Clinic Name Medication Agreement Process Effective Version #: Document #: Next Review: Page 1 of 8 SCOPE: Medication Agreement Process PURPOSE: Define the steps, parameters, and team responsibilities for establishing, maintaining, and voiding Medication Agreements in the Clinic POLICY: MEDICATION AGREEMENTS: 1. Medication Agreements are an agreement between the Primary Care Provider, the Patient, and the clinic staff to provide controlled substances to the patient in the context of education on material risk of opioids, patient agreement to safety rules, and prescriptions on a defined schedule 2. Medication Agreements have 3 components: a. Material Risk Notification (Safety education) b. Safety Rules/Requirements (what the clinic requires of the patient) c. Meds on Agreement (the actual medication/strength/sig/quantity of planned prescriptions) 3. All patients receiving prescriptions for controlled substances with a MED (morphine equivalency per day) of 10mg or more for at least 6 months consistently are required to be on a medication agreement. It is recommended that medication agreements be established after 3 months of continual use (but required at 6 months) 4. See Narcotic Management algorithm TABLE OF CONTENTS: 1. Section 1 New or Annual Renewal of Medication Agreements 2. Section 2 Managing and updating existing Medication Agreements 3. Section 3 Voiding/Discontinuing/Holding Existing Medication Agreements SECTION 1: PROCESS FOR NEW/ANNUAL RENEWAL OF MED AGREEMENT: Medical Assistant process: MA scrub process for Provider Appointment: 1. MA scrubs schedule and identifies patients with a med agreement that needs to be renewed, or a patient that has been on controlled substances greater than 3 months and needs a new med agreement established. 2. Print labels (3 for med agreement, 2 for PtProtect UDT, at least 5 extra for Registered Nurse Care Coordinator if needed) 3. Label medication agreement and Chronic Pain Questionnaire 4. Prepare for PtProtect UDT: Print face page and pt label, apply label to urine cup
Page: 2 of 8 5. If controlled substances do not include narcotics, the MA and PCP are responsible for completing the medication agreement with the patient at the visit. (RNCC does not need to be involved) 6. If controlled substances do include narcotics, label Chronic Pain Questionnaire (4 page document) 7. If controlled substances do include narcotics, either PCP will complete Med Agreement or designate to RNCC. a. If RNCC will be doing med agreement, discuss with RNCC: b. If schedule allows, schedule an RNCC co-visit same day, after PCP visit i. Use RNCCs last name to locate schedule ii. In a patient note enter CV, PCP Initials, MA c. If RNCC cannot see patient same day, plan to schedule an RNCC f/u appt while patient is at PCP appointment d. Give RNCC extra label for scheduled patient. (to use on Opioid Risk Tool) MA visit process: 1. Room patient 2. Explain to patient plan for annual renewal of Med Agreement, or establishing a new med agreement and that collecting a urine sample is our standard process a. If patient declines giving a sample, or is resistant beyond MA comfort/problem solving level, defer conversation to PCP/RNCC 3. Escort patient to bathroom and collect PtProtect UDT. (see PtProtect UDT collection process for more detail) a. If patient is on narcotics, give PtProtect UDT carbon copy to RNCC b. If patient is not on narcotics, MA holds carbon copy until results are received and approved/addressed by PCP 4. If patient is on narcotics, when they return to the exam room hand them the Chronic Pain Questionnaire l (4 page document) and ask them to complete it while they are waiting for the PCP. 5. Leave 3 page Med Agreement Document open to the Meds on Agreement page with the PCP paperwork for the appointment. 6. Med Agreement completion: a. If patient is not on narcotics, MA or PCP reviews safety rules of medication agreement item by item, allow time for questions, has patient sign, MA or PCP signs as witness, and offer patient a copy of agreement. i. Complete New/Renewal/Update, Pharmacy, on meds on agreement page (page 3) ii. Completed Med Agreement goes to Rx team iii. MA or PCP document in notes section of appointment that med agreement was completed b. If patient is on narcotics and RNCC is seeing patient that day, alert RNCC that PCP is done, give RNCC the med agreement with page 3 completed by PCP. c. If patient is on narcotics and RNCC cannot see patient that day: i. Schedule patient to come back another day for RNCC appointment. ii. Collect Brief Pain Survey from patient if completed. If not completed, ask them to bring it back to RNCC visit
