Team-Based Opioid Project. Group Health
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The document summarizes a team-based approach to opioid management led by researchers from the University of Washington and Group Health Research Institute. It lists the key members of the research team and notes that the project is funded by an AHRQ grant. It then provides background data on the high rate of opioid prescriptions in Washington State and details of the team-based approach, including use of a patient registry, treatment agreements, urine drug screening, and policies around opioid dosage and risk mitigation.
Team-Based Opioid Project. Group Health
- 2. University of Washington-Group Health ResearchTeam Michael Parchman, MD, MPH Director, MacColl Center for Innovation Group Health Research Institute parchman.m@ghc.org Laura-Mae Baldwin, MD, MPH Professor, Department of Family Medicine University of Washington lmb@uw.edu Brooke Ike, MPH Project Manager and Practice Facilitator University of Washington bike2@uw.edu DavidTauben, MD Chief of Pain Medicine University of Washington
- 5. Key Components of theTeam Based Opioid Management Approach
- 6. Support for the Project
- 7. Support for the Project
- 8. Quality Improvement AND Research
- 9. Funded by AHRQ Grant # 1R18HS023750-01
- 13. IN WASHINGTON STATE, THERE ARE 77 OPIOIDS OR PRESCRIPTION PAIN MEDICATIONS WRITTEN FOR EVERY 100 PEOPLE.
- 16. 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Rx Opioids Benzodiazepines Psychostimulants
- 17. • Hydrocodone/acetaminophen (119 Million)
- 18. 0 2 4 6 8 10 Group Health 2010 VHA 2011 OddsRatioRelativetoLowDoseCOT <20 mg. MED 20 to < 50 mg. MED 50 to <100 mg. MED 100+ mg. MED
- 19. 2007 Guidance recommending increased caution in COT 2010 Multi-faceted COT risk mitigation initiative Trescott, Beck, Seelig &Von Korff Health Affairs, 2011 Group Health Actions Regarding Opioids Prescribing
- 20. Percent of COT patients receiving > 120 mg. morphine dose 0 2.5 5 7.5 10 12.5 15 17.5 20 22.5 25 2006 2007 2008 2009 2010 2011 2012 2013 2014 %Receivinghighdose(≥120mg) GH group practice physicians Community physicians (GH contracted network)
- 24. Registry Element Suggested Frequency Type of Data Patient demographics: age, sex, marital state, race/ethnicity Baseline Categorical and Numeric Medication, Dose and frequency Every visit Numeric Med review for concurrent use of sedatives Every visit Categorical (yes/no) Random Urine Drug Screen All new patients; prn per policy Categorical (positive: yes/no) PEG Scale (Function and Pain) Every visit Numeric State Prescription Registry Check Every 6 months Categorical (yes/no) Prescription Opioid Misuse Index (POMI) survey Every 6 months Numeric PHQ-2 Every 6 months Numeric
- 31. Diverse Perspectives • First step: gather an accurate baseline picture • Different roles and clinics = different perspectives It is essential to get a sense of these different understandings to help build consensus & inform the quality improvement initiatives.
- 32. • Divide into groups Two tasks: 1. For each item, circle the description that best matches your clinic. If your group cannot agree, write that down too. 2. On each sheet, write down which of the listed topics is most ripe for improvement at your organization and why. • Be prepared for one member to share • No right or wrong answers Want to give additional feedback? Please feel free to email me at bike2@uw.edu or call me at 206-685-1052.
