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CLIPP Index <
 CLIPP
(Consultation and Liaison in Primary Care Psychiatry) Manual
Transfers from Mental Health Service Care into Shared Care
The CLIPP Liaison Clinician in the Transfer Process
General Principles
The role of the CLIPP liaison clinician involves guiding selection of
referred clients, transfer of that client to the care of the selected
GP and monitoring and follow-up of transferred clients.
Key Points
- The clinician will determine the appropriateness of referrals according
to selection criteria guidelines.
- The liaison clinician will prepare and write the transfer summary,
then co-ordinate the transfer process.
- The liaison clinician will if necessary intervene to provide assertive
outreach for brief periods to re-establish clinical relationships that
show signs of breaking down.
Specifics
Identifying Likely Candidates
This involves discussion with the referrer along with extraction of pertinent
information from the case notes to determine whether transfer via CLIPP
is the best option of care available for that client at that time. The
aim at transfer is for the client's symptoms to be well-controlled on
medication with a manageable level of side effects and a stable, supportive
psycho-social environment.
It may be helpful for you as the CLIPP liaison clinician to go through
the standard referral form with the case manager. Either you or the case
manager should establish if there is a pre-existing relationship with
a GP, and then complete a GP contact form. If there is a pre-existing
relationship with a GP that is not with a CLIPP practice then the transfer
will probably not be appropriate. However, sometimes discussion with the
current GP may result in the possibility of a referral and these situations
need to be addressed on a case by case basis.
The initial review of prospective clients also includes:
- Cost of provision of current medication in the GP setting. If the
client's medication regime would be prohibitively expensive under PBS
and they currently receive their medication from the AMHS then this
will need to be addressed prior to consideration of transfer.
- The presence of any significant current medication side effects is
important, also current mental state including compliance and insight.
- Existing relationship with another GP.
- Financial and psycho-social circumstances of the patient.
- Appointment frequency and required input at the mental health service.
- Any hospital admissions, or crisis intervention service involvement
over the last five years should be reviewed.
- The carers understanding of the client's condition and likely response
to the proposal of transfer are also significant.
Where clients are not considered to be suitable for transfer the CLIPP
liaison clinician will discuss the issues with the referrer and provide
recommendations to address the problems if possible.
The Initial Meeting
Purpose and Setting - The initial meeting serves to further assess suitability
for transfer and provide information. This usually involves the referring
doctor or case manager, the CLIPP liaison clinician and the client. This
meeting is usually held at the AMHS during the client's next regular appointment.
It provides an opportunity for the CLIPP liaison clinician and the client
to be introduced to each other.
It will also provide the client with an overview of the transfer process
and a copy of the client information brochure. It is important to highlight
to the client and any carer that the situation will be reviewed regularly
by the CLIPP psychiatrist and that the GP is welcome to discuss any concerns
that may arise with the CLIPP team.
Clinical Review and Accessibility Issues - In conjunction with the referring
case manager, the CLIPP liaison clinician assesses the client's mental
state to further determine the suitability for transfer to GP care. As
the CLIPP liaison clinician you should:
- Examine the success or failure of past medications and any unwanted
side effects in the patient.
- Review and ensure that prospective clients have an established support
network and social structure, particularly those clients who display
marked negative symptoms.
- Determine if the client holds a current Health Care Card and a Medicare
Card.
- Assess the proximity of the GP and the pharmacy to the client's home.
- Determine the availability of both public or private transport for
the client.
- For non-English speaking clients assess the feasibility of attending
a CLIPP GP doctor of the same nationality. Arrange for an interpreter
if necessary.
The client should be advised that the selection for this transfer process
is generally for clients with known effective maintenance medication,
a stable psychosocial environment, a confirmed diagnosis, a good understanding
of their psychiatric condition, and a willingness to take indicated medications.
Clients should be encouraged to discuss general health concerns with
a GP via the CLIPP program. The benefits of the CLIPP model and the positive
impact the program has had on other clients in terms of access and a more
normalised treatment setting should also be discussed with the patient.
You should review the expected medication costs with clients. Clients
should be informed of the existence of the safety net scheme and that
clients receiving concessional benefits are made aware that they will
receive a modest fortnightly level of financial assistance toward purchasing
medications. Pensioners should be given any additional financial assistance
possible.