Page: 3 of 8 RNCC visit process: (for patients with narcotics included in Med Agreement) 1. Explain to patient what Med Agreement is as appropriate 2. Review completed Chronic Pain Questionnaire with patient, and address remarkable responses as appropriate 3. Complete Opioid Risk Tool and establish low or high risk status 4. If Sleep Apnea screening is positive, consult with provider about additional test orders 5. Review Medication Agreement in its entirety with patient, allow for questions 6. Obtain signatures and offer patient copy of medication agreement 7. Complete New/Renewal/Update, Pharmacy, and Risk Level on meds on agreement page (page 3) 8. Complete MED section of meds on agreement page if not already done 9. Forward completed medication agreement to Rx team (make sure PCP has signed it) 10. Document results of Chronic Pain Questionnaire and Opioid Risk Tool in visit EMR notes section 11. If patient is high risk: a. Obtain RNCC order for Chronic Pain Management b. Add Patient to RNCC patient list c. Add RNCC to patient care team on Snap Shot d. Add RNCC to Patient Care Coordination note on Snap Shot e. Add CARE MANAGEMENT CHRONIC PAIN HR to patient problem list i. Or add CHRONIC PAIN as additional item if CARE MANAGEMENT entry already exists: i.e. CARE MANAGEMENT DIABETES/CHRONIC PAIN HR ii. In problem list entry, problem overview (where care plan belongs): enter Chronic Pain high risk, PtProtect UDT every 3 months f. Enter patient into RNCC tickler system (can be manual or use remind me or staff message feature in EMR) for every 3 month PtProtect UDT collection 12. Follow up on PtProtect UDT results when they become available. (usually 2-3 days) PCP process at visit: 1. Review patient s prescriptions for Controlled Medications 2. Complete page 3 of medication agreement indicating Meds on Agreement, sig, number dispensed, and refill interval 3. Indicate if patient is on auto refill or not (no auto refill means patient still needs to call in when they are almost out of medication, appropriate for PRN - prescribed but not on a schedule - prescriptions) 4. Hand off Medication agreement to MA if no narcotics or to RNCC if narcotics are included Rx teams follow up process: 1. Rx team receives new or annual renewal of Medication Agreement 2. Rx team updates Problem list a. New Entry for Medication Agreement with start date b. Update annual renewal date in problem list entry if appropriate c. Add Low Risk / High Risk to Problem list entry if indicated by RNCC d. Add patient to Rx team tickler system for scheduled prescriptions e. Follow remaining Rx team process for managing controlled prescriptions on med agreement (see Rx Med Agreement Process)
Page: 4 of 8 SECTION II: MANAGING AND UPDATING EXISTING MEDICATION AGREEMENTS MA process: 1. MA scrubs schedule looking for patients on existing medication agreements 2. MA looks at snapshot/problem list/medication Agreement entry at indicator of LR or HR. If no entry, assume LR (this may be a benzo only patient without a risk score-which means the MA and PCP are responsible for managing and monitoring, or a patient who has not yet had a med agreement with an RNCC) 3. MA reviews most recent PtProtect UDT collected a. If low risk or no risk, and no PtProtect UDT within last six months, plan to collect PtProtect UDT at upcoming patient appointment i. Print labels and face sheet, prepare sample container b. If high risk, and no PtProtect UDT within last 3 months: i. Notify RNCC patient is coming in ii. Schedule co-visit if requested iii. Print labels and prepare PtProtect UDT process 4. When rooming patient, plan to collect PtProtect UDT sample before or after visit as time allows 5. At patient appointment, if MA becomes aware the PCP has made ANY changes to the prescriptions for controlled medications: a. print and label a medications on agreement page of med agreement, (page 3) b. indicate update c. Ask PCP to complete Medication/strength/sig/#dispensed d. Include all medications on med agreement, not just the medications that were changed at today s visit e. Sign form as completed by f. Forward page to Rx team g. Check if there are prescriptions printed that are no longer accurate, awaiting pick up that need to be voided 6. If patient is high risk and issues of any kind come up around the controlled medication prescriptions, forward them on to the RNCC RNCC process: 1. Check tickler file at the beginning of every month and note patients due for a PtProtect UDT in the coming month. a. Complete the following, OR these tasks may be delegated to an MA/Scheduler: i. Review patient schedules and note any scheduled visits within the appropriate time frame of next required PtProtect UDT ii. On scheduled PCP visit, edit note by adding PtProtect UDT due iii. Schedule co-visit as appropriate iv. Print label and face page for PtProtect UDT sample v. Notify RNCC of date and time of scheduled appointment
