CBIS - GPSC

Taking Wellness to Heart! Metabolic MonitoringWHO: All Mental Health andSubstance Use clientsWHEN: Face to face, when file is opened or at earliest opportunity (i.e., when it is therapeuticallyappropriate to do so), and prior to initiating psychotropic medication treatment.Screening / intakeFrontline MHSUClinician take baselinehealth and risk levelPrevention, intervention, and ongoing monitoring and maintenanceMHSU Clinician and Physician review baselinehealth and risk level and follow up as appropriateMHSU Clinician and Physician repeat screening andfollow up regularly1. At baseline, retrievevulnerabilitiesinformation.2. Take and/or recordbaseline measures:waist circumference,weight, blood pressureand recent lab work.3. Retrieve medicationinformation.4. Complete Diabetes-DKA checklist.5. If unable to retrieveinfo, look for alternativeways, flag for follow up,and document.6. Complete follow upsection of form: currentrisk, repeat measuresin X months, etc.MHSU Clinician follow up:1. Determine risk levels andmonitoring frequenciesand confirm with andnotify MHSU Psychiatrist/Physician of risk.2. Provide or reviewparticipation in healthylifestyle education.3. Provide smokingcessation education and/or brief intervention (ifrequired).4. Schedule next monitoringappointment.5. Share information withrelevant parties (e.g.,GP).MHSU Psychiatrist/Physician follow up:1. Determine/confirmrisk level andmonitoringfrequencies.2. Treat and/or referto GP/specialist,as required.3. Requests labtests.4. Consider riskbenefitofmedicationtherapy.5. Share informationwith relevantparties (e.g., GP).HIGH RISKMODERATERISKLOW RISKPhysicalmeasuresRepeat monthlyfor 3 months anduntil stable, then3-monthly.Repeat 3-monthly.Repeat annually.LabinvestigationsRepeat 3-monthlyfor 6 months anduntil stable, thenannually.Annually; if ≥ 5%weight increase,repeat 6-monthlyuntil stable.Repeat annually.1. Continue to treat and/or refer to GP/specialist, asrequired.2. Continue to provide or review participation in healthylifestyle education.3. Continue smoking cessation education and/ or briefintervention (if required).4. Continue to share information with relevant parties(e.g., GP).HEALTHY LIFESTYLE EDUCATION: At each stage/review point, clients should be referred to healthy lifestyleeducation and/or their participation in education should be reviewed for opportunities to be enhancedRevised April 11, 2011 Page 1 of 2 Mental Health and Substance Use