The format of the CLIPP transfer summary should be discussed with the
client (and carer if applicable), emphasizing the linkages between services
supporting the model, the periodic psychiatric review, the accessibility
of the AMHS if necessary, and also the competence of the GP. Clients should
be assured that CLIPP liaison clinician would be in attendance at the
first appointment with the GP.
Medications and Pharmacy - As there can be extreme variation in the costing
of both oral and depot medications it is advisable to confirm which proprietary
name and manufacturer offers the cheapest price. Clients and carers should
be aware that the exact preparation may change from time to time if generic
substitution occurs to keep the cost down. The price of filling dosette
boxes needs to be considered and negotiated with the pharmacy.
Pharmacies known to CLIPP may offer discounts on the more expensive medications
and the pharmacy nearest to the CLIPP GP is usually recommended. It is
important for the CLIPP liaison clinician to telephone the pharmacy prior
to the transfer date to ensure that the pharmacy has enough stock of the
clients prescribed medication.
Where there is a well established relationship with another pharmacy
the client or carer may choose to remain with that pharmacy. This may
especially be the case where the client is a resident with a special accommodation
hostel that has an established relationship for all its residents.
Home Visit
The home visit is arranged at a mutually convenient time for the client
and the carer/spouse and an invitation to attend can also be made to the
referring CLIPP liaison clinician/medical officer if appropriate. At this
time the information required to complete the standardised measures can
be collected. These may well include the Life Skills Profile, GAF and
SF-12 Health Survey. These have proven useful measures in helping to ascertain
functional levels and identify unmet needs which should receive attention
prior to transfer.
The CLIPP liaison clinician should:
- Write down the cost of medication for the client and provide them
with details of the GP practice, such as address, phone number, GPs
name, psychiatrists name, and a photocopy of the relevant Melway map
with practice and pharmacy highlighted.
- Review the transfer process with the client and carers.
- Assess the client's psycho-social situation and if doubts arise regarding
adequate levels of support in the home environment then these need to
be clarified prior to transfer.
- Provide the client and carer/spouse with the opportunity to ask questions
and clarify any unclear issues.
Preparation and Writing of the Transfer Summary
The transfer summary is the responsibility of you as the CLIPP liaison
clinician and is the tool that guides the GP on how to work with their
new patient. It needs to be comprehensive yet concise in order to be a
useful tool for the GP. (See Appendix 2) You
should review all volumes of the client's case history, extracting pertinent
information necessary to complete the transfer summary, as follows:
Diagnosis - Throughout the years of the client's treatment differing
diagnoses may have been made. It is important to confirm these diagnoses
and then transfer this information to DSM-IV or ICD 10 codes.
Medication - Record the degree of compliance to medication, both
oral and depot, and what factors influence compliance, e.g. does compliance
depend on the client's carer reminding them? Asses the current medication
regime including how long client has been on this regime and note the
side-effects of the current medication and how these have been managed.
Note any medications that may have been tried in the past that had significant
adverse side-effects.
Psychiatric History - In the summary of psychiatric history include
any alerts to dangerous or suicidal behaviour, overview of any hospital
admissions and the minimum and maximum recommended dose level of the current
psychotropic medication/s.
Future Management Plan - Record the desired frequency of appointments
with the GP and the psychiatrist, depending on the needs of the client.
List the actions that the GP will be required to perform at each appointment.
This will usually be a list of 3-5 activities aimed at developing the
doctor/patient relationship, assessing the client's mental state, and
keeping abreast of the psycho-social situation, as well as addressing
general physical needs.
Cardinal Signs of Relapse - Provide specific information and include
examples of the client's presentation when relapsing. For example, if
the particular client's thought content becomes grandiose then include
an example of this in the transfer summary. The GP will not be familiar
with the client's presentation when becoming unwell and it is important
to provide plenty of information to the GP so they have an increased likelihood
of detecting these changes earlier rather than later.
Frequency of Regular Investigations - This is applicable if a
client is on a type of psychotropic medication that requires regular investigations.
Response to Non Attendance - If a client does not attend an appointment
then the guidance for the GP as to what to do should be found here. Usually
this will involve making a phone call to the client or their carer, other
involved family member or a residential contact person. If that is unsuccessful
then this section should direct the GP to inform the CLIPP liaison clinician
and request follow-up support.
Other Identified Contingency Plans - The CLIPP liaison clinician
will identify any possible problems and make practical recommendations
to rectify them. These matters will be specific for each transferred client.
