chronic opioid therapy

1 | Group Health Solutions for Transforming Care

Standardized Opioid Prescribing

Paul Fletcher, MDAssistant Medical Director, Primary Care, Group Health Physicians

Tom Schaaf, MDAssistant Medical Director, Primary Care Spokane Region, Group Health Physicians

Grant Scull, MDAssistant Medical Director, Family Medicine Residency, Group Health Physicians

Objectives

• Understand factors of success implementing standardized care across 25 medical centers

• Understand role of collaborative care planning in providing safer, patient centered clinical care

• Understand essential elements of a multidisciplinary guideline for chronic opioid prescribing

Group Health Solutions for Transforming Care | Chronic Opioid Therapy

Who we are

• Integrated health delivery system• Founded in 1946• Consumer governed, non-profit• Membership: 661,500 Staff: 9,365• Revenues (2009): $3 billion

• Group Health Research Institute

• 34 investigators

• 235 active grants, $39 million (2009)

• Multispecialty Group Practice

• 25 primary care medical centers

• 6 specialty units, 1 maternity hospital

• 985 salaried medical group members

• Contracted network• > 9,000 practitioners, 39 hospitals

Group Health

Outline

ProblemElements of program

The approach

Outcomes


Patient Story

Mr. Jones

•46 y/o shipyard worker with chronic pain

•Calls for monthly refills of oxycontin 90 pills every month

•PCP on vacation refill not approved by Friday afternoon

•Covering provider does not understand what is being treated and feels uncomfortable signing script


Patient Story

Mr. Smith

•59 retired driver with diabetes and

•Suffering wide variety of painful disorders

•Seeks narcotics from several different provider when being seen

•Reports being treated like an addict

•Deactivated, discouraged, no plan


Patient Story

Dr. D-F, new resident

•In her first week of continuity clinic

•Patient is 42, charming, articulate, “reasonable” and self employed

•Needs refill for narcotic for vague chronic pain, care plan created ?collaborative

•Months go by with no progress or follow through

•Loss of innocence


Patient Story

Group Health

•65 y/o health integrated health system

•Tolerating wide diversity in approaches

•Suffering from local squabbles

•Wasting energy on complaints and rework

•Deactivated, discouraged, no plan


What a pain in the …

• Disagreements among providers

• Patients getting confusing and conflicting messages

• At war with our patients

• Delays in prescription refills

• Patients are dying from overdoses


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

Group Health

Kaiser N CA

Opioid TherapyGroup Health Cooperative & Kaiser N California 1997-2005

Chronic Opioid Therapy:90 days &> 10 Rx fills and/or> 120 days supplyPersons with cancer excluded

Steady trend upwards

Boudreau et al, Pharmacoepi Drug Safety, 2009

0

2000

4000

6000

8000

10000

12000

14000

16000

'99 '00 '01 '02 '03 '04 '05 '06

Year

Nu

mb

er

of

death

s

prescription opioid

cocaine

heroin

Source: CDC

More Deaths from Prescriptions than Cocaine and Heroin


Higher dosing is deadly

0123456789

10

1-19 mg. 20-49 mg. 50-99 mg. 100+ mg.

Opioid Overdose Hazard Ratio (& rate per year)

Average Daily Opioid Dose in Morphine Equivalents

1.8 %

0.7 %

0.3 %0.2 %

9-fold increasein risk relativeto low-dose

patients

Dunn et al., Annals Int Med, 2010

**

**

ns

** p<0.05


The Population

10 to 70 patients per full time physician

900 - high dose (>120mg MED)3500 - med dose (20 – 119mg MED)2000 - low dose (<20mg MED)

6400 non cancer patients with daily narcotic use over 90 days


New Alignment of the Stars

Claire Trescott MD - Primary Care Medical Director with expertise in Addictive Medicine

Randi Beck, MD - Physical Medicine and Rehab physician receives a small innovations grant

State guidelines published 2007

State regulations January 2012


The Guideline

• Developed in parallel with state

• Patients stratified by dose and behavior

• Care plan elements defined

• Monitoring criteria defined (freq of visits and UDS)

• Referrals of high dose patients required


New Capabilities

New lean management system

Medical Home chassis in place

Ability to design new processes

Ability to put standard work in place in 25 clinics

Confidence that we can sustain

Care plans

Outreach

Prepared for Visit


New Approach

Standardized ImprovementMethodology

Understand Current State

Sponsor set goals and guardrails

Get front line workers to design the future

Rapid Process Improvement

Workshop

Design standard processes

Define roles and standard work

Outline training and measurement


Program Requirements

All patients on Chronic Opioid Therapy will have a collaborative care plan

Diagnosis

Patient Goals (function!)

Risk/benefit discussion

Medication and dose

Treatment plan

Instructions for follow up


Definitions of monitoring groups – 2011


Different requirements for monitoring and follow up


Assessment



Pain Contracts outmoded, new Pain “Agreement” for selected patients

Expectations for Patients:

•Request refills 7 days in advance

•Participate in Urine drug screens

•Use only one prescriber for narcotics


Opioid Fact Sheet and Treatment Agreement


Urine Drug Screening

It is recommended that the clinician have a discussion with the patient before the UDS that includes:

The purpose for testing What will be screened for What results the patient expects Prescriptions or any other drugs the patient has

taken Time of last dose of opioids Actions that may be taken based on the results of

the screen The patient should be notified that the results will

become part of their permanent medical record.


