Information for healthcare services - Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard

What the standard says

A person receives health care that is driven by their individual preferences, needs and values, and that upholds their personal dignity, human rights and legal rights. The person is supported to be an active participant in making informed choices about their care, together with their family, support people or nominated decision‑maker as appropriate.

What this means for Healthcare Services

Ensure that policies and procedures are in place to support healthcare providers to deliver person‑centred care to people with cognitive disability and impairment. These should
ensure that:

• Information and resources, such as shared decision‑making tools, are available to meet diverse health literacy, medicines literacy, communication and cultural needs
• The person’s family, support people or nominated decision‑maker have been identified and documented in the healthcare record
• The person and their appropriate family, support people or nominated decision‑maker are provided with information about their care
• The person and their appropriate family and support people are involved in decisions about their care to the greatest extent possible or to the extent that they choose (for example, if a person does not have capacity for decision‑making, they are still consulted to the greatest extent possible, by those who will make the decision)
• Reasonable adjustments are identified and implemented to facilitate the person’s active participation in decision‑making, including support to enable a person with capacity to make a decision, and support to increase participation by those without capacity.

Ensure adequate skills and competence in the workforce by:

• Providing rights‑based training and communication skills training to relevant members of the workforce
• Providing members of the workforce with training on capacity assessments
• Providing members of the workforce with training on techniques to support participation in decision‑making by people with cognitive disability or impairment.

Cultural safety and equity Understanding the person’s cultural background is essential to providing culturally inclusive, safe and responsive person‑centred care. Culture is central to the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples. Connectedness to family, community and country, the person’s role within family and community, and the significant sense of loss, grief and trauma from past and current events that many Aboriginal and Torres Strait Islander people experience may affect their choices for care. They may not identify or be comfortable with an individualised approach, and instead see their identity strongly connected with family, community and country. This means that planning the care of an Aboriginal or Torres Strait Islander person with cognitive disability or impairment should consider their individual connections. Person‑centred care approaches for people from CALD backgrounds should emphasise the role of cultural belonging and acknowledge potential cultural differences in beliefs about treatments, care and decision‑making. Alternative approaches may be required for people from CALD communities who are experiencing isolation and loneliness, and for those who do not have extended family networks, to support them to be active participants in their care. Consider the varying meanings of the term ‘family’ in different cultures. For example, family may include people who are not first‑ or second‑degree relatives but culturally have a close tie to the person or are important in their culture and link to country.

What the standard says

If psychotropic medicines are being considered, the person – and their family, support people or nominated decision‑maker as appropriate – is informed about the reason, intended duration, and potential benefits and harms of treatment. If use of a psychotropic medicine is agreed, informed consent is documented before use. In an emergency, or if the person does not have capacity to make a decision even with support, processes are followed in accordance with relevant legislation.

What this means for Healthcare Services

Ensure that policies and procedures outline requirements for providing psychotropic medicines information and obtaining and documenting informed consent.

Ensure that systems are in place for healthcare providers to provide information about psychotropic medicines and discuss their use with the person, and family members, support people and nominated decision‑makers as appropriate. To enable informed decision‑making, these discussions should include a description of the risks and benefits of taking or not taking psychotropic medicines.

Ensure that policies and procedures enable the person, family members and support people to receive information in ways they can understand and to have an opportunity to ask questions before consent is sought. Ensure policies and procedures support a person’s rights to make decisions and include the use of reasonable adjustments in line with the person’s needs. These should help the person, family members and support people to participate more effectively in decision‑making about their treatment, consistent with the NSQHS Partnering with Consumers Standard.

If a person needs supports and adjustments to enhance their participation in decision‑making, ensure that information about the types of support required is documented and accessible in clinical communications to all relevant healthcare providers. This is especially important when care is provided by a multidisciplinary team, and when a person is transferred or referred to another healthcare setting or healthcare provider. Processes for seeking informed consent should consider that the person’s capacity may fluctuate, and capacity should be reviewed periodically to ensure that consent remains valid. Ensure policies and procedures are consistent with relevant guidelines and legislation for assessing capacity and seeking informed consent (see Box 1) and for exemptions in emergency situations (see Box 2).

