Abstract

Author(s)

Catherine Goodwin and James Conely

Introduction

Clozapine for many people is the most effective treatment for their mental illness. Typically supported in tertiary services, its prescription requires high levels of monitoring for patient safety, side effects management and potential secondary health impacts. There are few options in the CESPHN region for managing Clozapine in a primary care setting. For many people this means that they must stay engaged in tertiary treatment services regardless of their mental health support needs.

Method

CESPHN partnered with SESLHD Clozapine Clinic to codesign a ‘Clozapine Comprehensive Care Coordination Service. The model aims to:
1. Improve the primary health care of non-cased managed Consumers who receive Clozapine therapy
2. Improve partnership and referral pathways between internal and external health care providers.
3. Improve the support between stakeholders for Consumers as their care is transitioning between health care services.
The model features a Clozapine Clinical Nurse Specialist to promote the program to GPs and provide ongoing education and support to participating practices.

Results & Findings

Oct 2021 – Mar 2023
• 20 Clients Supported to transition to GP Shared Care arrangements.
• 1496 Occasions of Service
• 95% of Consumers with an Engaged GP.
• 95% of Consumers stable on Clozapine and not re-admitted to tertiary care
• Consumer and GP experience of service to be showcased

Discussion

There are multiple barriers to establishing successful Clozapine therapy in a primary care setting. This project demonstrates that a focus on clinical coordination, training and supported transitions between primary and tertiary care can overcome these barriers. Consumer and GP experience of care and partnership highlights the benefits of this focus.