Addressing the Opioid Crisis in Ambulatory Care -...

89
Addressing the Opioid Crisis in Ambulatory Care Alicia Agnoli, MD, MPH Mary Ellen Benzik, MD Andrew Jorgensen, MD Greg Sawin, MD, MPH Randi Sokol, MD, MPH, MMedEd Facilitated by Mara Laderman, MSPH L9 These presenters have nothing to disclose April 21, 2017 9:30 AM – 12:30 PM

Transcript of Addressing the Opioid Crisis in Ambulatory Care -...

Addressing the Opioid Crisis in Ambulatory CareAlicia Agnoli MD MPH

Mary Ellen Benzik MD

Andrew Jorgensen MD

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Facilitated by Mara Laderman MSPH

L9These presenters have

nothing to disclose

April 21 2017930 AM ndash 1230 PM

Objectives

Understand the magnitude of the opioid crisis in the

United States

Describe different strategies to address multiple drivers

of the opioid crisis including physician prescribing

prescriber education treatment for opioid use disorder

and partnering with communities

Identify change ideas and strategies to overcome

barriers that they can test at their organization

Session Agenda

Faculty Introductions

Case Studies from three organizations (+ a break)

Table Top Discussions

Final QampA and wrap up

3

Faculty IntroductionsP4

5

New York Times httpwwwnytimescominteractive20160107usdrug-overdose-deaths-in-the-ushtml

Driver Diagram Addressing the opioid crisis in a

community

6

Address the opioid crisis in a

communityMeasuresbull Overdose ratebull Fatal overdose ratebull Individuals in treatmentbull Prescription opioid rate

Limit supply of opioids

Identify and manage opioid

dependent population

Treat individuals with opioid use

disorder

bull Prescribing practicesbull Dispensing practicesbull Diversionbull Pharmaceutical productionbull Availability of alternative pain

management treatment

This effort seeks to address treatment of both prescription and non-prescription opioids however it will not address supply of non-prescription opioids (namely heroin)

bull Compassionate consistent carebull Taperingbull Pain management educationbull Availability of alternative pain

management treatmentbull Education of patients and families

bull Identification individuals with opioid use disorder

bull Availability of detox facilitiesbull Availability of long-term ongoing

comprehensive addiction treatmentbull Availability of supportive social servicesbull Prevention of fatal overdose

Raise awareness of risk of opioid

addiction

bull Identification and education of patients at greater risk for addiction

bull Provider educationbull Adolescent educationbull Adult educationbull Reducing stigma around substance

abuse

Case Studies

How Can Primary Care Address the Opioid Epidemic

Use of an Interdisciplinary team-based group visit model to provide BuprenorphineNaloxone (BN) in primary care PCMH clinic

Alicia Agnoli MD MPH

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Objectives

Understand the magnitude of the opioid crisis in the

United States

Describe different strategies to address multiple drivers

of the opioid crisis including physician prescribing

prescriber education treatment for opioid use disorder

and partnering with communities

Identify change ideas and strategies to overcome

barriers that they can test at their organization

Session Agenda

Faculty Introductions

Case Studies from three organizations (+ a break)

Table Top Discussions

Final QampA and wrap up

3

Faculty IntroductionsP4

5

New York Times httpwwwnytimescominteractive20160107usdrug-overdose-deaths-in-the-ushtml

Driver Diagram Addressing the opioid crisis in a

community

6

Address the opioid crisis in a

communityMeasuresbull Overdose ratebull Fatal overdose ratebull Individuals in treatmentbull Prescription opioid rate

Limit supply of opioids

Identify and manage opioid

dependent population

Treat individuals with opioid use

disorder

bull Prescribing practicesbull Dispensing practicesbull Diversionbull Pharmaceutical productionbull Availability of alternative pain

management treatment

This effort seeks to address treatment of both prescription and non-prescription opioids however it will not address supply of non-prescription opioids (namely heroin)

bull Compassionate consistent carebull Taperingbull Pain management educationbull Availability of alternative pain

management treatmentbull Education of patients and families

bull Identification individuals with opioid use disorder

bull Availability of detox facilitiesbull Availability of long-term ongoing

comprehensive addiction treatmentbull Availability of supportive social servicesbull Prevention of fatal overdose

