Incorporating Best Practices

through Practice Organization & EMRs

in a Residency PracticeMathew Devine, D.O.

Associate Medical Director

Highland Family Medicine

Highland Family Medicine – Urban Family Medicine Residency

History

• Founded 1967

• Recent expansion to 12:12:12

• Urban Health Clinic

• 261 bed Critical care hospital

• P4 Residency program 2007

• 60 providers in practice

• Total patient population over 19, 000

• > 55,000 visits per year

Chronic Pain and Narcotic Use at Highland Family Medicine

2009

Objectives of this section

• Discuss contract and narcotics policy use in resident practices

• Identify importance of patient databases to support chronic pain

management in residency practices

• Review audit document used for peer review in residency practices

Use of EMR for tracking of Chronic Pain

• Use of Patient lists in EMR to create Chronic Pain Database

• Placing identifier on medication list for those on chronic

narcotics, “1-pain management agreement”

• Implementing peer review to audit charts of patients with

chronic pain

• Collaboration through EMR with Pain management clinic in

system, placing and tracking referrals

Peer Review/Audit process and results

Updated information to provided at live presentation

Use of urine toxicology in monitoring

Urine should contain the prescribed drug/s:

• If not, the patient may be diverting or providing a fake sample to cover

other substances, make sure you know what your UDS is capable of

detecting

Urine should be free of non-prescribed substances:

• If the patient is unable to relinquish alcohol / recreational drugs in order

to receive treatment, either treatment is not very important or the

other drugs are overly important, and addiction assessment/RX is

needed.

Urine drug screening results from practice

Updated information to provided at live presentation

Helping Patients Whose Pain is Not Relieved Through Group Visits

and Emotional Support

Mathew Devine, D.O.

Associate Medical Director

Highland Family Medicine

Objectives of this section

• Review the curriculum, patient selection, and data collection performed

for chronic pain group visit

• interpret the data from chronic pain group visits in regards to

improvement of functional status, depression, and identification of

addiction

•Discuss the tenets of creating a successful group visit format in residency

practices

Group VisitsAvailable at Highland Family Medicine

• Chronic Pain

• Diabetes

• Pediatric Asthma

• Depression

• In the pipeline:

•Prenatal visits

•Tobacco

Group Visit Format

Referrals from PCP/CCP to group

Closed group of 8 sessions over 6 months

Group size goal of 8-12 patients

Team consists of 2 providers, psychologist, nurse, and

resident(s)

Why Group Medical Visits?

•PCMH: AAFP; TransforMed

•Growing Literature supports benefits

•Improved clinical outcomes

•Patient satisfaction

•Provider satisfaction

•Cost-neutral

• Education

Group Visit Data

1. REALM

2. PHQ-9

3. DAST

4. AUDIT

5. PDQ – Functional assessment tool

6. Smoking and Anxiety history

7. Re-sign pain contract

8. Urine Drug Screen

9. Domestic Violence screen

10. How’s Your Health online survey

Functional Assessment - Data Review

• Used an evidence based assessment survey that

checks functional and psychosocial components of

the patient

• The higher functioning and emotional stable the

individual is the lower the scores

PDQ data from Chronic Pain group regarding: Functional assessment

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Initial visit and Last visit data

Chronic Pain Group Functional Assessment

PDQ data from Chronic Pain group regarding: Psychosocial assessment

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PDG Psychosocial Assessment Data

Pre and Post results

Depression Screening data

Information to be provided at session

Addiction

• Regardless of referral source – resident, nurse practitioner, or

attending, addiction was found to be heavily present in sample

of patients selected

• Majority of patients coming to group female

Addiction results

Resident involvement in Group process

• Get to observe them in group setting in motivation interviewing

and teaching to patients

• Work closely with them on EBM evidence for pain management

• Can follow their prescription habits

• Can provide more structure and an organized plan and

improved historical information of patients for further individual

management by providers using annual pain review assessment

Downsides of Group visit

• Billing

• If applicable patient has to be for each co-pay

• Increased time of session, planning, and calling/mailing to patients

• Patient difficulty with being on time to visit

• Identification of addiction early in process and losing individual from

group due to treatment or patient refusal to return

What other services are available to patients with chronic pain?

•Physical therapy

• Adjunct treatment

• Acupuncture

• Chiropractor

• Osteopathic Manipulation

• Massage therapy

• Hypnosis

• Behavioral health therapy

• Family therapy

• Pain management evaluation

• Support groups

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