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Clinical Track: Taking on Prescrip2on Drug Abuse
Across the Care Con2nuum
Daren Anderson, MD VP/Chief Quality Officer, Community Health Center, Inc.
Director, Weitzman Quality Ins?tute Associate Professor of Medicine, Quinnipiac University
Melissa Lamer, PharmD, BCPP Director of Behavioral Health Pharmacy Solu?ons
Magellan Rx Management
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Disclosures
• Daren Anderson has disclosed no relevant, real or apparent personal or professional financial rela6onships.
• Melissa Lamer PharmD, BCPP wishes to disclose she is an employee and is paid a salary form Magellan. She will present this content in a fair and balanced manner.
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Learning Objec6ves
1. Iden6fy the specific provider educa6on interven6ons that can play a role in decreasing prescrip6on drug abuse.
2. Evaluate how the applica6on of advanced health care data analy6cs enables the iden6fica6on and targe6ng of inappropriate behaviors related to prescrip6on drug abuse.
3. Analyze preliminary results of CHCI’s randomized trial of ECHO Pain Management, discussing the impact of the interven6on on provider, pa6ent and administra6ve outcomes.
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Strategies for Improving the Quality and Safety of Chronic Pain
Management in Primary Care
Daren Anderson, MD VP/Chief Quality Officer
Community Health Center, Inc. Director, Weitzman Quality
Institute Associate Professor of Medicine
Quinnipiac University
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Goals of Presentation
• To discuss current challenges in managing pain in primary care, particularly in medically underserved populations
• To describe the Stepped Care Model for Pain Management
• To describe primary care system interventions to improve quality of chronic pain management
• To explore methods to measure quality in chronic pain management
• To understand the Project ECHO model and how it can be used to improve the quality and safety of pain management in primary care
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Community Health Center, Inc.
Our Vision: Since 1972, Community Health Center, Inc. has been building a world-class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes and building healthy communities.
CHC Inc. Profile: " Founding Year - 1972
" Primary Care Hubs–13
" No. of Service Locations-218
" Licensed SBHC locations–24
" Organization Staff – 500
" 140,000 patients
" 400,000 visits
" Medical, dental, behavioral health
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Weitzman Quality Institute • Established in 2013 by the
Community Health Center, Inc.
• Named in honor of Gerald Weitzman, a community pharmacist, one of CHC’s founders, and a long-time board member
• Research Institute based in a large FQHC
• Promotes innovations in quality improvement science as well as critical investigation in primary care and systems redesign
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Academic Partners
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• Chronic pain affects approximately 100 million Americans1
• Annual cost of $635 billion in medical treatment and lost productivity1
• Majority of patients with pain seek care in a primary care setting2
• Primary Care Providers express low knowledge and confidence in pain management and receive little pain management education3
• Opioids are heavily relied on for pain management in primary care4
• Prescription opioid overdose is a major and growing public health concern5
Background
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• Increasing demand to identify and manage painful conditions
• Increasing rates of opioid abuse and diversion • Limited training in pain management • Limited access to specialists • Limited access to pain management specialty centers
The Challenge for the PCP
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CHC’s Stepped Care Model for Pain Management
STEP 1
STEP 2
STEP 3
Primary Care Medical Home Routine screening for presence & intensity of pain
Comprehensive pain assessment and follow up Documentation of function status and goals Management of common painful conditions
Primary care team-care: MA, RN Care managers Systematic Opioid Risk Assessment/Refill/Monitoring
Complexity
Treatment Refractory
Comorbidities
RISK
Tertiary Interdisciplinary Pain Centers
Referrals to community partners
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Chronic Pain in Primary Care: Baseline Data from a large health
system
Chart Review Data warehouse Provider/Staff surveys
Data sources:
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Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.
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EHR Data: Chronic Pain Algorithm
• All patients age 18 and older with at least one medical visit in the past year who met any of the criteria below:
• A visit with an ICD9 code specific for chronic pain (e.g. “chronic pain syndrome” 338.2X, 338.4)
• Two or more visits separated by 30 days or more with an ICD9 code for a painful condition
• Receipt of at least 90 days of opioid medication other than buprenorphine in one year
• One visit with an ICD9 code for a painful condition AND two or more pain scores greater than or equal to 4.
Data warehous
e
Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.