Cultural safety and equity Policies and training should support care that is culturally sensitive and culturally safe for Aboriginal and Torres Strait Islander people with cognitive disability or impairment. When providing care to Aboriginal and Torres Strait Islander people, provide access to translators and/or cultural interpreters as necessary, particularly during assessment, diagnosis and consenting processes. Healthcare providers need to recognise and be responsive to the cultural and linguistic needs of CALD people with cognitive disability or impairment. A variety of communication tools may be required, including working with bilingual, bicultural members of the workforce or professional interpreters across the whole service pathway, but especially during assessment and consenting processes. People with cognitive impairment or disability may lose second languages such as English. In such cases: Healthcare interpreters should be used Cultural and communication protocols should be followed Communication boards may be important aids – these and other useful resources can be obtained from the Centre for Cultural Diversity in Ageing.

What the standard says

A person with behaviours of concern is initially assessed for immediate risks to their safety and others. Further assessment is undertaken to identify clinical, psychosocial and environmental causes of the behaviours, and to understand the context in which they occur. Assessment is carried out by suitably trained individuals, and considers existing plans to support the person’s care and information from others who know the person well.

What this means for Healthcare Services

Ensure that systems are in place for healthcare providers to safely carry out a comprehensive assessment for people with behaviours of concern, and to document results in the person’s healthcare record. Such assessment should consider the behaviour’s context and its clinical, psychosocial and environmental causes. Clinical assessment should also include assessment for delirium. Ensure that policies and procedures support reasonable adjustments for people with cognitive disability or impairment to facilitate their assessment (see Related resources). This may include:

• Involving family members and support people in the assessment with the person’s consent, and involving nominated decision‑makers as appropriate. This may include allowing access for family, support people, and nominated decision‑makers access to the health care service outside regular visiting hours
• Considering the environment in which the assessment takes place and allowing for modifications to provide safe and supportive care (for example, moving the person to a quieter room)
• Referring to any care plans that document existing behaviours and management strategies, such as advanced care plans or behaviour support plans (required for recipients of aged care services and some recipients of NDIS services).

Ensure that any records of legal nominated decision‑makers, guardianship or administration orders are kept in an easily accessed place. Ensure all members of the workforce who care for the person are aware of these arrangements.

Train and educate the workforce about the potential causes of behaviours in people with cognitive disability or impairment, including in relation to trauma‑informed care. Ensure that all those involved in providing care are aware of the role of care plans, including any behaviour support plans required under aged care or NDIS regulations for recipients of these services. Support referral to suitably trained providers if required to assess behaviours and contributing psychosocial or environmental factors.

Cultural safety and equity Consider the communication needs of people with cognitive disability or impairment, including needs related to culture, during an assessment. Assess the person’s level of understanding of verbal communication and English language, and their ability to communicate their needs. Consider support and make reasonable adjustments for those who have limited speech or a primary language other than English. The presence of a support person may enable better communication. People with cognitive disability or impairment may not tolerate assessment. Consider adjustments to support assessment, such as moving the person to a separate room or using Easy Read resources or visual aids to explain what will happen. Provide care that is culturally safe and informed to Aboriginal and Torres Strait Islander people with cognitive disability or impairment, and use translators and/or cultural interpreters when appropriate, particularly during assessment. Consider the varying meanings of the term ‘family’ in different cultures. For example, family may include people who are not first‑ or second‑degree relatives but culturally have a close tie to the person or are important in their culture and link to country.

What the standard says

Non‑medication strategies are used first‑line and as the mainstay of care when responding to behaviours of concern. The choice of strategies is individualised to the person, and is documented and communicated to all those involved in their care.

What this means for Healthcare Services

Ensure that systems, processes and resources are in place for the multidisciplinary team to offer and use appropriate non‑medication strategies in response to behaviours of concern both first‑line and as part of ongoing care.

Establish appropriate leadership and governance for oversight of these systems.

Ensure each member of the workforce is trained and competent in the use of non‑medication strategies – appropriate to their role and scope of practice – that could be implemented for a person with behaviours of concern. This may involve identifying specialist clinicians or lead clinicians at a healthcare service level to train the workforce in the use of de‑escalation techniques and other non‑medication strategies.

Provide systems to support documentation of the non‑medication strategies that are recommended and used for the person, and to embed strategies that are effective for the person into their care. Enable members of the workforce to implement environmental changes when appropriate, such as lighting, noise, signage (for example, toilet locations), privacy or access to outdoor space.

