University of Washington-Group Health Research Team
Michael Parchman, MD, MPH
Director, MacColl Center for Innovation
Group Health Research Institute
[email protected]
Laura-Mae Baldwin, MD, MPH
Professor, Department of Family Medicine
University of Washington
[email protected]
Brooke Ike, MPH
Project Manager and Practice Facilitator
University of Washington
[email protected]
David Tauben, MD
Chief of Pain Medicine
University of Washington
Key Components of the Team Based
Opioid Management Approach
Support for the Project
Support for the Project
Quality Improvement AND Research
Funded by
AHRQ Grant # 1R18HS023750-01
IN WASHINGTON STATE,
THERE ARE
77 OPIOIDS
OR PRESCRIPTION PAIN
MEDICATIONS
WRITTEN FOR
EVERY 100
PEOPLE.
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Rx Opioids
Benzodiazepines
Psychostimulants
• Hydrocodone/acetaminophen (119 Million)
Odds Ratio Relative to Low Dose COT
10
8
6
4
2
0
Group Health 2010
<20 mg. MED
20 to < 50 mg. MED
VHA 2011
50 to <100 mg. MED
100+ mg. MED
Group Health Actions Regarding
Opioids Prescribing
2007 Guidance recommending increased caution in COT
2010 Multi-faceted COT risk mitigation initiative
Trescott, Beck, Seelig & Von Korff
Health Affairs, 2011
Percent of COT patients receiving > 120 mg. morphine dose
25
22.5
% Receiving high dose (≥ 120mg)
20
17.5
15
Community physicians
(GH contracted network)
12.5
10
7.5
GH group practice
physicians
5
2.5
0
2006
2007
2008
2009
2010
2011
2012
2013
2014
PRIMARY CARE TEAMS:
Learning from Effective Ambulatory Practices
Registry Element
Suggested
Frequency
Baseline
Categorical and Numeric
Medication, Dose and frequency
Every visit
Numeric
Med review for concurrent use of
sedatives
Random Urine Drug Screen
Every visit
Categorical (yes/no)
PEG Scale (Function and Pain)
All new patients;
prn per policy
Every visit
Categorical (positive:
yes/no)
Numeric
State Prescription Registry Check
Every 6 months
Categorical (yes/no)
Prescription Opioid Misuse Index (POMI)
survey
PHQ-2
Every 6 months
Numeric
Every 6 months
Numeric
Patient demographics: age, sex, marital
state, race/ethnicity
Type of Data
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.
• 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 [email protected] or call me
at 206-685-1052.
Shared Vision
1. A shared vision for
safer and more cautious
opioid prescribing…
Responsibilities Assigned
2. Responsibilities for
practice change related
to chronic opioid therapy
(COT)…
1
…has not been formally
considered or discussed
by clinicians and staff.
1
…has not been assigned
to designated leaders.
Leader Driven Policies &
1
Guidelines
3. Leaders responsible for …have not developed
COT practice change
COT policies and
initiatives…
guidelines.
2
…has been discussed, and
preliminary conversations
regarding a clinic-wide
opioid prescribing
standard have begun.
3
…has been partially
achieved, but consensus
regarding a clinic-wide
opioid prescribing
standard has not yet
been reached.
2
3
…has been assigned to
leaders, but no resources
have been committed.
…is shared by leaders and
a quality improvement
group that has dedicated
resources.
2
3
…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.
4
…has been fully achieved,
including defining COT
and dose safety
thresholds. Clinicians and
staff consistently follow
prescribing standards and
practices.
4
…is shared by all staff,
from leadership to team
members. Dedicated
resources support
protected time to meet
and engage in practice
change.
4
…have worked with
providers and clinical
teams and have made
substantial progress in
implementing COT
policies, guidelines, and
the necessary standard
work.
COT Registry Used
4. Use of a COT registry
to pro-actively monitor
COT patients and their
opioid dose levels to
ensure their safety…
1
…is not possible with
existing data systems.
Registry Workflows
1
Established
5. Registry workflows to
…have not been
manage the registry, use developed.
registry data to prepare
for patient visits, improve
patient care, and monitor
progress toward overall
opioid reduction…
2
…is technically possible,
but it is difficult to get
useful reports.