Page: 5 of 8 vi. If no appointment is scheduled notify RNCC. 1. RNCC to coordinate PtProtect UDT with next Rx pick up or random call in as appropriate (per RNCC discretion) 2. RNCC to manage all high risk patients through consulting with PCP and diligent documentation which may include: a. Tapering patient down or off of controlled medications i. Always note on problem list medication agreement entry, OXYCODONE (or name of med) AGREEMENT ON HOLD (Rx team will change this when new medication agreement is established) ii. Add note TAPER IN PROCESS SEE ENCOUNTER DATE 1.13.14 (ex) to patient care coordination note, pointing to the date of the RNCC encounter that has the detailed plan for patients taper/taper schedule (remember to undue this when taper is complete) iii. Always have PCP sign printed copy of planned taper schedule and send to Medical Records for scanning b. Responding to requests for early refills c. Discrepant PtProtect UDT results d. Inappropriate/aberrant behavior e. Complaints from patients/staff/rx team regarding patient s behavior/interactions,etc. (involve management as needed). f. Reports of lost or stolen medications g. Involvement with law enforcement 3. At patient appointment, if RNCC becomes aware the PCP has made ANY changes to the prescriptions for controlled medications: a. print and label a medications on agreement page of med agreement b. indicate update c. Include all medications on med agreement, not just the medications that were changed at today s visit d. Ask PCP to complete Medication/strength/sig/#dispensed e. Forward page to Rx team **************************************************************************************** PCP Process: 1. At patient appointments, for patients on medication agreements, DO NOT print new prescriptions for the medications on agreement UNLESS you are making changes to the prescription a. If patient has a supply at home, it is preferred to have them use their current supply prior to writing new prescriptions when optional b. Ask MA to check for existing prescriptions that may already be printed and are waiting for patient to pick up. These Rxs need to be pulled and voided if being replaced with a new prescriptions c. Ask MA to prepare a new Meds on Agreement page and complete with the updated information for the controlled substance prescriptions d. Forward form to MA for completion and processing
Page: 6 of 8 Rx Process: 1. When initiating monthly prescriptions, check most recent PtProtect UDT and patient office visit against standard for risk level. If patient is out of compliance, notify PCP and team prior to initiating controlled substance prescription. 2. When receiving Meds on Agreement update, enter new meds on agreement into problem list entry. 3. Do not change the date on Problem list entry (this only changes at annual renewal) 4. Check to see if there are Rxs already printed and waiting for pick up that need to be voided and replaced. SECTION III: VOIDING/DISCONTINUING/HOLDING EXISTING MEDICATION AGREEMENTS MA Process: 1. If PCP notifies you of a void/discontinuation/or Hold on an existing medication agreement, create a documentation encounter in EMR and route to the Rx Team notifying them of voided med agreement a. Check if there are prescriptions printed awaiting pick up that need to be voided RN Process: 1. If patient medication agreement is on hold for taper or dose adjustments, add ON HOLD to medication agreement entry in Problem List 2. If PCP notifies you of a void/discontinuation on an existing medication agreement, create an encounter indicating med agreement to be voided (reference reason and PCP direction) and send a copy of the note to PCP and to the Rx team notifying them 3. If patient has consistent issues with their medication agreement, consult with PCP, develop a plan to taper off if appropriate, document plan in encounter note in EMR, and notify Rx team 4. Add No Narcotics, see encounter 2.14.14 (ex) to the top of Patient Care Coordination note in EMR 5. Remove RNCC from patient chart if appropriate (Patient Care Coordination note, Problem List, patient list, etc.) PCP Process: 1. If wanting to void/discontinue or hold patient s medication agreement, either: a. Notify MA or RNCC of plan OR b. Send a staff message in EMR to the Rx Team notifying them c. Include in your documentation the rationale for voiding/discontinuing Rx Process: 1. When notified of medication agreement to be voided or discontinued: a. Consult with PCP/RNCC whether item should stay on problem list as voided or be resolved on problem list b. Remove patient from Rx tickler system for scheduled prescriptions DEFINITIONS: MA: Medical Assistant PCP: Primary Care Provider
Page: 7 of 8 RNCC: Registered Nurse Care Coordinator EMR: Electronic Medical Record Rx: Prescription REFERENCES: Forms: HELP: For questions about this doctype, or assistance with understanding your obligations under this doctype, please contact End of DocType The last page of this policy document contains approval, review and revision information only.
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