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Demographics Pa2ents with Chronic Pain (20% of all
pa2ents)
Pa2ents without Chronic Pain (80%)
p-‐Value Two-‐Tail
Total Patients* 8152 % 32487 % Sex Male 2995 37% 13215 41% <0.0002
Female 5156 63% 19266 59% <0.0002 Age Age 18-‐29 856 11% 8679 27% <0.0002
Age 30-‐39 1483 18% 7163 22% <0.0002 Age 40-‐49 2319 28% 6758 21% <0.0002 Age 50-‐59 2243 28% 5644 17% <0.0002 Age 60-‐69 925 11% 2969 9% <0.0002 Age 69+ 326 4% 1274 4% 0.7482
Race Caucasian 3624 44% 12433 38% <0.0002 Black 1005 12% 4147 13% 0.2891 Hispanic 3138 38% 12866 40% 0.0667
Visits
Avg Visits/Yr 6.54 2.72 <0.0002 Opioids Any Opioid Rx 3280 40% 1870 6% <0.0002
90+ Days Opioid 1297 16% 0 0% <0.0002 Mental Hlth Pts w/ a CHCI BH Visit 1991 24% 3329 10% <0.0002 Pain Referrals Physical Therapy 1655 20% 953 3% <0.0002
Pain Management 573 7% 94 0% <0.0002 Physical Med and Rehab 700 9% 346 1% <0.0002 Orthopedic Surgery 1347 17% 677 2% <0.0002 Rheumatology 275 3% 159 0% <0.0002
Insurance Medicaid 5425 67% 15315 47% <0.0002 Medicare 1302 16% 3094 10% <0.0002 Uninsured 780 10% 7814 24% <0.0002
Data warehous
e • >female • Older • More
visits • More
opioids • More BH
Dx • More
referrals • Less
uninsured
* All adult patients in 2011 with at least one medical visit
Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.
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Data warehous
e 100%
37%
9%
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
All CHCI Chronic Pain Cohort Chronic Opioid Subset
Total Primary Care Medical Visits, 2012
.
Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
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0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
0% 0% 0% 0% 0% 0%
1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1%
1% 2% 2% 2% 2% 2% 2% 2% 2%
2% 2% 2% 2%
3% 3%
4% 4%
4% 5% 5% 5%
5% 5%
5% 5%
6% 7%
7% 7%
8% 10%
11% 11%
11% 11%
0% 2% 4% 6% 8% 10% 12%
Dudley MD, Robert-PD
Farb MD, Alan-PD
Kennedy APRN, Michelle
Moemeka MD, Angela
Seagriff APRN, Nicole
Ayubcha MD, Soussan- FP
Mohammadu MD, Fusaini
Bravo MD, Teresa-FP
Kobel PA, Cela
Martin MD, Monique
Quarles APRN, Kristie
Wessling MD, Kathleen
DeMarco APRN, Rachel-FP
Weir MD, Lori
Knoeckel APRN, Sarah
Weischedel MD, Anne-Katrin
Dresden APRN, Debra
Gellrich MD, Gabriella-FP
Doerwaldt MD, Hartmut-FP
Wilson APRN, Laura
Carden APRN, Pamela LOCUM
Lau MD, Wai Lang- IM
Barrow MD, Alvin
Butler MD, Danielle-FP
Lecce MD, Carl-FP
Swan APRN, Amanda
Kamat MD, Leena
Manning DO, Lynne
Rivera Godreau MD, Ivelisse--FP
Patel DO, Dipak--FP
Decker APRN, Patricia-FP
Percent of Panel Prescribed 90 Days of Opioids by PCP
Provider Names
Data warehous
e
Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
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Chart Review Results Baseline
2011
Chronic Opioid
Cohort
Presence of pain documented 65.3%
Provider's func6onal assessment documenta6on 6.7%
Provider's cause/source documenta6on 64.0%
Diagnos6c test reviewed 4.7%
Pain medica6on ordered 100%
Pain consult 10.7%
Documenta6on of treatment plan 96%
Pa6ent educa6on provided 16.0%
Diagnos6c Imaging ordered 22.0%
Pain reassessed 20.0%
Chart review
.
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Pain Survey Questions Item Statement Mean
Baseline 2011
Skilled chronic pain management is a high priority for me. 3.74*
My management of chronic pain is influenced by experience with addicted patients.
1.15
My management of chronic pain is influenced by fear of contributing to dependence.