Raise awareness of risk of opioid

addiction

bull Identification and education of patients at greater risk for addiction

bull Provider educationbull Adolescent educationbull Adult educationbull Reducing stigma around substance

abuse

Case Studies

How Can Primary Care Address the Opioid Epidemic

Use of an Interdisciplinary team-based group visit model to provide BuprenorphineNaloxone (BN) in primary care PCMH clinic

Alicia Agnoli MD MPH

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Session Agenda

Faculty Introductions

Case Studies from three organizations (+ a break)

Table Top Discussions

Final QampA and wrap up

3

Faculty IntroductionsP4

5

New York Times httpwwwnytimescominteractive20160107usdrug-overdose-deaths-in-the-ushtml

Driver Diagram Addressing the opioid crisis in a

community

6

Address the opioid crisis in a

communityMeasuresbull Overdose ratebull Fatal overdose ratebull Individuals in treatmentbull Prescription opioid rate

Limit supply of opioids

Identify and manage opioid

dependent population

Treat individuals with opioid use

disorder

bull Prescribing practicesbull Dispensing practicesbull Diversionbull Pharmaceutical productionbull Availability of alternative pain

management treatment

This effort seeks to address treatment of both prescription and non-prescription opioids however it will not address supply of non-prescription opioids (namely heroin)

bull Compassionate consistent carebull Taperingbull Pain management educationbull Availability of alternative pain

management treatmentbull Education of patients and families

bull Identification individuals with opioid use disorder

bull Availability of detox facilitiesbull Availability of long-term ongoing

comprehensive addiction treatmentbull Availability of supportive social servicesbull Prevention of fatal overdose

Raise awareness of risk of opioid

addiction

bull Identification and education of patients at greater risk for addiction

bull Provider educationbull Adolescent educationbull Adult educationbull Reducing stigma around substance

abuse

Case Studies

How Can Primary Care Address the Opioid Epidemic

Use of an Interdisciplinary team-based group visit model to provide BuprenorphineNaloxone (BN) in primary care PCMH clinic

Alicia Agnoli MD MPH

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Faculty IntroductionsP4

5

New York Times httpwwwnytimescominteractive20160107usdrug-overdose-deaths-in-the-ushtml

Driver Diagram Addressing the opioid crisis in a

community

6

Address the opioid crisis in a

communityMeasuresbull Overdose ratebull Fatal overdose ratebull Individuals in treatmentbull Prescription opioid rate

Limit supply of opioids

Identify and manage opioid

dependent population

Treat individuals with opioid use

disorder

bull Prescribing practicesbull Dispensing practicesbull Diversionbull Pharmaceutical productionbull Availability of alternative pain

management treatment

This effort seeks to address treatment of both prescription and non-prescription opioids however it will not address supply of non-prescription opioids (namely heroin)

bull Compassionate consistent carebull Taperingbull Pain management educationbull Availability of alternative pain

management treatmentbull Education of patients and families

bull Identification individuals with opioid use disorder

bull Availability of detox facilitiesbull Availability of long-term ongoing

comprehensive addiction treatmentbull Availability of supportive social servicesbull Prevention of fatal overdose

Raise awareness of risk of opioid

addiction

bull Identification and education of patients at greater risk for addiction

bull Provider educationbull Adolescent educationbull Adult educationbull Reducing stigma around substance

abuse

Case Studies

How Can Primary Care Address the Opioid Epidemic

Use of an Interdisciplinary team-based group visit model to provide BuprenorphineNaloxone (BN) in primary care PCMH clinic

Alicia Agnoli MD MPH

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

5

New York Times httpwwwnytimescominteractive20160107usdrug-overdose-deaths-in-the-ushtml

Driver Diagram Addressing the opioid crisis in a

community

6

Address the opioid crisis in a

communityMeasuresbull Overdose ratebull Fatal overdose ratebull Individuals in treatmentbull Prescription opioid rate

Limit supply of opioids

Identify and manage opioid

dependent population

Treat individuals with opioid use

disorder

bull Prescribing practicesbull Dispensing practicesbull Diversionbull Pharmaceutical productionbull Availability of alternative pain

management treatment

This effort seeks to address treatment of both prescription and non-prescription opioids however it will not address supply of non-prescription opioids (namely heroin)

bull Compassionate consistent carebull Taperingbull Pain management educationbull Availability of alternative pain

management treatmentbull Education of patients and families

bull Identification individuals with opioid use disorder

bull Availability of detox facilitiesbull Availability of long-term ongoing

comprehensive addiction treatmentbull Availability of supportive social servicesbull Prevention of fatal overdose

