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Page 1 of 1 August 20, 2018
MARY BASIL – ADMISSION CHECKLIST / REFERRAL
Referral Source: ______________________ PHN: _______________________________ Patient Name: _______________________ DOB: _______________________________ Patient’s Phone Number: ______________ Allergies: ____________________________
1. ____ Plan G initiated: Please fill out Plan G application and send a copy with application package.
2. ____ Safety: Inclusion / Exclusion criteria reviewed. 3. ____ Urine Drug Screen (completed if necessary) – please attach results 4. ____ Lab requisition: if required 5. Substance Withdrawal Plan:
___ ALCOHOL: Medications ordered as per protocol (included in this package) ___ OPIATES: Medications withdrawal orders as per protocol. ___ Suboxone initiation orders if required
BC Centre on Substance Use/Ministry of Health Guideline for the clinical management of Opioid use disorders states: Withdrawal management alone is not an effective treatment for opioid use disorder, and offering this as a standalone option to patients is neither sufficient nor appropriate.
___ STIMULANTS: Medications ordered as per protocol (included in this package)
6. ___ Concurrent medical conditions: if any ______________________________________________
7. ___ Concurrent psychiatric diagnosis: if any _____________________________________________
8. ___ Prescriptions: completed/attached for all ‘other’ medications required during stay 9. ___ Housing: Detox program staff will work with the individual to link to resources in
the community to support finding suitable housing if needed. If homeless the client is aware he/she may be discharged back to a homeless state.
10. ___ Handouts for clients: “What to Bring” and “Occupancy Guidelines” given to client for review.
Fax copies of all documentation to Mary Basil House (250) 426-4663
11. ____ As referring Physician, I am prepared to follow the patient while in the program,
OR ____ Mary Basin on-call Physician to follow the patient while in the program
PHYSICIAN’S NAME: ______________ PHYSICIAN’S SIGNATURE_________________________ DATE: ____________________________ CONTACT NUMBER ____________________________
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MARY BASIL – INCLUSION / EXCLUSION CRITERIA INCLUSION:
Client does not need to be hospitalized o No significant health risks, such as any history of previous
uncontrolled seizures, or complicated withdrawal predicted. o No physical or psychiatric symptoms (client is currently stabilized).
Client is independent with daily activities, able to mobilize, and willing to cooperate with treatment.
Client has been assessed by a physician or Nurse Practitioner and medications have been ordered as needed.
EXCLUSION:
Complicated withdrawal is predicted.
Has experienced difficult withdrawal requiring hospitalization in the past
Recent head injury or loss of consciousness (unrelated to the effects of intoxication).
Serious medical conditions / acute psychosis / high suicide risk.
Unable to climb a minimum of 3 stairs, high fall risk, poor mobility.
Unable to do ADLs including feeding, toileting and showering self.
Current severe nutritional disorder that requires medical care (eg. IV care).
Clients who are certified under the Mental Health Act.
Recent violent or physically aggressive behaviour. GENERAL INFO:
Physician and/or Nurse Practitioner support is required. Admissions and discharges are at the discretion of the Mary Basil Detox Center.
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STIMULANT WITHDRAWAL Protocol for Adults
STIMULANT Withdrawal Orders NURSING CONSIDERATIONS:
Monitor withdrawal symptoms using the Stimulant (Amphetamine) Withdrawal Questionnaire
Allow for sleep and increased dietary intake
MEDICATIONS:
Multivitamin 1 tab po daily
Dimenhydrinate 25-50mg PO/IM Q4-6H PRN for nausea
Acetaminophen 325-650mg PO Q4-6H PRN for pain/headache (max 4g/24 hrs)
Ibuprofen 200-400mg PO QID PRN for pain/headache
Ranitidine 150mg BID PRN for heartburn
Calcium Carbonate 400-1000mg PO chewable Q4H PRN for heartburn
Sennosides 8.6mg TAB – 2 Tabs BID PRN for constipation
Loperamide 2-4mg PO PRN for diarrhea
Please select one of the following if required: ⃝ Seroquel 25mg – 50mg PO BID x 2 weeks OR ⃝ Gabapentin 300 mg PO TID and 600mg PO QHS x weeks Physician / NP Signature Date/Time:
Mental Health Substance Use Centres or Child and Youth Mental Health Service Centres: Fax this form to Health Insurance BC at 250 405-3896.