1.36
I have adequate time to manage most patients with chronic pain. 1.81
Fear of narcotic regulatory agencies/administration influences my decisions regarding chronic pain management.
2.04
Analgesic side effects hinder my efforts to treat patients with chronic pain.
2.17
Patients I treat become addicted to opioids. 2.55
I use an opioid agreement with my patients. 4.45
I use a pain assessment or monitoring tool. 3.77
I am confident in my ability to manage chronic pain. 2.77
I am satisfied with the quality of resources available to help me manage patients with chronic pain.
1.53
Provider/ Staff
surveys
Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
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152.49
138
178
150
0.00
50.00
100.00
150.00
200.00
250.00
CHCI Providers (n=47) Davis et al. Valida6on Cohort: Internists (n=84)
Davis et al. Valida6on Cohort: Pain Experts (n=22)
Davis et al. Valida6on Cohort: Academic Physicians (n=27)
Avg CHCI KP50 Baseline Score Comparison Provider/
Staff surveys
.
Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
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Key Findings • Chronic pain is extremely common (up to 37% of visits) • Patients using opioids have >10 visits per year • Documentation of pain care is poor • Functional assessments are rarely documented • Pain care knowledge is low • Providers have low confidence in their pain
management skills • Providers feel that pain care is an important skill for
them
. Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
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Problem Goal Interven2on
Low pain knowledge/self efficacy
Increase knowledge and self efficacy
Online, team-‐based CME
Poor documenta6on of pain and func6onal status Poor documenta6on of pain reassessment
Improve documenta6on of pain care/func6onal status
• EHR templates for pain management visits
• SF8 Pain interference form (PROMIS tool)
• Opioid Risk Tool • COMM® form
Low rates of opioid monitoring/high varia6on in prescribing paherns
Reduce opioid prescrip6on varia6on and increase use of opioid agreements and u-‐tox monitoring
• Standard policy for opioid agreements
• Standard policy/procedure for utox
• Opioid dashboard • Opioid review
commihee
Limited behavioral health co-‐management
Increase BH-‐Primary care co-‐management
• Behavioral health co-‐loca6on
• Pain group therapy • Project ECHO
Low use of CAM Increase access to CAM Improved access/Co-‐loca6on of chiroprac6c, mindfulness program
Limited access to specialty consulta6on
Increase PCP access to specialty advice
Project ECHO
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Pain CME Options
• Conferences • REMS training
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CHCI Biannual Pain Management CME
• All PCP’s • 2 hours, biannually • Virtual Lecture
Hall® • Group format: PCP,
RN, BHP, PharmD
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Action Plan Problem Goal Interven2on
Low pain knowledge/self efficacy
Increase knowledge and self efficacy
Online, team-‐based CME
Poor documenta6on of pain and func6onal status
Poor documenta6on of pain reassessment
Improve documenta6on of pain care/func6onal status
• EHR templates for pain management visits
• SF8 Pain interference form (PROMIS tool)
• Opioid Risk Tool • COMM® form
Low rates of opioid monitoring/high varia6on in prescribing paherns
Reduce opioid prescrip6on varia6on and increase use of opioid agreements and u-‐tox monitoring
• Standard policy for opioid agreements
• Standard policy/procedure for utox
• Opioid dashboard • Opioid review
commihee
Limited behavioral health co-‐management
Increase BH-‐Primary care co-‐management
• Behavioral health co-‐loca6on
• Pain group therapy • Project ECHO
Low use of CAM Increase access to CAM Improved access/Co-‐loca6on of chiroprac6c, mindfulness program
Limited access to specialty consulta6on
Increase PCP access to specialty advice
Project ECHO
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Chronic Pain Follow-Up Templates • Click the HPI link and select the category Chronic Pain Follow
Up to document the necessary information:
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Pain Follow Up Assessment Forms
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Pain Follow Up Assessment Forms
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Pain Follow Up Assessment Forms
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Pain Follow Up Assessment Forms
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Action Plan Problem Goal Interven2on
Low pain knowledge/self efficacy
Increase knowledge and self efficacy
Online, team-‐based CME
Poor documenta6on of pain and func6onal status Poor documenta6on of pain reassessment
Improve documenta6on of pain care/func6onal status
• EHR templates for pain management visits
• SF8 Pain interference form (PROMIS tool)
• Opioid Risk Tool • COMM® form
Low rates of opioid monitoring/high varia6on in prescribing paherns
Reduce opioid prescrip6on varia6on and increase use of opioid agreements and u-‐tox monitoring
• Standard policy for opioid agreements
• Standard policy/procedure for utox
• Opioid dashboard • Opioid review
commihee
Limited behavioral health co-‐management
Increase BH-‐Primary care co-‐management
• Behavioral health co-‐loca6on
• Pain group therapy • Project ECHO
Low use of CAM Increase access to CAM Improved access/Co-‐loca6on of chiroprac6c, mindfulness program
Limited access to specialty consulta6on