Raise awareness of risk of opioid

addiction

bull Identification and education of patients at greater risk for addiction

bull Provider educationbull Adolescent educationbull Adult educationbull Reducing stigma around substance

abuse

Case Studies

How Can Primary Care Address the Opioid Epidemic

Use of an Interdisciplinary team-based group visit model to provide BuprenorphineNaloxone (BN) in primary care PCMH clinic

Alicia Agnoli MD MPH

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Driver Diagram Addressing the opioid crisis in a

community

6

Address the opioid crisis in a

communityMeasuresbull Overdose ratebull Fatal overdose ratebull Individuals in treatmentbull Prescription opioid rate

Limit supply of opioids

Identify and manage opioid

dependent population

Treat individuals with opioid use

disorder

bull Prescribing practicesbull Dispensing practicesbull Diversionbull Pharmaceutical productionbull Availability of alternative pain

management treatment

This effort seeks to address treatment of both prescription and non-prescription opioids however it will not address supply of non-prescription opioids (namely heroin)

bull Compassionate consistent carebull Taperingbull Pain management educationbull Availability of alternative pain

management treatmentbull Education of patients and families

bull Identification individuals with opioid use disorder

bull Availability of detox facilitiesbull Availability of long-term ongoing

comprehensive addiction treatmentbull Availability of supportive social servicesbull Prevention of fatal overdose

Raise awareness of risk of opioid

addiction

bull Identification and education of patients at greater risk for addiction

bull Provider educationbull Adolescent educationbull Adult educationbull Reducing stigma around substance

abuse

Case Studies

How Can Primary Care Address the Opioid Epidemic

Use of an Interdisciplinary team-based group visit model to provide BuprenorphineNaloxone (BN) in primary care PCMH clinic

Alicia Agnoli MD MPH

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Case Studies

How Can Primary Care Address the Opioid Epidemic

Use of an Interdisciplinary team-based group visit model to provide BuprenorphineNaloxone (BN) in primary care PCMH clinic

Alicia Agnoli MD MPH

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

How Can Primary Care Address the Opioid Epidemic

Use of an Interdisciplinary team-based group visit model to provide BuprenorphineNaloxone (BN) in primary care PCMH clinic

Alicia Agnoli MD MPH

Greg Sawin MD MPH

Randi Sokol MD MPH MMedEd

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Centers for Disease Control and Prevention Vital Signs Variation Among States in Prescribing of Opioid Pain Relievers and

Benzodiazepines mdash United States 2012 MMWR 2014 63(26)563-568

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Gap between with pastyear OUD ampcombinedbuprenorphineamp methadonecapacity

OUD amp Treatment Capacity

Gap=914000

Jones CM et al Am J Public Health 2015

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Asthma HTNAddiction

(ETOH Opiates)

Etiology

Lifetime

Prevalence (USA)129 90 9

Heritability

(genetics)036 - 07 025 - 05 034 ndash 055

EnvironmentAir quality SES

Cultural salt intake

stress

Peer group

behavior SES etc

Personal Choice Smoking Exercise Diet Exercise Decision to use

Relapsing Course

seeking care

each year to

achieve

symptomatic

relapse

70 50 30 ndash 50

Importance of

Patient

Engagement

Medication

Adherence Rates 40 40 50-70

Lifestyle

Adherence Rates 30 30

meeting national

quality goals 30- 50 30- 50

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Chronic Disease Model Approach to OUD

+Medication

Manage Cravings

Prevent

Withdrawals

Behavioral Treatment

Develop healthy

coping skills

Build Community

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Medication Assisted Treatment (MAT) for OUD

bull Methadone and buprenorphine

rarr most evidence for recovery

bull At 1 year 40-60 of patients maintained on

methadone or buprenorphine remain sober

bull Naltrexone - less effective

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Office-Based Opioid Therapy (OBOT)

bull Buprenorphine MATbull Medically effective

bull Cost-effective

bull Safe

bull Higher patient satisfaction

bull Higher provider satisfaction

bull Underutilized

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

What happens in group

bull Urine drug screens

(publically posted)settle (prior to group)

bull Introductions (3m)

bull Ground Rules (2m)

bull Didactic (10m)

bull Check-in(45m)

bull Prescriptions (we use

paper) (at end)