Policies should incorporate use of the person’s regulated aged care or NDIS behaviour support plan and take into account the information provided in the plan, as well as any information provided by the person’s family, support people or care provider.

Cultural safety and equity Consider causes for behaviour that may relate to a lack of cultural safety, including previous experiences of health care. Consider appropriate non‑medication strategies that will meet a person’s cultural needs. Be aware of the person’s sense of family and connection and if a lack of contact is worsening the person’s behaviours of concern.

What the standard says

If a person has a plan to support their behaviour, it is used to inform and support their care. The person’s response to care provided under the plan – including any use of psychotropic medicines – is continually assessed, documented and communicated to inform regular updates to the plan and prescribing decisions.

What this means for Healthcare Services

Healthcare services that provide care to people with cognitive disability or impairment who
have an existing behaviour support plan should:

• Provide guidance and protocols to ensure the behaviour support needs outlined in the person’s behaviour support plan are recognised and responded to during their care, which can prevent escalation of behaviours of concern and reduce the need to use restrictive practices such as psychotropic medicines
• Ensure that acknowledgement and use of the person’s behaviour support plan and relevant feedback about the person’s response are included in the person’s healthcare record and correspondence, and that this is shared appropriately with other providers of care and support
• Establish relationships with local aged care and disability coordinators or case managers who can assist in escalation of plan reviews or provide other expert advice when required.

Healthcare services that are responsible for ensuring that a behaviour support plan is
developed should:

• Ensure that behaviour support plans are clear and concise so they are easy to use by the person, their family, support people and healthcare providers
• Ensure that behaviour support plans consider feedback provided by other healthcare providers about the person, including further behaviour support needs that may arise in healthcare settings, such as during hospitalisation
• Refer to guidelines for developing behaviour support plans provided by the NDIS Quality and Safeguards Commission or Aged Care Quality and Safety Commission, as relevant.

What the standard says

Psychotropic medicines are considered in response to behaviours of concern only when there is a significant risk of harm to the person or others, or when the behaviours have a major impact on the person’s quality of life and a reasonable trial of non‑medication strategies has been ineffective. Psychotropic medicines are also considered when a mental health condition has been diagnosed or is reasonably suspected following a documented clinical assessment. The reason for use is clearly documented in the person’s healthcare record at the time of prescribing.

What this means for Healthcare Services

Ensure policies outline the safe and appropriate use of psychotropic medicines and the steps that should be followed prior to prescribing. For emergency, short‑term and ongoing use, including PRN medicines, this includes assessing whether appropriate non‑medication strategies have been systematically trialled for a reasonable period of time, according to the reason for use (for example, whether the medicine was used in an emergency or in a less acute context).

Ensure documentation of the reason for prescribing for any psychotropic medicine, including for medicines prescribed PRN, regardless of the indication or therapeutic use. This includes documenting the diagnosis or, in the case of a suspected mental health diagnosis in a non‑verbal person, the clinical assessment conducted and the expected effect of the medicines.

Ensure that all medication charts including electronic charts include indications for use of psychotropic medicines. If medicines are used PRN, ensure documentation about use – as well as the behaviours observed when prescribed for behaviours of concern – is available to facilitate a fully informed review of the medicines’ effectiveness.

Establish processes to audit the appropriateness of any psychotropic medicine prescribing, including medicines prescribed PRN.36 Auditing processes should include evidence of the clinical assessment and rationale for prescribing. In the context of behaviours of concern, this should include auditing evidence of an inadequate response to non‑medication strategies prior to prescribing psychotropic medicines.

What the standard says

A person’s response to psychotropic medicines is regularly monitored and reviewed according to the person’s individual needs and goals of treatment. The benefits and harms of treatment, and the potential for dose adjustment or cessation are considered at each review. The outcome is documented and communicated, along with the timing of the next review.

What this means for Healthcare Services

Establish processes to ensure a quality use of medicines approach to the monitoring and review of psychotropic medicines.