Increase PCP access to specialty advice
Project ECHO
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CHCI standard policy for chronic opioid therapy:
• All patients receiving COT* must have: – Signed opioid agreement scanned and
saved in the EHR – Utox at least once every 6 months – Follow up visit every 3 months
*COT defined as receipt of 90 days or more of prescription opioid analgesic medication
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Opioid Management Dashboard
Provider Names
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Opioid Review Committee
• Committee with oversight over opioid prescribing – Formulary – High dose opioid oversight – Can require review before Rx – Can review outliers – Establish internal guidelines
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Action Plan Problem Goal Interven2on
Low pain knowledge/self efficacy
Increase knowledge and self efficacy
Online, team-‐based CME
Poor documenta6on of pain and func6onal status Poor documenta6on of pain reassessment
Improve documenta6on of pain care/func6onal status
• EHR templates for pain management visits
• SF8 Pain interference form (PROMIS tool)
• Opioid Risk Tool • COMM® form
Low rates of opioid monitoring/high varia6on in prescribing paherns
Reduce opioid prescrip6on varia6on and increase use of opioid agreements and u-‐tox monitoring
• Standard policy for opioid agreements
• Standard policy/procedure for utox
• Opioid dashboard • Opioid review
commihee
Limited behavioral health co-‐management
Increase BH-‐Primary care co-‐management
• Behavioral health co-‐loca6on
• Pain group therapy • Project ECHO
Low use of CAM Increase access to CAM Improved access/Co-‐loca6on of chiroprac6c, mindfulness program
Limited access to specialty consulta6on
Increase PCP access to specialty advice
Project ECHO
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• University of Bridgeport • Six CHC sites: 4 Chiropractors + students • 1-2 days per week • Internal referral in ECW • ECW custom HPI folders • Collaborative management for pain/
musculoskeletal problems Results • Number of Unique Patients Seen – 77 • 98.7% completely satisfied • 98% stated their condition was improved after
treatment
CHC-University of Bridgeport Integrated Chiropractic Care
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Expanded Access to Chiropractic
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Photo of acupuncture
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Action Plan Problem Goal Interven2on
Low pain knowledge/self efficacy
Increase knowledge and self efficacy
Online, team-‐based CME
Poor documenta6on of pain and func6onal status Poor documenta6on of pain reassessment
Improve documenta6on of pain care/func6onal status
• EHR templates for pain management visits
• SF8 Pain interference form (PROMIS tool)
• Opioid Risk Tool • COMM® form
Low rates of opioid monitoring/high varia6on in prescribing paherns
Reduce opioid prescrip6on varia6on and increase use of opioid agreements and u-‐tox monitoring
• Standard policy for opioid agreements
• Standard policy/procedure for utox
• Opioid dashboard • Opioid review
commihee
Limited behavioral health co-‐management
Increase BH-‐Primary care co-‐management
• Behavioral health co-‐loca6on
• Pain group therapy • Project ECHO
Low use of CAM Increase access to CAM Improved access/Co-‐loca6on of chiroprac6c, mindfulness program
Limited access to specialty consulta6on
Increase PCP access to specialty advice
Project ECHO
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Behavioral Health Integration for Pain Management
• Co-location of Behavioral health and primary care
• Warm handoffs • Group therapy • BH participation in Project ECHO
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COGNITIVE-BEHAVIORAL THERAPY (CBT)
• GOAL: Move person from passivity, stress- reactivity and hopelessness to hopefulness, resourcefulness, and action
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METHODS FOR IMPROVED COPING WITH PAIN
– Cognitive Restructuring – Acceptance and Adaptation – Reframing – Distraction – Repetitive movement – Relaxation – Imagery – Motivation – Planning and Pacing Daily Activities – Goal Setting – Medication Management
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Action Plan Problem Goal Interven2on
Low pain knowledge/self efficacy Increase knowledge and self efficacy
Online, team-‐based CME
Poor documenta6on of pain and func6onal status Poor documenta6on of pain reassessment
Improve documenta6on of pain care/func6onal status
• EHR templates for pain management visits
• SF8 Pain interference form (PROMIS tool)
• Opioid Risk Tool • COMM® form
Low rates of opioid monitoring/high varia6on in prescribing paherns
Reduce opioid prescrip6on varia6on and increase use of opioid agreements and u-‐tox monitoring
• Standard policy for opioid agreements
• Standard policy/procedure for utox
• Opioid dashboard • Opioid review commihee
Limited behavioral health co-‐management
Increase BH-‐Primary care co-‐management
• Behavioral health co-‐loca6on • Pain group therapy • Project ECHO
Low use of CAM Increase access to CAM Improved access/Co-‐loca6on of chiroprac6c, mindfulness program
Limited access to specialty consulta6on
Increase PCP access to specialty advice
Project ECHO
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NEJM 6/2011 • Prospective cohort study
comparing HCV Rx at UNM with Rx by primary care clinicians at 21 ECHO sites in rural areas and prisons in NM.