- 34. Shared Vision 1 2 3 4 1. A shared vision for safer and more cautious opioid prescribing… …has not been formally considered or discussed by clinicians and staff. …has been discussed, and preliminary conversations regarding a clinic-wide opioid prescribing standard have begun. …has been partially achieved, but consensus regarding a clinic-wide opioid prescribing standard has not yet been reached. …has been fully achieved, including defining COT and dose safety thresholds. Clinicians and staff consistently follow prescribing standards and practices. Responsibilities Assigned 1 2 3 4 2. Responsibilities for practice change related to chronic opioid therapy (COT)… …has not been assigned to designated leaders. …has been assigned to leaders, but no resources have been committed. …is shared by leaders and a quality improvement group that has dedicated resources. …is shared by all staff, from leadership to team members. Dedicated resources support protected time to meet and engage in practice change. Leader Driven Policies & Guidelines 1 2 3 4 3. Leaders responsible for COT practice change initiatives… …have not developed COT policies and guidelines. …have developed COT policies and guidelines but have not implemented them. …have developed COT policies and guidelines and started working with providers and teams to implement them. …have worked with providers and clinical teams and have made substantial progress in implementing COT policies, guidelines, and the necessary standard work.
- 35. COT Registry Used 1 2 3 4 4. Use of a COT registry to pro-actively monitor COT patients and their opioid dose levels to ensure their safety… …is not possible with existing data systems. …is technically possible, but it is difficult to get useful reports. …is relatively easy. Reports are provided on a regular basis, but aren’t consistently used to monitor progress. …is easy, and reports are actively used to monitor progress toward more cautious opioid prescribing. Registry Workflows Established 1 2 3 4 5. Registry workflows to manage the registry, use registry data to prepare for patient visits, improve patient care, and monitor progress toward overall opioid reduction… …have not been developed. …are in development, but not established. …are established, but aren’t consistently implemented. …are established and consistently implemented. Responsibilities are assigned and protected time is available to complete assigned responsibilities.
- 36. Polices & Standard Work 1 2 3 4 6. COT policies and standard work for all opioid prescribing (including refills, dose escalation, tapering)… …either do not exist or do not cover many prescribing situations. …are well-defined but have not been discussed with all clinic staff and providers …are well-defined and have been discussed with all clinic staff and providers, but the training needed to implement them has not yet taken place. …are well-defined and have been discussed with all clinic staff and providers, and the training needed to implement them has taken place. Treatment Agreements 1 2 3 4 7.Formal written COT treatment agreements… …do not exist. …have been developed but are not in use. …have been developed and are partially implemented into routine care and/or reminders. …are fully implemented. Most patients have a signed treatment agreement. Urine Drug Screening 1 2 3 4 8. A urine drug screening policy… …does not exist. …has been developed, but is not in use. …has been developed and is partially implemented into routine care and/or reminders. …is fully implemented. Urine drug screening is consistently implemented according to clinic policy.
- 37. Co-Prescribing Sedatives 1 2 3 4 9. Formal written policies and standard work for avoiding co-prescribing of opioids and sedatives… …have not been discussed or developed. …have been discussed or developed but do not influence care. …have been developed and are partially implemented into routine care and/or reminders. …are fully implemented so that co-prescribing of opioids and sedatives is consistently avoided. PDMP Monitoring 1 2 3 4 10. Formal written policies and standard work for periodically checking the PDMP for COT patients… …have not been discussed or developed. …have been discussed or developed but the PDMP data are rarely checked. …have been developed and the PDMP data are sometimes checked. …are fully implemented so that PDMP data are consistently checked. Patient Education 1 2 3 4 11. Patient education materials that include explanation of the risks, and limited benefits of long-term opioid use… …have not been discussed or developed. …have been developed but are rarely used in routine clinical care. …have been developed and are partially implemented into routine care. …are fully implemented and used routinely in patient care when COT is considered or prescribed.
- 38. Prepared COT Patient Visits 1 2 3 4 12. Before routine clinic visits, patients receiving COT … …are not identified. There is no advance preparation for patient visits for chronic opioid therapy. …are sometimes identified, but there is no discussion or advance preparation for visits with COT patients. …are identified, and a discussion or chart review to prepare for the visit sometimes occurs. …are consistently identified, and are discussed before the visit. The chart is reviewed and preparations made to address safe COT use. Standard Work for Prepared Visits 1 2 3 4 13. The work needed to prepare for a visit with patients receiving or potentially initiating COT… …has not been defined. ...has been partially defined, but work/tasks are not delegated across the team, and implementation is inconsistent. ...has been clearly defined, work is delegated across the team, and is often implemented. ...has been clearly defined, work has been delegated across the team, and is consistently implemented.