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

What Happens Between Groups

bull RN amp MD call ldquostrugglingrdquo patients or new

patients to check in

bull Care coordination with psych SW PCP Parole

officers DCF patients currently inpatient (in

IOP detox residential)

bull Follow up with patientrsquos urine drug screens (ldquoso

your urine came back with cocaine in ithelliprdquo)

bull Ongoing screening of new patient referrals +

intake appts

bull Prepare didactics

rarr RN amp MD time ~5-6 hoursweek each

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Resident perspective

bull deeper more authentic understanding of patients

bull value of team-based approach

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Patient perspective group keeps them honest holds them accountable

Itrsquos showing up every week and knowing

that you have to be accountable for your

actions For me Irsquom all about

consequences hellip therersquos another 80 times

where Irsquove almost slipped up and thought

about this group and didnrsquot do it because

I didnrsquot want to look at all yrsquoall in the face

and say I did it again

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Patient perspective Group fosters shared identity

Itrsquos good to have and to be in an atmosphere with those other people like you that understand youhellip

you know I feel like Irsquom not alone therersquos other people you know similar situations I have

support you know I donrsquot really have support outside of here My family you know theyrsquore

there but theyrsquore not -- my sisters arenrsquot addicts so they donrsquot understand it My parents donrsquot

understand it So it just feels good I donrsquot feel alone coming here

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Patient perspective over time group creates supportive community

In the beginning I really didnrsquot care about

anybody I didnrsquot care about myself I didnrsquot

care what anybody had to say Irsquom like ldquoIs it

three orsquoclock yet Like can I get the fck out

of hererdquo Now I look forward to coming

coming here and seeing everybody

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Clinic perspective

bull Destigmatizes addiction

bull Comprehensive care treat addiction while

treating other medical problems in 1 care

bull Lucrative + minimal staff

1 clinic session

-1 FD 1 RN 1 MA 1 MD

-20-30 patients

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Estimated Staff Resource TimeWeek

(care of 40-50 pts)

Doctor 7 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours group prep

bull 3 hours screening + intakes

bull 2 hours coordinating care

bull 1 hour notes

LPN 10 hours

bull 2 hours group

bull 1 hour Team meeting

bull 3 hours intakes

bull 4 hours phone follow ups + care

coordination

Front Desk 3 hours

bull 2 hours calls appointment

managementscheule prep

bull 1 hr Team meeting

MA 7 hours

bull 2 hours group

bull 2 hours group prepfollow up

bull 3 hours paperwork

Resident 5 hours

bull 4 hours group afternoon

bull 1 hour didactic prep

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

ReferencesBarry DT Moore BA Pantalon MV et al Patient Satisfaction with Primary Care Office-Based

BuprenorphineNaloxone Treatment Journal of General Internal Medicine 2007 22 (2) 242ndash45

Berger R Pulido C Lacro J Groban S Robinson S Group medication management for buprenorphinenaloxone in opioid-dependent veterans J Addict Med 20148(6)415-20

Center for Health Information and Analysis Access to Substance Use Disorder Treatment in Massachusetts April 2015

Clark RE Smanaliev M Baxter JD Leung GY The Evidence Doesnrsquot Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine Health Affairs 2011 30 (8) 1425ndash33

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction A Treatment Improvement Protocol TIP 41 Substance Abuse and Mental Health Services Administration 2004 Web

Cunningham CO Sohler NL McCoy K Kunins H Attending physiciansrsquo and residentsrsquo attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital Fam Med 200638(5)336-40

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

ReferencesNational Institute on Drug Abuse (NIDA) (2014) The Science of Drug Abuse and Addiction Treatment and Recovery

accessible at httpwwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictiontreatment-recovery

Maremmani I Pani PP Pacini M Perugi G Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroine addicts J Subst Abuse Treat 2007 33(1) 91-98

Mattick RP Breen C Kimber J Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioiddependence Cochrane Database Syst Rev 2014

Mitzner IL Eisenberg M Terra M MacVane C Himmelstein DU Woolhandler S Treating Opioid Addiction With Buprenorphine in Community-Based Primary Care Settings Ann Fam Med 2007 5(2) 146ndash150

