symptom) sleep disturbance, aches, pains, teeth/dental problems, reduced libido, lethargy, excessive sweating

Any known problems with illicit drug use? Yes No

Any recent symptoms or issues relating to the patient whichmayberelevanttotheirtreatmente.g.health,social,financial,family or emotional problems Yes No

Would you like the prescriber to contact you? Yes No

Pharmacist's telephone number: _______________________________________

PHARMACIST’S SIGNATURE:_________________________________________

Date:__________________

3Return to Summary GPMHCP 3Return to Summary GPMP

NSW BRANCH

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39.



Monitoring Stability in Community Dosed OTP Patients by Pharmacists 3Return to Summary GPMHCP

3Return to Summary GPMP 3Return to Step 6

Name:_____________________________________________ Dosing period: _______________________________________

Pharmacy name: ___________________________________

Factor Outcome Comment

Any missed doses (insert number)*

Erratic/threatening behaviour (Y or N)*

Payment (up to date or $ debt)*

Episodesofrefuseddosing/presentingintoxicated*.

Recent diversion attempts*

Concerns over patient stability*

Last dose and reported medication stability

Dose changes (up, down, the same)

Pathology requests for urine screen provided to patient by pharmacy (number, no, or N/A)

Child risk or protection issues

* any of these may lead you to request an early clinic or prescriber review

Please answer the following questions

Are you happy to continue to provide dosing for this patient? yes no

Do you think they are doing well? yes no

Do you think the number of takeaways provided is appropriate? yes no

Do you have any concerns at all about this patient? yes no

Would you like someone from the clinic to contact you? yes no

Any other comments?

Pharmacist _______________________________________ Date _______________________________________ Patient _______________________________________ Date _______________________________________

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40.



Prescription Shopping Program 3Return to Assessment

Medicare Australia provides a service which assists doctors to identify patients who are getting PharmaceuticalBenefitsScheme (PBS)medicinesinexcessofmedicalneed.Formoreinformation,gototheMedicarePrescription Shopping Program website.

Usually, patient consent is obtained before a GP accesses this service, however Medicare Australia has the authority to disclose withoutconsent,specificandlimitedPBSinformationtoadoctorabouttheirpatientswhomaybegettingPBSmedicineinexcessofmedicalneed.ThespecificdetailsofthecircumstancesunderwhichthismayoccuraredetailedbythefederalOfficeofthePrivacyCommissioner in InformationSheet19-2007 The Prescription Shopping Information Service (PSIS) and The Privacy Act.

First, the doctor needs to register, that is, complete and sign the Registration Formandfaxitto(02)61247820.MedicareAustraliawillprovideconfirmationofregistrationbyfaxwithin2businessdaysorbymailifafaxnumberisnotprovided.Onceregistered,adoctorcancalltheInformationService24hoursaday,sevendaysaweekon1800631181.

MedicareAustraliacanalsocontactaprescriberiftheirpatientisidentifiedunderthePrescription Shopping Program.

Medicare Urine Drug Screen Item Numbers*

Driving

UndertheMedicareBenefitsSchedule(MBS),Category6PathologyServices,thereareanumberofMedicareitemnumbersavailableforurinedrugscreeninginvariouscircumstances.ThemostappropriateforGPstousewiththosepatientsonanOTPisitem66626,whichhasalimitof36servicesperyear.

ForotherpatientsnotonanOTP,item66623maybemoreappropriate.Pathologylaboratoriesareabletoadviseonthismatter.Forfurtherinformation, see Search the MBS.IfaparticulartestisrequiredGPsshouldconfirmwhichdrugswillbetestedforinadditiontoopioids.

‘TheRoadTransport(SafetyandTrafficManagement)Act1999providespolicewiththepowertostopapersonsuspectedofdrivingundertheinfluenceofanydrug.Thereisnoevidencethatmethadonehasanyeffectondrivingskillswheretheindividualisonastabledose.Aperson’sdrivingmay,however,beimpairediftheyhavejustcommencedmethadonetreatment,havehadachangeindoseorhaveusedalcoholorotherdrugsinadditiontotheirmethadonetreatment.Asaresult,methadonetakeawaydosesarelabelledwithawarningtothiseffect.Aswithalldrugs,includingalcohol,itistheindividual’sresponsibilitytogaugetheirabilitytodrive.Healthprofessionalsareadvisedtoinformanindividualofthepotentialeffectofadrugondriving-relatedskills.TheuseorattempteduseofavehicleundertheinfluenceofalcoholoranyotherdrugincludingmethadoneisanoffenceprosecutedundertheRoadTransport(SafetyandTrafficManagement)Act1999.’ExtracttakenfromthecurrentissueoftheNSW‘GuidelinesforPolice:MethadoneandotherPharmacotherapies’,page6.

Theissueofdrivingisoneofconcerntobothindividualsandtocommunities.Lossofalicencetodrivehasthepotentialtodramaticallyaffectanindividual’slivingstandards.Thesignificanceofthisshouldbefullyunderstoodbyallparties.Wherethereisconcernaboutfitnesstodrive,theclinicianshouldadvisethepatientoftheirconcernsandrequestthattheynotifytheirlocaldrivingauthority.Incaseswheretheclinicianisconcernedbytherisksthatthepatientposestothemselvesandtoothers,shouldtheycontinue to hold a driving licence, consideration should be given to the patient’s doctor directly notifying the driving authority in theirState.Forfurtherinformationpleasegotowww.austroads.com.au.