- 39. Empathic Communication 1 2 3 4 14. Patient-centered, empathic communication emphasizing patient safety… …is not used in visits with COT patients to discourage COT use and dose escalation or to encourage tapering. …is infrequently used to discuss COT use, dose escalation, or to encourage tapering. …is sometimes used to discuss COT use, dose escalation, or to encourage tapering. …is consistently used to discuss COT use, dose escalation, or to encourage tapering. Patient Involvement 1 2 3 4 15. Involving COT patients in decision- making, setting goals for improvement and providing support for self-management… …is not done routinely. …is sometimes implemented by discussing treatment options and goals, but this is not documented in a care plan. Patient education pamphlets are available. …is usually implemented. Patient goals and action plans are documented in a care plan. Follow visits refer to and update goals and plans. …is consistently implemented. Patient goal setting, action plans and self-management skills are supported by practice teams trained in shared decision making and self-management support techniques. Care Plans 1 2 3 4 16. Care plans for chronic pain management and COT… …have not been developed …are developed and recorded but reflect only the prescribing clinician, the medication regimen and a monitoring schedule. …are developed collaboratively with patients and include self- management and clinical goals, but they are not routinely recorded or used to guide care. …are developed collaboratively, include self-management and clinical goals, and are routinely recorded and used to guide care.
- 40. Identifying Complex Patients 1 2 3 4 17. The work needed to identify opioid misuse, diversion, abuse, addiction and for recognizing complex opioid dependence… …is not done routinely. …is sometimes done. …is usually done, but follow-up when problems are identified is inconsistent. …is consistently done, with consistent follow-up when problems are identified. Behavioral Health Resources 1 2 3 4 18. Behavioral health (mental health and chemical dependency) services… …are difficult to obtain reliably. …are available from behavioral health specialists but aren’t timely or convenient. …are available from behavioral health specialists and are usually timely and convenient. …are readily available from behavioral health specialists who are onsite or who work in an organization that has a referral protocol or agreement with our practice setting.
- 41. Monitoring Progress 1 2 3 4 19. A system to measure and monitor progress in COT practice change… …has not been developed. …has been developed, including overall tracking goals, but regular tracking reports on specific objectives have not been produced. …is used to produce regular tracking reports on specific objectives. Leadership reviews are done occasionally, but not on a formal schedule. …has been is fully implemented to measure and track progress on specific objectives. Leadership reviews progress reports regularly and adjustments and improvements are implemented. Assessing and Modifying 1 2 3 4 20. Adjustments to achieve safer opioid prescribing based on monitoring data… …are not being made. …are occasionally made, but are limited in scope and consistency. …are often made and are usually timely. …are consistently made and are integrated in overall quality improvement strategies.
- 46. BUILDING BLOCKS BRAINSTORM CHANGES WE WANT TO MAKE (REVIEW THE SIX BUILDING BLOCKS HIGH-IMPACT CHANGES @ WWW.IMPROVINGOPIOIDCARE.ORG FOR IDEAS) 30, 60 OR 90-DAY GOAL MAKE IT SMART: SPECIFIC, MEASUREABLE, ACTIONABLE, REALISTIC, AND TIME-BOUND Leadership & consensus Use a registry to proactively manage patients Revise policies and standard work Prepared, patient- centered visits Caring for complex patients Measuring success
- 47. GOAL 1: LIST THE STEPS NECESSARY TO ACHIEVE THIS AIM (WHAT) PERSON RESPONSIBLE (WHO) WHEN WHERE 1. 2. 3. 4. 5. 6.
- 48. GOAL 2: LIST THE STEPS NECESSARY TO ACHIEVE THIS AIM (WHAT) PERSON RESPONSIBLE (WHO) WHEN WHERE 1. 2. 3. 4. 5. 6.