Rowe T Jacapraro J and Rastegar D Entry into Primary Care-Based Buprenorphine Treatment Is Associated with Identification and Treatment of Other Chronic Medical Problems Addict Sci Clin Pract 2012 7 (1) 22ndash22

Rudd RA Aleshire N Zibbell JE Gladden MR Increases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014 Centers for Disease Control MMWR Morb Mortal Wkly Rep 2016 64(50) 1378-82

Sokol R et al Training Family Medicine Residents to Treat Opioid Use Disorder (OUD) with Buprenorphine-Naloxone (BN) via a Group Visit Team-based Approach Adv Med Educ Pract In Review

Sokol R et al Why Use Group Visits for Opioid Use Disorder Treatment in Primary Care A Patient-Centered Qualitative Study Substance Abuse In Review

Substance Abuse Treatment Group Therapy Treatment Improvement Protocol (TIP) Series No 41 Rockville MD Center for Substnce Abue Treatment Substance Abuse and Mental Health Services Administration (SAMHSA) 2005

Suzuki J Zinser J Klaiber B et al Feasibility of Implementing Shared Medical Appointments (SMAs) for Office-Based OpioidTreatment With Buprenorphine A Pilot Studyrdquo Subst Abuse 2015 36(2)166ndash169

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Questions

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Small Clinic Big IssuesAndrew Jorgensen MD FACP FAAPChief Medical Officer Outer Cape Health Services

Orlando Florida

Session Code

IHI SummitApril 20 ndash 22 2017

IHISummit

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Opiate Overdose Deaths in Massachusetts34

Source Massachusetts Department of Public Health Data brief Opioid-related overdose deaths Among Massachusetts residents Boston Commonwealth of Massachusetts Department of Public Health 2017 Feb Available from httpwwwmassgoveohhsdocsdphstop-addictioncurrent-statisticsdata-brief-overdose-deaths-february-2017pdf

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Opiate Overdose Deaths on Cape Cod

bull 395 overdose deaths on Cape Cod from 2000-2015

bull Barnstable County ranked No 3 for fatal overdoses in the state in

2015 with 303 deaths per 100000 people

35

Source Massachusetts Department of Public Health USCensus | Chart Gregory Bryant Cape Cod Times

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

bull Rural FQHC formed 1987

bull Serves Eight outermost towns of Cape Cod

bull 200 square-mile catchment area

bull Designated by HRSA as underserved for Medical

Dental amp Mental Health

bull Closest Emergency Room is one hour away from

Provincetown

About Outer Cape Health Services36

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

OCHS-Provincetown

bull 16 exam rooms

bull CHC farthest from a hospital

in Massachusetts (60 miles away)

bull Renovated 2010

OCHS-Wellfleet

bull 8 exam rooms

bull Oldest CHC building

in Massachusetts

(1966)

OCHS-Harwich

bull 5 small exam rooms

bull Rental space opened 2011

37

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

38

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Chronic pain case management

Two-pronged approach

bull Optimizing risk management by PCP team

bull Changing prescriber behavior

39

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Chronic Pain Case Management

(CPCM) Program

bull Pilot began March 2015

bull Registry of patients receiving opiate Rxrsquos developed

bull Tiered consistent risk monitoring by nurse case

manager oversees registry

bull One-on-one meetings with providers

bull Team discussions

40

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Chronic Pain Registry excerpt41

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

NIDA Opioid risk tool42

Source wwwdrugabusegovnidamed-medical-health-professional

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Tiered risk structure43

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

CPCM Workflow and Guidelines44

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier ldquoAverage

riskrdquo

CPCM 3 Risk Tier ldquoLow

riskrdquo

Tier description

High daily dose = MS equiv 100mg or

higherday or

Benzo use or

Red flags

or a combination of these risks

10-99 MS equivalentdaily

No benzo

No red flags

Bulk of patients

Low dose lt10 mg MS equivday

No benzo

No red flags

Problem List

RN selects tier using the description

above PCP input may be sought if

questions

March 2016 patient lists have been tiered

by DONMed Director as a starting point

using June data

RN can change the tier as doses reduce or

benzo use stops or red flag issues resolve

RN locates ldquodummy code CPCM1rdquo just as

you would find any ECW problem list

assessment code

Adds to lsquotop of problem listrsquo for easy

reference

Same

Dummy code CPCM2

Same

Dummy code CPCM3

PEG scale

MA asks pt to complete at visit prior to PCP

visit (paper form)