Select the most applicable options.
I certify that: a. The patient has been hospitalized for a psychiatric condition.
b. Without prescribed medication, the patient is likely to be hospitalized for a psychiatric condition.
c. Without prescribed medication, the patient or another person is likely to suffer serious physical or psychological harm, or economic loss.
PSYCHIATRIC MEDICATION COVERAGEAPPLICATION FOR PHARMACARE PLAN G
A. TO BE SIGNED BY THE APPLICANT (PLEASE SEE INSTRUCTIONS ON REVERSE)
HLTH 3497 Rev. 2016/12/21 PAGE 1
NOTE: FORMS SUBMITTED BY UNAUTHORIZED PERSONS OR WITH INCOMPLETE MANDATORY FIELDS WILL BE RETURNED. If applicant contact information is not provided, the applicant cannot be notified of coverage expiration.For more information on Plan G or to access this form online, visit www.gov.bc.ca/pharmacareprescribers.
If you have received this fax in error, please write “MISDIRECTED” across the front of the form and fax it back to the sender.
Name - mandatory Phone Number
Address Postal Code
Personal Health Number (PHN) - mandatory Birthdate (YYYY / MM / DD)
Personal information on this form is collected under the authority of section 22 of the Pharmaceutical Services Act for the operations of PharmaCare’s Psychiatric Medications Drug Plan (Plan G). The personal information will be used to support the applicant to be a Plan G beneficiary. Personal information will be released to PharmaCare and to a Mental Health Substance Use Centre for the provision of drug benefits. If you have any questions about the collection of personal information on this form, contact your local health authority or Health Insurance BC (HIBC)–from the Lower Mainland: 604 683-7151 or, from elsewhere in B.C., toll free at 1 800 663-7100. This information will be used and disclosed in accordance with the Freedom of Information and Protection of Privacy Act and the Pharmaceutical Services Act.
Applicant Signature - mandatory Date Signed
B. PRACTITIONER ONLY – TO BE SIGNED BY THE PRESCRIBING PRACTITIONER (PHYSICIAN OR NURSE PRACTITIONER)
Name of Prescribing Physician or Nurse Practitioner
Physician/Nurse Practitioner: Fax this form to your local Mental Health Substance Use Centre, Child and Youth Mental Health Service Centre, OR the mental health contact at your local health authority to complete Section C for approval. Do NOT fax directly to Health Insurance BC.
Phone Number Fax Number
Signature of Prescribing Physician or Nurse Practitioner - mandatory
C. MENTAL HEALTH SUBSTANCE USE CENTRE / HEALTH AUTHORITY ONLY – APPROVAL
1 year Less than 1 year
Authorization Expiration
Centre Name - mandatory
Name of Director or Designate
Date Signed
D. HEALTH INSURANCE BC PROCESSING
I declare that the cost of prescribed psychiatric medication is a significant barrier to my taking my medication. I have no other financial coverage, and I believe I qualify for Medical Services Plan Premium Assistance ($42,000 family adjusted net income plus $3,000 per dependent).
Practitioner College ID Number - mandatory
Site Location ID
Signature of Director or Designate - mandatory
Phone Number Fax Number
Date SignedExpiry Date (YYYY / MM / DD)This authorization will expire in:
PSYCHIATRIC MEDICATION COVERAGEAPPLICATION FOR PHARMACARE PLAN G
HLTH 3497 PAGE 2
Instructions for Authorized Persons completing this form:
If the applicant is unable to sign the form:
1. Ensure all required fields are complete.
2. Have the applicant verbally declare that they meet the Plan G eligibility requirements but are unable to sign the Plan G application.
3. Write “Verbal Declaration” in the Applicant Signature box of the Plan G application.
4. Sign your name as a witness in the Applicant Signature box beside the words “Verbal Declaration.”
If the applicant is unwilling to sign the form:
1. Ensure all required fields are complete.
2. Have a person who is legally empowered* to sign the application on behalf of the applicant sign their name in the Applicant Signature box of the Plan G application.
3. Indicate in writing, beside their signature, the legal authority that empowers them to make the declaration on the applicant’s behalf.
OR
*A person legally empowered to sign must be one of the following: a committee appointed under the Patients Property Act, a person acting under a power of attorney, a litigation guardian, or a representative acting under a representation agreement.
PLAN G
Plan G coverage is provided for a set period not exceeding one year. When this period expires, the practitioner may re-apply for continued coverage.