Continued Involvement of CLIPP Liaison Clinician - If AMHS CLIPP
liaison clinician is to remain involved for a period of time following
the transfer then the length and nature of the involvement is to be recorded.
Organisation of Transfer Day
An appointment is made at the general practice for the transfer meeting.
This consists of firstly, a review meeting with the CLIPP psychiatrist,
CLIPP liaison clinician and client, followed by a second meeting which
will also include the GP who will be managing the client's care. It is
advisable to allow 30 minutes for each of these two meetings. Ideally,
transfer day could coincide with next depot due or in time to prescribe
further medication. When booking these appointment times the CLIPP liaison
worker should inform reception staff that they are for a new CLIPP transfer
and that a file will need to be organised.
The CLIPP liaison clinician should:
- Inform the client and carer of appointment times and date, and then
place a reminder call the day before the transfer meeting. It is important
to let the patient know who will be present at the meeting including
the CLIPP liaison clinician.
- Remind clients to bring all Medicare and any other health care cards
carried.
- Contact the pharmacy to ensure an adequate supply of medication.
- Confirm travel arrangements with the client and check that the client
has the map detailing address and phone numbers of general practice
and pharmacy.
- Discuss the transfer with CLIPP psychiatrist and book an interpreter
if necessary.
- For some clients giving them a lift to the GP clinic for the first
appointment may be most courteous and effective.
Transfer Day
It is important that reception staff are aware that a CLIPP transfer
is scheduled. As the CLIPP liaison worker you should attend the review
appointment with the CLIPP psychiatrist, client and carer. This meeting
will provide an opportunity to review the client and to clarify any last
minute concerns or details.
Before the client meets with the GP, a meeting between the CLIPP liaison
clinician, psychiatrist and GP should occur. At this meeting the CLIPP
transfer summary is discussed with the GP by the psychiatrist and the
CLIPP liaison clinician. This discussion should cover the summary of psychiatric
history; the required frequency of appointment with the GP; diagnostic
information; details of current medication, the patient's compliance and
any side effects, and importantly the details of the management plan.
The transfer summary document should also be reviewed and clarified if
necessary.
The next stage is to formally introduce the client to the GP. The client
is informed that the GP has been given both a verbal and written hand
over of the client's history and CLIPP summary. Present and future planned
psychiatric treatment, plus any possible general health concerns (for
example diabetes, pap smears) are discussed. The GP writes a prescription
for the patient, current medication (oral and/or depot) and ensures that
the next appointment with the GP is scheduled.
Encourage feedback from the patient and carer regarding the transfer.
This can be used as another opportunity to clarify any outstanding issues.
After having seen the psychiatrist and the GP, it will often be helpful
for you as the CLIPP liaison clinician to accompany the patient and the
carer to the pharmacy to purchase medication. At this time the patient
should establish their concessional benefits entitlement with the pharmacy.
If on depot medication, the ampoules ideally should be appropriately
and securely stored at the General Practice. Oral medication should go
home with the patient. It may be best for the CLIPP liaison clinician
to supply the first ampoule from the AMHS in order to streamline the process.
Documentation and Structured Assessments
As the CLIPP liaison clinician you should complete a registration form
to update the patient's registration when the patient is accepted for
transfer. These details should be entered on the CLIPP data base (usually
a subset of the main AMHS data base). The CLIPP Liaison Clinician should
also describes the progress of transfer process in client's case history
and completes questionnaires i.e. Life Skills Profile, the Role Functioning
Scale and SF-12 Health Survey. The CLIPP liaison clinician should then
complete these questionnaires and ensure that these details and the transfer
summary is available for the GP at the time of transfer. All this information
should then be placed in the CLIPP records and client's case history at
the AMHS.
Monitoring and Follow-Up
The CLIPP liaison clinician will remain involved in the monitoring and
follow-up of all CLIPP transfers who remain in shared care. Formal monitoring
occurs via a telephone call every 3 months by the CLIPP coordinator.
The GP may request a consultation with the CLIPP psychiatrist in order
to get support and further ideas in managing a CLIPP transfer. The GP
may initiate CLIPP follow-up if, at a routine appointment with the transferred
patient, the GP feels that the patient is becoming unwell and is in need
of more support at this time than the GP is able to offer.
The CLIPP liaison clinician is able to offer direct support and practical
assistance to patient, carer and GP and also is well placed to enlist
the support of crisis services after-hours if necessary.