• 407 patients with no previous treatment
• Primary endpoint was SVR. • 57.5% at UNM and 58.2%
at ECHO sites achieved SVR.
• Serious adverse events occurred in 13.7% at UNM and 6.9% at ECHO sites.
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Project ECHO University of New Mexico
“The mission of Project ECHO is to develop the capacity to safely and
effectively treat chronic, common and complex diseases in rural and
underserved areas and to monitor outcomes.”
Dr. Sanjeev Arora, University of New
Mexico
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Technological Infrastructure
• Video conferencing system for ECHO team
• Mobile teleconferencing platform (Vidyo©)
• Webcam/iPad/ smart phone for end-users
• EHR
60
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• 2 hour weekly sessions • Case submission form • Expert specialty team • ECHO Project
Coordinator • 15-20 min didactic
presentation • Case presentations
(2-10) • Primary care providers
join from anywhere
Structural Features
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Unique Features of CHCI Project ECHO
• Google Sites project page
• ECHO blog • Twitter for questions/
comments from participants and observers
• Integration of behavioral health and primary care through co-presentation
• National participation
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Project ECHO Pain Management
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Project ECHO Buprenorphine
Primary Care Marwan Haddad, MD, MPH
Psychiatry Richard Feuer, MD
Behavioral Health Cliff Briggie Psy.D, LADC, LCSW
Nursing Jonathan Arocho, LPN
Medical Assistance Omar Perez
65
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Bup Case Presentation Form
66
Page 1 Page 2
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Provider Comments
• The sessions are “fascinating”, with “great didactic” presentations and a “collegial feel” that provides “the opportunity to…inspect my own clinical reflexes”. -- ECHO Medical Provider
• Sessions are “informative and feature helpful information on the types of patients I see in everyday practice”. -- ECHO Medical Provider
• “I have learned a lot and want to find a way to share this knowledge with the other providers at my site.” -- ECHO Medical Provider
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Connecticut Community
Health Center, Inc.