Tapering or weaning patients off COT


Referral Criteria



Care Plans Documented in the AVS and summarized on the problem list

The “responsible clinician”

Condition treated

Relevant work up findings and consultants

Clear expectations for patient and care team

• prescription instructions and refills

• Visit frequency

• urine drug screening


Wrapping up the documentation:Add GHC.17 CHRONIC OPIOID THERAPY CARE PLAN and Comment to Problem List



Refills

Care teams – email provider with required information

Providers - Write in 7 day increments

Pharmacy - Hold until refill day

Medication Changes or denials

Patients only notified by provider or RN


Medication Refill Considerations

Before refilling a prescription, clinicians are encouraged to:

Calculate and document the total MED. Calculate and document the total acetaminophen dose (including

prescribed and OTC):

• Acute: Max single dose 1000mg, max daily dose 4000mg (For elderly and patients with alcohol or liver disease, max single dose 650mg, max daily dose 2000mg)

• Long-term use (>10 days): Max daily dose 2500mg

Follow best prescribing practices:

• Order medication in multiples of 7 days and include “to last __ days”

Must use this language - Pharmacy will be looking for this language to cue their standard work

• Provide specific instructions (i.e. schedule for taking)Group Health Solutions for Transforming Care | Chronic Opioid Therapy

ImplementationStandard work on the MH Chassis

Integrated into outreach and pre-visit

Pain and function questions in rooming

Pain and function scales built into Wellness tab

Care plans updated and postedin EMR


Implementation

Training

•Each chief and champion trained for 8 hrs

•Online course required for all clinicians 4 hours: MD, PA, RN, Clinical Pharmacist

•New process and highlights of the training presented to whole team 2 hours

•Coaches available for difficult conversations


ImplementationMeeting the Jan 2012 Deadline

Population verified by pcp All patients

invited inCare plan completion tracked and incentive payment at end of year

Q4 2010Q4

2010Q1

2011Q1

2011Q3-42011Q3-42011

Q22011Q2

2011

Dummy code on

problem list

High risk invited in


New Methods

Measurement at the process level

Patients diagnosis confirmed

put on problem list

seen, care plans in place

Linked measures from individual provider to clinic to division

Performance visible and

discussed weekly at each level


Implementation

0%

20%

40%

60%

80%

100%Percent of COT patients with care plans

Guideline implementationSeptember 2010


Physician Barriers

• Physicians reluctant to order UDS

• Confusion how to react to abnormal UDS

• Some very large number of patients

• Do not see a problem with their own patient management

• Physicians refusing to prescribe

• Over-delegate tough messages

• Unable to follow the care plan


Patient Story


Mr. Jones has agreed to a slow taper PCP monitoring functional status

UDS shown some marijuana, clinician agreed to continue prescribing

Care plan on problem listCovering MD signs for vacationing

PCP

Mr. Smith now has a clear plan, gets his refills every 28 days

Very happy with the no fuss and bother

Provider hoping for a reactivation program and hoping to taper him

down someday

Patient Story

Dr. D-F, new resident

•Advice from attendings and peers is more standardized

•Easy to tell patient “this is how we do things here”

•New physicians continue to get tested by roving patients


Summary of COT work

• Cultural change regarding this population: Not at war with them but trying to keep them safe and get them into the best treatment available.

• Decreasing the clinical variation is an implicit goal, high doses very visible, medical decision making is clear and behavior auditable


7%

13%

50%

15%

21%

64%

0%

10%

20%

30%

40%

50%

60%

70%

80%

All COT patients

High dose COT patients

COT Patients Receiving Urine Drug Screeningin a Year by Dose

Baseline(2008-9)

Guideline Planning(2009-10)

Guideline Implementation

(2010-11) Group Health Solutions for Transforming Care | Chronic Opioid Therapy

0%

1%

2%

3%

4%

5%

Percent Receiving COT (70+ days supply/quarter)Group Health Integrated Group Practice vs. Network

GuidelineImplementation

GuidelinePlanning

IGP

Network


0%

5%

10%

15%

20%

25%

COT Patients Receiving Average Daily Dose > 120 mg MED (%): Group Health IGP vs. Network

IGP

Network

17.8 % > 120 mg. MED

9.4 % > 120 mg. MED

GuidelineImplementation

GuidelinePlanning


Current Status

• Best rollout ever

• Decreased patient complaints

• Decreased tension in the clinics

• Fewer patients on high doses

• Much more urine screening

• Starting to develop better programs for chronic pain

• Factors of success: sponsorship, methods and processes in place, met real problem, state mandates, financial incentives


Case Studies

47 | Group Health Solutions for Transforming Care | Chronic Opioid Therapy

Group Health public access on-line training site

http://www.group-health-practice-improvement-for-opioids.org/Password = 1234

State of Washington COT guidelines and other resourceshttp://www.agencymeddirectors.wa.gov/opioiddosing.asp

Questions

For additional information on Group Health

Innovations, go to: www.GHinnovates.org

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