Policies & Procedures

SAMPLE

The goal of this section is to offer sample language for facilities interested in developing home medication and self-administration policies, and single use case agreements. These sample policies can be used to generate ideas or as a template to review, modify, and potentially incorporate into existing policies. These samples are based on policies used in Minnesota and North Carolina-licensed programs. For more information and resources designed to help providers facilitate access to inpatient and residential behavioral health facilities, visit the Provider Toolkit.

***Please note: These sample policies are for informational purposes only. Facilities are responsible for ensuring any policy, procedure, and form adopted meets all applicable licensing requirements and goes through appropriate legal review prior to adoption.

The Centers for Medicare and Medicaid Services (CMS) State Operations Manual permits inpatient psychiatric facilities to allow patients to bring medications into a facility from home and allow patients to self-administer medication provided that facilities have policies and procedures in place to implement these practices. Many states also require that both mental health and substance use disorder treatment facilities develop policies and procedures if they want to permit home medication and self-administration. If adopted by mental health and substance use facilities, these types of policies can facilitate greater access for people with bleeding disorders. 

  • Many facilities do not have specialty medications available in their facility pharmacies or have relationships with pharmacies that can dispense specialty medications. Therefore, it can be difficult for an individual with a bleeding disorder to get their prescribed specialty medication in the facility. If individuals are permitted to bring their prescribed medications from home, this can avoid the need for the facility to procure it. Ultimately, this can allow people with bleeding disorders to access both their essential home medications and their mental health care.

  • Facilities have expressed concern about accepting people with bleeding disorders because of a lack of facility staff to or comfort in administering required infusion or injection medications. If individuals are permitted to self-administer their medications (self-infuse or self-inject), it can remove the barrier of requiring facility staff to be trained in administering infusions or injections and facilitate greater access.

  • If self-administration of medication is not an option and the facility does not have staff available to administer an infusion or injection, bringing in an external provider may be the best approach to ensure access. Some facilities may require a “single use case agreement” to permit an outside provider to administer medication onsite. If a facility initially states that its license does not allow external providers, this may be a regulatory or contractual issue worth exploring further.