MA enters PEG info from form into ECW

HPI ldquoPEGrdquo at visit

For example P9 E8 G6=23

Discards paper form

Same Same

Opioid Risk Tool

Located in ROS

PCP completes risk assessment at least

once (not onceyear) for PCP information

about risk

Same Same

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

CPCM Workflow and Guidelines45

CPCM 1 Risk Tier

ldquoHigh riskrdquo

CPCM 2 Risk Tier

ldquoAverage riskrdquo

CPCM 3 Risk Tier

ldquoLow riskrdquo

UDS capture by MARN

Monthly

At visit or

RX pickup

RN Prompts the prescription in med closet or

the OV note

RN reminds PCP to order UDS monthly

standing order

Quarterly

At visit or

RX pickup

RN Prompts the prescription or the OV note

RN reminds PCP to order monthly standing

order (in case random UDS requested by RN)

Annually

At visit or RX pickup

RN Prompts the prescription or the OV note

Monthly standing order UDS at RN discretion

(in case random UDS req by RN)

PMP (Physician Monitoring Program) check by RN delegate

Quarterly

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Delegates need to be notarized- see Medical

Director for details

Every 6 months

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

Annual check

RN printsign

To provider to signfile

MA delegate may be assigned to do this for

PCPs by RN

RN review of CPCM patient list at least monthly

To ensure PCP OV every 3 months per

policy

RN (who can assign MA) to reach out to

non-compliant pt to facilitate OV

To prompt upcoming OVs if

UDSContract due

To ensure new patients added appropriately

and promptly for CPCM

Same Same

Call-in for pill countsUDS

Random pill counts suggested quarterly

By RN or provider for any red flag or

concern

If patient seems inappropriate at RX pick-up

or OV call-in within week

DNKA call-in within week

Same Consider random pill count periodically otherwise

same

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Bell curve of risk tiers46

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Changing provider behavior

bull Follow new MA and CDC guidelines with frequent reminders

bull Expectations for tapering high MEQ

bull Optimizing safer strategies Honest group discussions

bull Regularly scheduled meetings with PCPs and RNs

bull Initially optional before regular meetings now part ofprovider meeting

bull Model best practices practice difficult conversations

bull Team-building team support critical

bull Quarterly statistic tracking

bull Existing general monthly peer review

47

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Concurrent State Efforts48

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Measures of success

bull Improvement in urine drug screening PMP annual

agreements (80 goal)

bull Decline in numbers of patients being prescribed high

dose opiates

bull More referrals to OCHS Behavioral Health

bull Improvement in PCP satisfaction with care for patients

with pain

49

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Patient enrollment in CPCM program50

195

200

205

210

215

220

225

230

235

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Distribution of risk tiers51

0

10

20

30

40

50

60

70

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Tier 1 Tier 2 Tier 3

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Results52

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Controlled substance agreement status

Up to date Expired None on file

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Results53

0

10

20

30

40

50

60

70

80

90

100

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016

PMP report status

Up to date Out of date Never

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Results54

0

10

20

30

40

50

60

70

80

90

Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov-16 Dec-16 Jan-17 Feb-17

Urine drug screening

Up to date Out of date Never

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Results55

82

84

86

88

90

92

94

96

Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Office visits up to date

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Reasons for discontinuation of Rx56

15

13

3

69

Diedmovedtransferred

Stopped prescribing due todiscordant UDS

Referred to pain specialist

Tapered off no longer needed

77 discontinued (82016 ndash 22017)

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Challenges amp barriers

bull Changing behavior is hard work not just for patients but

for providers as well

bull Like all change processes providers have different

capacities for change

bull Nurse Care Manager is a grant funded position and it is

an effort to embed work in care teams

bull Morning discussion meeting useful but the work can

overwhelm other important efforts at the Health Center

57

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Success stories

bull 54 year-old woman with chronic abdominal pain related to cirrhosis from Hepatitis C

bull Initially using Oxycodone 90 mg every 6 hours also using other high risk medications including clonazepam and Ritalin

bull Began seeing her when prior PCP retired patient very resistant to weaning

bull Worked closely with behavioral health team including co-located Psychiatrist to manage overall risk

bull Treated her Hepatitis C

bull Patient also worked on her abusive relationship with her husband

bull After 12 months no longer using any opiates

58

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Future amp sustainability

bull Working on embedding care management in to primary

care teams as part of PCMH

bull Spread approach to other high risk medications such as

benzodiazepines

bull Integrate metrics in to overall quality improvement efforts

to help with sustainability

59

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Remembering those lost to addiction60