Plan G coverage may be extended to new residents who have not yet qualified for the B.C. Medical Services Plan (MSP). In this case, the practitioner must submit a written request with the application for Plan G coverage, detailing the patient’s compelling need for exceptional coverage. If approved, Plan G coverage will be provided for a period of three months, during which time the patient must apply for MSP.
Page 1 of 1 August 20, 2018
Please give to client to review before admission. WHAT TO BRING
Health Care Card and Extended Health ID
Comfortable clothing sufficient for 4 days
Appropriate sleepwear including socks or slippers for your feet
Long distance phone card if you want to call long distance
Toiletries: toothbrush, toothpaste, hair products, deodorant, hair dryer, shaving supplies, lotion (NO PRODUCTS CONTAINING ALCOHOL OR AEROSOLS WILL BE ALLOWED)
If you smoke please bring enough cigarettes (in unopened packages) for 5 days. We do not allow opened packages of cigarettes brought in, chewing tobacco, hand rolled cigarettes, flavoured cigarettes, cigars. Nicorette gum or nicotine packages are acceptable but must be brought into the program new/unopened. E-juice brought into the program must be sealed and unopened.
WHAT NOT TO BRING The following list contains items that clients are not permitted to have in their possession. If these items are brought into the program, they will be kept locked up until you complete the program.
No outside food or drinks, including water, candy, or chewing gum
No cell phones, computers, tablets, music equipment, televisions, i-pods, mp3 players, clock radios, cameras
No expensive jewellery or excessive cash
No hair dye, bleaching products, nail polish or remover
No perfume, cologne, aftershave, strong perfumed lotions and bath products
No alcohol or drugs
No pictures or photos that depict alcohol/drug usage, violence or sex
No weapons of any king, including scissors
No clothing that depicts alcohol, drugs, sex, or violence
No straight razors and/or razor blades
No pillows, blankets, sheets, towels, or stuffed toys
No Zippos, lighter fluid or butane
No E-juice that is alcohol or cannabis flavoured
No short shorts, halter tops, shirts that show your midriff
Page 1 of 1 August 20, 2018
OCCUPANCY GUIDELINES
1. Visitors are not allowed at the withdrawal management program.
2. All alcohol, drugs, and paraphernalia found in the possession of a client will be confiscated and destroyed. Use of alcohol or other drugs at the program may result in termination of services.
3. Staff reserves the right to conduct room searches at any time there may be a concern for the safety of clients and staff.
4. All products containing alcohol (e.g., mouthwash, hair spray, cologne, after shave, etc.) will be confiscated at time of admission and returned at time of discharge.
5. All items considered to be a threat to client safety (e.g. scissors, razors, knives.) will be confiscated at time of admission and returned at time of discharge. Clients may use safety razors and other hygiene-related “sharps” only with permission.
6. Cell phones, computers, tablets, CD’s, DVD, I-pods, MP3 players and other devices are not allowed to remain in a client’s possession while at the withdrawal management program. These items will be stored with other client valuables and returned at time of discharge.
7. Smoking: Cigarettes, E-vapes, cigars, lighters, matches, etc. will be confiscated at time of admission and stored in the staff office. Smoking is restricted to designated outdoor areas. Clients will be allowed to go outside to smoke every two hours when staff is available to supervise. Smoking indoors is strictly prohibited and may result in termination of services. Clients taking medicates that are incompatible with nicotine will not be allowed to smoke while in the withdrawal program. All tobacco products and lighters will be returned to clients at time of discharge.
8. Clients must inform unit staff of special dietary needs or food allergies so that arrangements can be made.
9. Clothing items that advertise or glorify alcohol, drugs, sex, or violence cannot be worn.
10. Quiet time will begin at 11:00pm for the benefit and comfort of all clients in the program
11. Client phone calls are permitted but should be scheduled ahead of time. Telephone calls should be limited to 10 minutes. This opportunity may be restricted further if it is impacting your success in the program.
12. Any physical contact between clients, including consensual sex, is prohibited.
13. Physical fighting, threats, harassment, damage to or theft of property are prohibited and may result in legal charges and removal from the program.
I, ___________________________________ have read the client occupancy guidelines and agree to remain in
compliance with these terms. If I experience difficulty with any aspect of it, I will approach staff for guidance.
Client Signature _________________________________ Date ________________________