13 primary care health
centers across the
state
Over 130,000 medically
underserved patients
Arizona El Rio
Community Health Center
16 practice locations in Tucson, AZ
73,000 patients
280,000 visits per year
Delaware Westside
Community Health Center
9 practices in Delaware
23,000 patients
Affiliation with University of
Delaware
California
Open Door Community
Health Center
2 primary care sites
Northern CA region
Coming soon: 10 additional sites from Maine 7 additional sites from New Jersey
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Study Findings
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Improvements in Opioid Agreements and uTox Screening
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2.7
2.7
2.7
2.7
5.4
14.6
14.6
2.7
13.5
5.4
5.4
10.8
10.8
20.6
20.6
18.9
83.8
91.9
91.9
86.5
83.8
64.7
64.7
78.4
0 20 40 60 80 100
spent enough time with me
thoroughly explains the treatment(s) I receive
treats me respectfully
listens to my concerns
answered all my questions
advises me on ways to avoid future problems
gives me detailed instructions regarding my home program
Overall, I am completely satisfied with the services I receive
Percent of Patients
My chiropractor:
Pt satisfaction with chiropractic services assessment tool
Disagree Agree
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92.1%
50.0%
21.1% 18.4% 18.4% 13.2%
7.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Back Neck Leg Arm Hand/ Wrist Other Foot/ Ankle
Perc
enta
ge
of
Pat
ients
CHCI Chiropractic Services General Area of Treatment
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Decrease in average # of visits for patients with chronic pain
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Decrease in severe pain
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Chronic Pain Cohort
Prescription of any opioid medication in patients with and without chronic pain
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Decrease in Chronic Opioid Prescribing
Prescription of 90+ days of any opioid medication in patients with and without chronic pain
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Chronic Pain Cohort
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Chronic Pain Cohort
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Next Steps • Combine system redesign work with Project ECHO
– QI Training – IHI “Breakthrough Series Collaborative”
• Population level data • Complete controlled trial of Project ECHO • Expand access to ECHO
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Summary of Pain Management Best Practices
• Required pain CME for all PCPs • Structured Opioid Risk Assessment • Pain management follow up and monitoring frequency
based on risk assessment • Routine review of state prescription drug monitoring
website • Standard opioid agreement for all patients receiving
chronic opioids • uTox q6 months minimum • Multimodal care, onsite when possible:
– Co-management with Behavioral health – Chiropractic – Acupuncture – Mindfulness
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Conclusions • Chronic pain is highly prevalent in primary care • Knowledge and adherence to guidelines for
management of pain is variable • Health IT can be used to identify patients with chronic
pain • Use of an opioid management dashboard can improve
safety and monitoring • A multifaceted QI initiative aimed at improving pain
management in primary care is improving quality at CHC
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Comments or Questions?
_________________________
Daren Anderson, MD
VP/ Chief Quality Officer
Community Health Center, Inc.,
Director
Weitzman Quality Ins?tute
860.347.6971 ext.3740
_________________________
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References References: 1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academy Press, 2011. 2. Breuer B, Cruciani R, Portenoy R. Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: A National Survey. South Med J 2010;103:738-747. 3. Ponte C, Johnson-Tribino J. Attitudes and Knowledge About Pain: An Assessment of West Virginia Family Physicians. Fam Med 2005;37:477-480 4. Okie, S. 2010. "A Flood of Opioids, A Rising Tide of Deaths." The New England journal of medicine 363 (21): 1981-5. 5. Centers for Disease Control and Prevention. 2010. Emergency Department Visits Involving Nonmedical Use of Selected Prescription Drugs - United States, 2004–2008. Washington, DC: DHHS. Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
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Taking on Prescrip6on Drug Abuse Across the Care Con6nuum
Melissa Lamer, PharmD, BCPP Director of Behavioral Health Pharmacy Solu?ons Magellan Rx Management
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Financial Disclosures
• Melissa Lamer PharmD, BCPP wishes to disclose she is an employee and is paid a salary form Magellan. She will present this content in a fair and balanced manner.
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Learning Objec6ves
• Iden6fy the specific provider educa6on interven6ons that can play a role in decreasing prescrip6on drug abuse.
• Evaluate how the applica6on of advanced health care data analy6cs enables the iden6fica6on and targe6ng of inappropriate behaviors related to prescrip6on drug abuse.
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Startling Trends in Substance Use and Abuse
Prescrip2on drug abuse is the fastest growing drug problem
• From 2004-‐2011 emergency room visits due to the use of non medical use of opioids has increased 183%1
• Over 54% of pa6ents were sent home; only 2.4% who were referred to detox or treatment programs2
11th consecu2ve year of increasing drug overdose deaths2
• Higher morphine equivalent dosing greatly increases risk
• Many deaths involve combined mental health medica6ons use such as benzodiazepines, an6depressants, and an6psycho6cs2
1 Drug Abuse Warning Network, 2011. 2 Pharmaceu?cal Overdose Deaths, United States, 2010.” Journal of the American Medical Associa?on. 2012.