Source Cape Cod Times

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

QuestionsP61

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Break

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

System-Level Approach to Opioid Prescribing

Dr Mary Ellen Benzik

Chief Medical Officer

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

MissionWe provide innovative high-value health care solutions to companiesimproving the health and well-being of the people we serve

VisionWe will transform the delivery of health care as a trusted partner to the companies we serve Together we will create a culture of health and become our patientsrsquo most cherished benefit

OUR GUIDING PRINCIPLE

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

STEP 1 ndash CREATE THE CONVERSATION

bull Physician leadership

bull Create a clear message and a burning platform

ldquo This is a national crisis not a QuadMed crisis and we are a critical part of the solutionrdquo

78 people die every day in opioid-related deaths

28470 people a year

Equal to a ldquo911 eventrdquo every six weeks

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

STEP 2 ndash COLLECT DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

Pro

vid

ers

Ph

ysic

ian

Lead

ers

hip

Exe

c Le

ade

rsh

ip

Clin

ical

Le

ade

rsh

ip

Co

mp

lian

ce

IT Qu

alit

y

Trai

nin

g

Lega

l

Lab

Op

era

tio

ns

HR

Fin

ance

Emp

loye

rs

Pai

n M

gmt

Exp

ert

s

2016

Educate providers

Share data

Create opioid prescribing policy

IT decision support

2017

Roll out policy

Monthly data sharing

Increase learning opportunities

Integrate KPIs bonus structure

Create strategy for our community

STEP 3 ndash DEVELOP A WORK PLAN

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTROLLED SUBSTANCE PRESCRIBING POLICY

KEY FACTORS IN THE POLICY

1 Patient and provider to review and sign controlled substance policybull Patient agrees to use

one pharmacy bull To only take meds as prescribed bull Will have QM as their

medical home not obtaining narcotics from any other provider

bull Agree to urine drug testing and pill counts as deemed necessary by the provider

2 If a patient states their medication is stolen ndash a police report must be filed prior to replacing medication

3 A urine drug screen must be obtained when the medication is initially prescribed and as deemed necessary by the provider at least annually

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

KEY FACTORS IN THE POLICY

4 State registries must be queried with each initial and refill prescription

5 A query score is to be generated ndash with an assessment for potential abuse or addiction

6 QuadMed providers are strictly prohibited from issuing prescriptions for controlled substances for the maintenance of drug

or alcohol addiction andor for detoxification treatment to patients If a QuadMed provider has a patient who is in need of addiction treatment the QuadMed provider should refer the patient to an existing facility through the following website findtreatmentsamhsagov

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

IT TOOLS TO HELP US BE SUCCESSFUL

bull Workflow sheet

bull Capacity to query the state database from EMR

bull Tool to calculate the morphine mg equivalents in EMR

bull Linkage in the tool to find treatment programs in the area

bull Narcotic pain contract

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FEATURES

bull Document a patientrsquos pain score at its worst and best

bull Document neuropathic pain

bull Document hypersensitivity or fibromyalgia pain

bull Document location of pain intensity and how the pain affects the patientrsquos daily living

bull SOAPP and COMM tools are available within the form

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CHRONIC PAIN QUESTIONNAIRE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTROLLED SUBSTANCE FORM FEATURES

bull Compliance counters reset after one year

bull Morphine Milligram Equivalent (MME) calculator

bull Order urine drug screen and results

bull Document random pill count

bull Launch directly to state prescription monitoring program

bull Document medication contract on file

bull Opioid risk tool

bull Set next refill dates

bull Direct access to pain contracts

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Calculating the total daily dose of opioids helps identify patients who may benefit from closer monitoring reduction or tapering of opioids prescribing of naloxone or other measures to reduce risk of overdose

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTROLLED SUBSTANCE FORM

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTROLLED SUBSTANCE FLOWSHEETS