Ensure policies and procedures are in place to outline the processes for monitoring and reviewing a person’s medicines, including:

• Identifying monitoring requirements according to individual needs, and how these will
  be documented
• Identifying the most appropriate healthcare providers responsible for conducting a medication review
• Documenting the timing of the next review, in line with the person’s individual needs and the goals of treatment
• Documenting and communicating actions and recommendations to ensure they are accessible to all those involved in a person’s care (for example, the use of paper‑based or electronic forms)
• Engaging with family, support people and support workers when reviewing a person’s
  medicines and seeking feedback about changes in the person’s behaviour
• Ensuring the results of a review are discussed with the person and, if appropriate, parents, family, support people, support workers and other relevant people, including the person’s general practitioner or other regular prescriber
• Identifying and prioritising for review people who are most at risk of, or have experienced, medicine‑related harm
• Monitoring the duration of psychotropic medicines use, the appropriateness of review intervals and trends in medicine‑related harms identified during a review, which could also include harms that have been prevented.

Access Australian Government–funded medication review programs, such as Home Medicines Review (HMR) or Residential Medication Management Review (RMMR), if relevant (see Box 3).

Services responsible for the behaviour support plan should ensure those who developed it are regularly reviewing the person to ensure that the planned support strategies are in place and their usefulness is assessed when the dose of a psychotropic medicine is modified or being ceased, and reviewing the plan with regard to the person’s needs.

Considerations when reviewing a person’s medicines

Consideration should be given to potential barriers to people taking an active role in a review of their medicines. People with cognitive disability or impairment who may have difficulty communicating verbally or participating in decisions about their care may require support or a nominated decision‑maker to be present.

A person’s involvement in decisions about their medicines may also vary over time. Consideration should be given to adjusting the timing of a medication review to occur when a person may have the capacity to be involved. If appropriate, family members, support people or nominated decision‑makers should be involved in the review. Healthcare services should ensure that documentation about a person’s nominated decision‑maker is available to all prescribers and those involved in the person’s care. This must include contact details that are up to date and easily accessible.

Cultural safety and equity All people from all communities or groups should be supported to have their medicines reviewed, irrespective of diversity, background, age, location or personal circumstance.1 Consider extra supports required to ensure a person’s understanding and involvement in the review, including involvement of Aboriginal or Torres Strait Islander health workers or practitioners, interpreters, family or other support people.

What the standard says

When the health care of a person is transferred, information about their ongoing needs is shared with the person, their family or support people and the healthcare and service providers continuing their care. This includes information about behaviour support plans or other strategies. If psychotropic medicines are prescribed, the reason for use, intended duration, timing of last administration, and plans for monitoring and review are documented and communicated to support the person’s ongoing care.

What this means for Healthcare Services

Ensure that systems, policies and procedures are in place that support healthcare providers to effectively communicate comprehensive, accurate and up‑to‑date information about a person’s ongoing care when a transition of care occurs. This communication should include any medicine‑related needs and any risks to the person’s behaviour that may arise with the
transition of care.

Ensure policies and procedures:

• Include the need to transfer documentation about strategies known to be effective in supporting a person’s behaviour, which may avoid the use of psychotropic medicines; for example, the person’s behaviour support plan, if they have one, or documentation in the discharge summary
• Include the requirement for a current medicines list to be transferred to enable continuity of medicines management
• Outline expectations about the timeframe in which communication should occur – emphasising that timely communication is critical to the relevance of the information – and what to do if information is not received.

If psychotropic medicines are prescribed for behaviours of concern, ensure documentation is transferred with the person, outlining:

• Behaviours that have been observed
• Causes for the behaviour observed
• Non‑medication strategies that were tried or used
• Reason for prescribing the psychotropic medicine
• Effectiveness of the medicine on the target symptoms
• Potential adverse effects that may affect their care plan (such as falls risk)
• Ongoing monitoring requirements
• Plans for review or discontinuation of the medicine.

In acute healthcare services, implement the relevant NSQHS Standards and refer to the Guiding principles to achieve continuity in medication management to support best practice and safe and quality use of medicines at transitions of care.

With the person’s consent, information should be transferred securely, for example, through a secure messaging system, on paper, or by uploading to digital systems such as the person’s My Health Record. This provides other clinicians with access to details about the person’s care and their medicines, which can be vital for informing ongoing care in the community. Sharing information about the care provided in all care settings is especially important if the person transitions to interim care (rehabilitation or respite care) before returning to their usual residence and healthcare provider. Ensure the transfer of information takes into account consent requirements and the person’s right to privacy and confidentiality.

Aged care homes may need to use additional documentation to support the safe and quality use of medicines at transitions of care. Examples include the Interim Residential Medication Administration Chart or the Aged Care Transfer-to-Hospital Envelope.