*DetailscurrentatJune2007

3Return to Contents

http://www.health.gov.au/pbs#http://www.health.gov.au/pbs

http://www.medicareaustralia.gov.au/providers/programs_services/pbs/prescription_shop.shtml

http://www.privacy.gov.au/publications/IS19_07.html

http://www.medicareaustralia.gov.au/resources/pbs/ma_prescription_shopping_info_service_registration_form.pdf


http://www9.health.gov.au/mbs/search.cfm#http://www9.health.gov.au/mbs/search.cf

www.austroads.com.au

41.



Links to Resources

New South Wales Medical Board http://www.nswmb.org.au

Search the Medicare Benefits Schedule http://www9.health.gov.au/mbs/search.cfm

Support services For patients (NSW) AlcoholandDrugInformationService(ADIS)Sydney0293618000orforcallersoutsideSydney1800422599

For health professionals NSWDrugandAlcoholSpecialistAdvisoryService(DASAS)Sydney0293618006orforcallersoutsideSydney1800023687

For GPs GP Psych Support provides GPs with patient management advice from psychiatristswithin24hours http://www.psychsupport.com.au/

GP Care For diagnostic and treatment related information go to http://www.gpcare.org/

Clinical Guidelines NSW Health New South Wales Opioid Treatment Program Clinical Guidelines for Methadone and Buprenorphine Treatment of Opioid Dependence (2006) http://www.health.nsw.gov.au/policies/gl/2006/pdf/GL2006_019.pdf

Australasian Chapter of Addiction Medicine Clinical Guidelines: Assessing Suitability for Unsupervised Medication Doses in the Treatment of Opioid Dependency (2006) http://www.racp.edu.au/index.cfm?objectId=1A4852EF-FF7C-429D-B7D38051518D41CF

Australian General Practice Network (AGPN) Divisions Directory http://www.agpn.com.au/site/index.cfm?module=DIVISION&state_code=NSW

For comprehensive information on the Better Access initiative, go to http://www.primarymentalhealth.com.au/site/index.cfm?display=18157 then go to the Better Access Orientation Manual.

Patient Pathways http://www.primarymentalhealth.com.au/client_images/74941.pdf

Three components of the Better Access initiative http://www.primarymentalhealth.com.au/client_images/74978.pdf

Fees and Rebates for Better Access items http://www.primarymentalhealth.com.au/client_images/76001.pdf

Finding a Mental Health Allied Health Professional http://www.primarymentalhealth.com.au/site/index.cfm?display=18177

Can Do initiative: Managing Mental Health and Substance Use in General Practice http://www.primarymentalhealth.com.au/site/index.cfm?display=15142

Chronic Disease Management (CDM) http://www.adgp.com.au/site/index.cfm?display=333

Mental Health Nurses Incentive Program http://www.primarymentalhealth.com.au/site/index.cfm?display=24625

Department of Health and Ageing GP Mental Health Care Plan (GPMHCP) information http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-gp-mental-health-care-medicare

GPMHCP Referrals to Allied Health Mental Health http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-programs-amhpm

GP Management Plan (GPMP) and Team Care Arrangement (TCA) information http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease

GPMP/TCA Referrals to Allied Health and Dental Health (not Mental Health) http://www.health.gov.au/internet/wcms/publishing.nsf/Content/Allied+Health+and+Dental+Care+initiative

45YearOldHealthCheck http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-45check

Aboriginal Health Check http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pacd-medicare-resource-kit

Prescription Shopping Program http://www.medicareaustralia.gov.au/providers/programs_services/pbs/prescription_shop.shtml

Privacy information related to Prescription Shopping Program http://www.privacy.gov.au/publications/IS19_07.html

PharmaceuticalBenefitsScheme http://www.health.gov.au/pbs

FORMS Sample GPMHCP (scroll down page) http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-gp-mental-health-care-medicare

Sample GPMP and TCA (scroll down page) http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease-forms

Referral Form GPMP Allied Health (not Mental Health) http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-medicare-health_pro-gp-pdf-epcahs-cnt.htm

Referral Form GPMP Dental Health http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-epcdc-cnt.htm

HMR Referral Form http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/dmmrreferral.pdf

Medication Management Plan Form http://www.health.gov.au/internet/wcms/publishing.nsf/Content/72874007E87EA090CA256F19001D0364/$File/medmngtform.pdf

Home Medicines Review (HMR) Information Department of Health and Ageing http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm

The Pharmacy Guild http://beta.guild.org.au/mmr/content.asp?id=421 (National Secretariat) http://www.guild.org.au/nsw/content.asp?id=1082 (NSW Branch)

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http://www.nswmb.org.au


http://www.psychsupport.com.au/





http://www.agpn.com.au/site/index.cfm?module=DIVISION&state_code=NSW







http://www.adgp.com.au/site/index.cfm?display=333




http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-programs-amhpm

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-programs-amhpm

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease



http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-45check

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-45check

http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pacd-medicare-resource-kit

http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pacd-medicare-resource-kit



http://www.privacy.gov.au/publications/IS19_07.html

http://www.health.gov.au/pbs
















http://www.guild.org.au/nsw/content.asp?id=1082

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