The Client or Patient in the Transfer Process
General Principles
Many people with mental health problems recover such that their care
might be looked after by a GP. However often the transfer between specialist
care and the care of a GP is a time when information can be lost, and
the GP may not be working with a good level of expert support.
In this program, a psychiatrist visits the General Practitioner's clinic
and works with the GP. Hence there is regular communication between the
GP and a specialist. The transfer which takes place through this shared
care model aims to ensure that correct and helpful information goes to
the GP, and that GPs provide the care in a way that has some sharing with
the mental health service. Before care is transferred a clinical worker
with a special role in helping this go smoothly will spend some time with
you discussing the information that should go to the GP.
People seeing GPs are usually referred to as patients rather than clients
or consumers. Though this is more of a medical term it usually seems more
appropriate to a GP setting. Often people will find being a patient of
a GP less stigmatising than being a client of a mental health services.
Patients in this shared care model are regularly seen by a GP and less
frequently, usually once or twice a year, seen by a psychiatrist.
Key Points
- The liaison worker will help make sure the information going to the
GP is correct and useful, and then will arrange your introduction to
the GP practice.
- There is some work involved in getting the transfer process into GP
shared care right.
- Mental health staff will keep involved and will be able to assist
if you need more care than the GP can offer.
Specifics
Your case manager will discuss the process of transfer with you. The
CLIPP liaison clinical worker will then explain each stage of the process.
It is important to try and keep an appointment diary, as the process
of transfer will involve additional appointments for you. One of the important
questions the liaison clinician will be asking you is what are the important
things the GP should be watching for that would probably show up if you
were getting sick again. If you could give this some thought that would
be helpful.
The clinical team will do their best to ensure that the transfer process
goes as smoothly as possible and there is no loss in continuity of your
appointments or provision of medication. However please also try and keep
an eye on this yourself. You should get in touch with the liaison clinical
worker or your case manager if you feel there is any loss in contact throughout
the process.
The Psychiatrist Role in the Transfer Process
General Principles
The CLIPP liaison clinician will usually begin the co-ordination process
of introducing you as the psychiatrist to transfer clients. These clients
may be known to you from the AMHS but more commonly will not be. You should
find that the CLIPP liaison clinician has already gone through some process
of induction of the patient into the GP practice. There should also be
a quite clearly drafted proposed transfer plan and this may have been
discussed with you if there are any unclear points. The CLIPP liaison
clinician should have reviewed the clinical notes and should be quite
familiar with the prior history.
Key Points
- CLIPP liaison clinician co-ordinates transfer of client to GP clinic.
- The transfer process enables development of rapport between the client,
any carer, yourself and the GP.
- The transfer process offers the opportunity to clarify and model the
monitoring process with the GP.
- Monitoring includes three monthly case note review.
- Transfer clients are reviewed clinically initially six monthly at
the GP clinic.
Specifics
Discuss the Client with the CLIPP Liaison Clinician in Private
A discussion with he client will give you an idea of what issues have
been involved in preparing the ground for this transfer of care and will
provide information relating to the person and alert you to any sensitivities
or potential problems in relation to this transfer.
Meet with the Client and the Clinical CLIPP Liaison Clinician
The purpose of this meeting is to introduce yourself to give another
chance for the client to be informed about the process, and to make sure
that there is a shared understanding of what is about to happen. It can
be helpful in this meeting to go through a brief rehearsal of the mental
state check tasks and the regular monitoring procedures that need to be
carried out with the individual patient before the GP joins the meeting.
This can provide you with a clear idea of how difficult or otherwise monitoring
will be for the GP, and can provide a useful opportunity for you to have
rehearsed a modeling process which will follow.
Invite the GP to Join the Meeting
- Introduce GP and the client to each other.
- Review the key points in terms of the required tasks for the GP in
managing the patient, and check out that these appear clear. It may
be helpful to actually repeat the earlier procedure of checking the
regular tasks of monitoring for cardinal signs of relapse so that you
provide the GP with a model of the way in which a psychiatrist monitors
specific mental state signs in this particular patient.
- After some of this has been done allow the GP to take a more forward
role. Not uncommonly this involves the GP making some preliminary overtures
about whether physical health screening or monitoring tasks have been
carried out. This is often useful ground on which a GP can begin to
establish rapport, working outward from their own core competencies.
