Remote Cognitive Adaptation Training During and After COVID-19.
Remote Cognitive Adaptation Training During and After COVID-19.
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COVID-19 期间和之后的远程认知适应培训。
DOI：
10.1176/appi.ps.20220441
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发表时间：
2022
期刊：
影响因子：
--
通讯作者：
Li,Feiyu
中科院分区：
文献类型：
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作者：
Velligan,Dawn;Lara,Frankie;Li,Feiyu
氯氮平是对难治性精神分裂症患者最有效的抗精神病药物，被认为是对两种或多种其他抗精神病药物的充分试验无反应的患者的标准治疗。尽管其上级疗效，氯氮平是利用不足，增加氯氮平处方代表了公共卫生的优先事项。为了解决氯氮平利用不足的问题，我们开发了一个质量改进项目，旨在增加剑桥健康联盟（一个位于大波士顿的公共安全网卫生系统）的氯氮平处方。在2015年，我们创建了一个氯氮平诊所，建立了一个小组精神病学访问，利用初级保健为基础的现场实验室，创建患者提示表，通过研讨会和氯氮平诊所轮换加强居民教育，为患者举办教育会议，将临床药剂师纳入氯氮平护理，并启动了监测心肌炎的协议。每周一次的氯氮平小组访视由多学科团队的两到三名成员（包括精神科医生、精神病学住院医师、执业护士和临床药剂师）协助，并为新开始使用氯氮平、经历不良反应或想要讨论的患者提供支持分享经验。我们的氯氮平诊所试图通过创建一个工具包来扩大患者和提供者对扩大氯氮平使用的支持，该工具包可供其他卫生系统使用，以克服患者、提供者和系统相关的障碍。干预措施包括提供者和患者教育，电子健康记录（EHR）优化和电子咨询支持。此外，一个季度氯氮平特定的精神病学部门通讯传达了我们的举措的更新。我们通过内部Google网站为供应商创建了一个集中的氯氮平特定资源。面向提供者的提示表提供了关于氯氮平处方的信息和管理不良反应的提示。现有的面向患者的提示表进行了扩展，以提供额外的资源，以获得有关氯氮平和不良反应的管理的一般信息。所有举报单都在网站上提供，方便提供者查阅。研讨会和精神病学，内科和家庭医学部门的大轮有针对性的提供者教育。此外，精神病学居民和精神科医生的介绍达到了潜在的氯氮平供应商。介绍内容包括使用氯氮平的好处、不良反应的处理、如何与患者谈论氯氮平以及提供有关药物的其他详细信息的可用资源。在每次演讲之前分发调查，以衡量提供者对氯氮平的态度并评估现有知识，目的是每年提供教育演讲和调查，以跟踪态度和知识的变化。使用EHR，我们开发了一个最佳实践警报（BPA），以通知精神病提供者基于精神分裂症谱系疾病诊断，两种或两种以上抗精神病药物的历史处方，以及以前没有氯氮平处方的潜在候选人。建立报告，以根据共病情况和临床特征（如迟发性运动障碍、自杀行为史或近期精神病住院治疗）确定氯氮平治疗的候选者。该团队还分享了EHR中的文档模板，作为提供者的检查清单，以标准化安全和全面的氯氮平治疗。对所有与氯氮平有关的问题实施了电子健康记录中的电子咨询程序。咨询请求可能包括具体的氯氮平相关的.
Clozapine is the most effective antipsychotic medication for individuals with treatment-resistant schizophrenia and is considered standard of care for patients whose conditions have not responded to adequate trials of two or more other antipsychotics. Despite its superior efficacy, clozapine is underutilized, and increasing clozapine prescribing represents a public health priority. To address clozapine underutilization, we developed a quality improvement project aimed at increasing clozapine prescribing at Cambridge Health Alliance, a public safetynet health system based in Greater Boston. In 2015, we created a clozapine clinic that established a group psychiatric visit, utilized primary care–based onsite laboratories, created patient tip sheets, enhanced resident education through seminars and a clozapine clinic rotation, held educational sessions for patients, integrated a clinical pharmacist into clozapine care, and initiated protocols for monitoring myocarditis. The weekly clozapine group visit was facilitated by two to three members of a multidisciplinary team (comprising a psychiatrist, psychiatry resident, nurse practitioner, and clinical pharmacist) and provided support for patients newly starting clozapine, experiencing adverse effects, or wanting to discuss shared experiences. Our clozapine clinic sought to broaden support among patients and providers for expanded clozapine use by creating a tool kit that could be used by other health systems to overcome patient-, provider-, and system-related barriers. Interventions included provider and patient education, electronic health record (EHR) optimization, and e-consult support. Additionally, a quarterly clozapine-specific psychiatry department newsletter communicated updates on our initiatives. We created a centralized clozapine-specific resource for providers via an internal Google Site. Provider-facing tip sheets provided information on clozapine prescribing and tips for managing adverse effects. Existing patient-facing tip sheets were expanded to provide additional resources for obtaining general information on clozapine and management of adverse effects. All tip sheets were available on the website for easy access by providers. Seminars and grand rounds for psychiatry, internal medicine, and family medicine departments targeted provider education. Moreover, presentations for psychiatry residents and staff psychiatrists reached potential clozapine providers. Presentations included benefits of clozapine use, adverse effect management, how to talk with patients about clozapine, and available resources providing additional details on the medication. Surveys were distributed before each presentation to gauge attitudes of providers toward clozapine and evaluate existing knowledge, with the goal of providing educational presentations and surveys annually to track changes in attitudes and knowledge. Using the EHR, we developed a best practice alert (BPA) to notify psychiatric providers of potential candidates for clozapine treatment on the basis of schizophrenia spectrum illness diagnosis, historical prescriptions for two or more antipsychotic medications, and no previous prescription for clozapine. Reports were built to identify candidates for clozapine treatment on the basis of comorbid conditions and clinical features (eg, tardive dyskinesia, history of suicidal behavior, or recent psychiatric hospitalization). The team also shared documentation templates in the EHR as checklists for providers to standardize safe and comprehensive clozapine care. An e-consult process within the EHR was implemented for all clozapine-related questions. Consultation requests could include specific clozapine-related …