Managing Psychotropic Medications During the Coronavirus Emergency 3/23/2020

These are difficult times for everyone and this special edition of SmartCare E-Weekly is being sent out early to provide guidance on recommended practice with regard to renewing and as needed adjusting psychotropic medications for patients in the face of the constraints of the health emergency.

SmartCare’s on demand provider line (858) 880-6405 is and will be operational to support clinical decision making in PCP settings. Our SmartCare Patient/Parent Line (858) 956-5900 also remains accessible for patients and families seeking support and assistance. Community mental health services are evolving on a day to day basis. We have been actively compiling information about what clinics and services are available and remain open at this time and how to access them.

-Maximizing patients’ access to appropriate meds is indicated and, absent evidence of contraindications, continuing existing psychotropic regimens is fully appropriate, even when face-to-face contact with the patient is not feasible.

-California’s State Department of Health Care Services’ (DHCS) Behavioral Health Information Notice 20-009 (dated 3/19/20) clearly states that tele-video and telephonic interactions can be used to provide clinical services including obtaining information about a patient’s status and needs with data collected from both the patient and family members though extra efforts should be made to optimize confidentiality and HIPAA compliance.

-Telephone interactions are HIPAA compliant and telephone contacts should include inquiry as to whether the patient is exhibiting any symptoms (e.g., tremor) that would be observed in a face-to-face or tele-video visit.   Active inquiry about efficacy, side effects and any other concerns should be incorporated into telephone interchanges.

-Tele-video platforms should be HIPAA compliant.   In exceptional cases where full HIPAA compliance is not feasible, alternative video platforms may need to be used with patient/parent advisement given and consent obtained after discussion as to pros and cons and limitations of said media mediated interactions.   End around techniques that might be considered when using a non-HIPAA compliant might include using a non-HIPAA video platform while using a separate phone line for audio communications.

-Adjusting medication dosages and even starting a new medication may be warranted and appropriate if supported by the patient’s and/or the parent’s input – but cautious deliberation and discussion as to risks and benefits, potential side effects, and desired effects should occur and be documented, with patient/parent’s verbal consent noted in charting.

-Documentation in the clinical record should be completed as per routine and the type of tele-interaction with patient and family should be documented and parent/youth’s consent for the tele-visit should be noted as well, with brief indication that tele-visit was used in context of the virus situation.

-It also would make sense for prescriptions to be transmitted to the pharmacy electronically, called in or mailed directly to the pharmacy as feasible.

-Wherever possible, deferring routine lab testing would seem advisable but when clinically indicated required lab orders should be sought — balancing risks of virus exposure vs clinical need for data to manage the patient’s situation.

– Plans for follow up contact should be made and options for PRN contact should be discussed.

-Safety plan issues should be discussed and appropriate resources for a crisis situation should be reviewed, prioritizing the least intensive but clinically appropriate options — avoiding ERs when feasible.  Scheduling a face-to-face contact at your clinic could be considered if feasible and appropriate.

-Clinical inquiry as regards the family’s general security and their comfort or discomfort with Stay at Home requirements would be appropriate and recommendations as to how to manage any challenges should be offered.

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