- Prior to the GP leaving to resume their clinic schedule, briefly recap
main points of the meeting.
- You should let the patient know that you will see them again in six
months or so to review how things are going.
- Assure patient that you and the other program staff are available
if more should be needed than the GP can provide.
Debrief with the CLIPP Liaison Clinician; Record
Include review of whether or not any possible problems have been identified
during the course of this earlier process. Document details of review
meeting in both General Practice file and patient's psychiatric services
case history along with the photocopy of the CLIPP transfer summary.
Follow Up Case Note Review
Every three months the administrator will send a casenote review form
to the practice on a transferred client. Ask reception staff to retrieve
the notes, then you review the case notes and fill the casenote review
form, checking that care is continuing. This involves checking on: frequency
of follow up from the GP; whether or not they have been seen by you at
due review dates, and whether any regular investigations required are
being done. If all is well this will take a small number of minutes to
complete.
If there are problems take necessary action to secure continuing follow
up. If clinical review by you is overdue, then arrange this with the GP
and/or reception staff.
Follow Up Clinical Review
At an arranged clinical review, reassess the clinical situation, with
a carer present if appropriate. Complete the HoNOS checklist. Compare
your current HoNOS ratings to the previous assessment. This serves as
an aid to program monitoring and also as a screen for clinical deterioration.
File the completed review form in the GP casenotes and return a copy to
the administrator. Advise the GP of any indicated change in management
The Administrator in the Transfer Process
General Principles
As the administrative assistant you ensure that all CLIPP Case Transfer
Summary notes/documentation are received dealt with appropriately.
Key Points
- Receive Transfer Case Notes from CLIPP liaison clinician
- Ensure that all documentation is complete.
- Process all documentation appropriately.
- Manage electronic reminder systems for periodic follow-up of client
progress.
Specifics for the Administrator
CLIPP Transfer Registration
- Register patient in appropriate record system.
- Create Transfer Register using the information in the Transfer Summary:
- CLIPP No., Patient Name, Address, Telephone No., H&CS No., Practice,
GP Name, Psychiatrist Name, Transfer Date, HONOS, SF-36, RFS, LSP.
- Make diary entry in an electronic diary format using Transfer Date
and make a recurring 3 monthly reminder ongoing.
- Place a copy of the Transfer Summary, SF36, RFS, LSP, GP profile,
HoNOS, and patient registration form, in the sequential file.
Follow Up Procedures
Every three months when reminded for each patient, generate a routine
note review form and send it to the psychiatrist, at the GP practice concerned.
Check for return, note return when happens, and file in clinical casenotes
when returned.
When a Psychiatrist returns a copy of the Progress note on a transferred
Client, Place a copy with the transfer summary with CLIPP administration
and a copy with the client record at the appropriate centre.
See Appendix 2 for a copy of the above mentioned
forms.
The Program Coordinator in the Transfer Process
General Principles
The Program Coordinator is responsible for overseeing the administration
of the CLIPP program and participating in quality assurance processes.
Key Points
- Coordinator is responsible for oversight and administration of Quality
Assurance processes, and monitoring attachments with GPs.
- Organiser of the position can usefully take responsibility for the
annual application and report to RACGP for continuing medical education
point adjudication.
Specifics
Telephone Satisfaction Survey
Client details are entered into an electronic diary from which are obtained
weekly lists of clients due for a three monthly phone contact. The administrative
worker can provide support with this. After three months in shared care,
clients are asked questions according to a client satisfaction questionnaire
(see Appendix 2). Subsequent phone calls may
be three monthly, or six monthly or less frequently, depending on the
stability of the client in contact with the GP.
If problems emerge that are judged to require follow up they are referred
to either the clinical liaison clinician or the psychiatrist consulting
to that particular GP clinic. This may result in a home visit, a file
check, discussion with the GP, or a review of the client by the psychiatrist
depending on the nature of the problem.
Administrative Functions
- Convene the CLIPP Reference Group meetings on a regular basis.
- Monitor the function of the General Practice attachments, regularly
assessing activity levels and the interpersonal function of the attachment
involved in the CLIPP service.
- Provide continual clinical input into case tracking processes as administered
by the CLIPP administrative assistant.
- Support the development of a General Practice education program for
mental health related issues to support and augment the model in practice.
- Provide the annual evaluation and report on CLIPP to RACGP and ensure
maintenance of continuing medical education point accreditation.
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