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

CONTINUOUS QUALITY IMPROVEMENT

ldquoYou canrsquot manage what you canrsquot measurerdquo - Peter Drucker

bull Number of mg of morphine equivalents being prescribed by the network

bull Opioids with benzodiazepines (BZD) or antidepressants

bull Opioids with sleep apnea

bull Patients with high-dose opioids

ldquoIn God we trust everyone else must bring datardquo - Deming

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

END OF 2017 DATA

Start of our QM journey into safe opioid prescribing

October 6 2014Hydrocodone Class Change

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

bull Analyzed data to select providers

bull Meet monthly to discuss the challenges and provide support to safely manage patients

bull Team controls the agenda and discussion topics to focus on areas of need

bull Will shape the program for the remainder of the group

PROVIDER LEARNING COHORT

Patients with MME gt 100 and BZD (July through December 2016) 60

36Patients with MME gt 100 (January 2017)

Count of PID Match Clinical_Date

RxResponsibleProvi

derLast MMEDay Jul Aug Sep Oct Nov Dec Grand Total

McGriff MD 2 14 16

120 2 2

180 2 12 14

Whyte MD 3 4 2 2 2 13

135 3 2 2 2 2 11

180 2 2

Ness MD 3 3 6

135 3 3

1425 1 1

150 1 1

180 1 1

Wyer MD 2 3 5

135 1 1

180 1 3 4

Ashbrooks MD 2 2 4

150 2 2 4

Peterson MD 1 1 1 1 4

120 1 1 1 1 4

Krueger MD 1 1 1 1 4

120 1 1 1 1 4

Bagshahi MD 2 2

120 2 2

Asmundsen PA 2 2

120 2 2

Brodie MD 1 1 2

120 1 1 2

Fakhoury MD 2 2

180 2 2

Grand Total 9 26 5 4 9 7 60

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

SAFE PRESCRIBING

bull Integrated into QuadMed KPIsreported to the board

bull Metric is part of the management and provider bonus calculation

bull Peer review of charts for all providers prescribing opioids over 100 MME and concurrent BZD Providers role to limit the number of

patients to be peer reviewed Organizational support of the peer

review structure bull Mandatory completion of education and

knowledge assessment for all providers on the controlled substance policy with HR implications for non-compliance

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

PROVIDERS RESPONSE bull ldquoThe policy gives me a frame to begin

the discussion with my patientsrdquo bull ldquoThe decision support tool helped me

learn about the MME and made it easy to do the right thingrdquo

bull ldquoThe learning cohort gives me the opportunity to work this through with other providersrdquo

PATIENT STORY bull Provider helped a patient move from

extremely high MME with BZD to a successful weaning of all her meds

bull ldquoShe was a new person more alive and engaging to everyone in the health centerrdquo

SAFE PRESCRIBING FEEDBACK

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

IT TAKES A COMMUNITY ndash NEXT STEPS

1 IT clinical decision support bull Adding weaning template and

calculator to the EMR tools bull Adding discharge education bull Considering discharge information

on disposal of medications

2 Clinical aspects bull Getting health centers to utilize

their local 211 resources bull Signage in the health centers bull Standardization of the stocking

and prescribing of naloxone in the health centers

bull Continuing to adjust the policy

3 Monitoring and training bull Continued training using

computer-based resources bull Monthly data sharing at the

CMO forum bull Tracking and engaging with

all new providers at 30 60 and 90 days

4 Partnering with employers in high-risk geography

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Experience Solutions Results

THANK YOU ndash KEY RESOURCES

bull httpswwwcdcgovdrugoverdoseindexhtml

bull wwwscopeofpainorg

bull wwwopiodprescribingorg

bull httpstoresamhsagovproductOpioid-Overdose-Prevention-Toolkit-Updated-2016All-New-ProductsSMA16-4742

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Exercise

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Topic Tables

1 Safe opioid prescribing ndash changing provider behavior at

the individual level

2 System changes to facilitate evidence-based care

3 Patient education about chronic pain pain

management and risks of opioids

4 Using teams to treat addiction in primary care

5 Making addiction treatment more accessibleavailable

6 Linking with community-based efforts

7 Other topics ndash please nominate

P88

Final QampA and Wrap UpP89

Final QampA and Wrap UpP89