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Medicaid is One of the Most Vulnerable Popula6ons for Abuse
• Medicaid recipients are prescribed pain killers at twice the rate of non-‐Medicaid recipients and are at six 6mes the risk of overdose1
• Washington study iden6fied that 45% of people who died were enrolled in Medicaid2
• A combina6on of 4 variables have been found to predict increase risk for opioid dependence3
-‐ Age -‐ Depression -‐ Psychotropic Medica6ons
-‐ Pain Impairment
• Medicaid is the largest payor for mental health services4
-‐ This will con6nue to be of greater importance with Medicaid Expansion
1 CDC, 2011 2 Interagency Guideline on Opioid Dosing for Chronic Non-‐Cancer Pain 3Pain Physician, 2012 4CMS Bulle?n, 2012 hXp://medicaid.gov/Federal-‐Policy-‐Guidance/Downloads/CIB-‐12-‐03-‐12.pdf
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Tradi6onal Management Methods
• Controlled substance monitoring to increase awareness of pa6ent u6liza6on paherns
• Leverages a pharmacist driven educa6onal campaign and requiring provider registra6on and checking for certain pa6ents
• 6 months aper implementa6on - Registra6on up from 4.4% to
86.5% - Database access up from 15.8% to
58.9% - Last quarter 247 unique provider
ran a query (45.2%)
• Audits iden6fy pharmacies and providers dispensing/prescribing higher quan66es of controlled substances than peers
• Medica6on use evalua6ons iden6fy use of medica6ons with addi6ve effects -‐ Narco6cs + muscle relaxants +
psychotropic medica6ons • Lock-‐in high risk individuals to one
prescriber or pharmacy for all controlled substances -‐ Prescrip6ons/pa6ent/month dropped
15% during the lock and 38% post-‐lock -‐ Average # of drugs/pa6ent dropped
15% during and 36% post-‐lock
Prescrip2on Drug Monitoring Program Ini2a2ve (PDMP)
Retrospec2ve Medica2on Reviews
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Ques6on
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While Tradi6onal Methods Are Needed They Are Not Enough
• Despite the release many community providers are not accessing these important databases
• There is addi6onal administra6ve burden on the providers by requiring them to go online, register and frequently revisit the site
• Open it does not account for prescrip6on in other states
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To Best Manage Opioid Abuse We Need a Smarter Solu6on
• Maximizes knowledge by leveraging evidence-‐based guidelines to create ac6onable recommenda6ons
• Works with mul6disciplinary teams and industry leaders to iden6fy high profile targets
• Engages providers through mul6-‐modal communica6ons techniques including face-‐to-‐face, telephonic, virtual and email
• Push data out to providers instead of pulling them in to get it saving 6me, resources and increasing ease
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Receipt of Medical, Behavioral, &
Rx Data
Evidence-‐Based Algorithms Clinical Outreach Outcomes
• Medical, behavioral, lab, and/or pharmacy data received by our data warehouse
• Extract created, data scrubbed
• Leverages expert clinicians to create ac6onable informa6on
• Algorithms iden6fy non-‐compliant prescribing paherns and stra6fy others
• PCP & BH Providers - Mul6-‐channel consulta6on - Educa6onal materials
• Quality indicator monitoring
• Impact analysis • Ac6vity tracking
Advanced proprietary clinical algorithms iden6fy prescribing paherns that are inconsistent with evidence-‐based guidelines resul6ng in
personalized provider consulta6ons
Whole Health RxSM Integrated Solu6on for Whole Member Health Management
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To See the Whole Pa6ent, Pharmacy and Medical Claims Systems Must be Integrated
• Mul6ple opioid prescrip6ons from mul6ple doctors and pharmacies
• High dose medica6ons • Over use of short ac6ng
analgesics without long-‐ac6ng medica6ons
• Early refills
• Hospital admissions for overdoses admissions
• Diagnosis claims to iden6fy substance abuse
• Methadone opioid maintenance claims are not in pharmacy data
• Cancer diagnosis requiring higher dosing
Pharmacy Data Medical Data
Whole Pa2ent Management
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• Suboxone® u6liza6on in combina6on with other opioid medica6ons
• High cumula6ve diazepam equivalent daily doses
• Concomitant benzodiazepine and opioid therapy
• High cumula6ve morphine equivalent daily dosing
• Opioids from mul6ple prescribers and pharmacies
• Methadone and concomitant medica6on monitoring
• Cumula6ve early refills
Repor2ng and Profiling
Early Pa6ent Iden6fica6on and Provider Outreach is Cri6cal to Improving Outcomes
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Cumula6ve High Risk Report Combining mul6ple ini6a6ves is key to addressing
poten6al dangerous behavior