2
3
4
…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.
3
4
…are in development, but …are established, but
not established.
aren’t consistently
implemented.
…are established and
consistently
implemented.
Responsibilities are
assigned and protected
time is available to
complete assigned
responsibilities.
Polices & Standard
Work
6. COT policies and
standard work for all
opioid prescribing
(including refills, dose
escalation, tapering)…
Treatment Agreements
7.Formal written COT
treatment agreements…
Urine Drug Screening
1
…either do not exist or
do not cover many
prescribing situations.
1
…do not exist.
1
8. A urine drug screening …does not exist.
policy…
2
3
…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.
2
3
…have been developed
but are not in use.
2
…has been developed,
but is not in use.
…have been developed
and are partially
implemented into
routine care and/or
reminders.
3
…has been developed
and is partially
implemented into
routine care and/or
reminders.
4
…are well-defined and
have been discussed
with all clinic staff and
providers, and the
training needed to
implement them has
taken place.
4
…are fully implemented.
Most patients have a
signed treatment
agreement.
4
…is fully implemented.
Urine drug screening is
consistently
implemented according
to clinic policy.
Co-Prescribing Sedatives
1
9. Formal written policies
and standard work for
avoiding co-prescribing of
opioids and sedatives…
…have not
been
discussed or
developed.
PDMP Monitoring
10. Formal written policies
and standard work for
periodically checking the
PDMP for COT patients…
Patient Education
11. Patient education
materials that include
explanation of the risks, and
limited benefits of long-term
opioid use…
1
…have not
been
discussed or
developed.
1
…have not
been
discussed or
developed.
2
…have been discussed or
developed but do not
influence care.
2
…have been discussed or
developed but the PDMP
data are rarely checked.
2
…have been developed but
are rarely used in routine
clinical care.
3
…have been developed and
are partially implemented
into routine care and/or
reminders.
3
…have been developed and
the PDMP data are
sometimes checked.
3
…have been developed and
are partially implemented
into routine care.
4
…are fully implemented so
that co-prescribing of
opioids and sedatives is
consistently avoided.
4
…are fully implemented so
that PDMP data are
consistently checked.
4
…are fully implemented and
used routinely in patient care
when COT is considered or
prescribed.
Prepared COT Patient
Visits
12. Before routine clinic
visits, patients receiving
COT …
Standard Work for
Prepared Visits
13. The work needed to
prepare for a visit with
patients receiving or
potentially initiating
COT…
1
…are not identified.
There is no advance
preparation for patient
visits for chronic opioid
therapy.
2
…are sometimes
identified, but there is
no discussion or
advance preparation for
visits with COT patients.
1
2
…has not been defined.
...has been partially
defined, but work/tasks
are not delegated across
the team, and
implementation is
inconsistent.
3
…are identified, and a
discussion or chart
review to prepare for
the visit sometimes
occurs.
3
...has been clearly
defined, work is
delegated across the
team, and is often
implemented.
4
…are consistently
identified, and are
discussed before the
visit. The chart is
reviewed and
preparations made to
address safe COT use.
4
...has been clearly
defined, work has been
delegated across the
team, and is consistently
implemented.
Empathic
Communication
14. Patient-centered,
empathic
communication
emphasizing patient
safety…
1
2
3
4
…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
15. Involving COT
patients in decisionmaking, setting goals
for improvement and
providing support for
self-management…
1
…is not done routinely.
2
…is sometimes
implemented by
discussing treatment
options and goals, but
this is not documented in
a care plan. Patient
education pamphlets are
available.
3
…is usually implemented.
Patient goals and action
plans are documented in a
care plan. Follow visits
refer to and update goals
and plans.
Care Plans
16. Care plans for
chronic pain
management and
COT…
1
…have not been
developed
2
…are developed and
recorded but reflect only
the prescribing clinician,
the medication regimen
and a monitoring
schedule.
3
…are developed
collaboratively with
patients and include selfmanagement and clinical
goals, but they are not
routinely recorded or used
to guide care.
4
…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.
4
…are developed
collaboratively, include
self-management and
clinical goals, and are
routinely recorded and
used to guide care.
Identifying Complex Patients
17. The work needed to
identify opioid misuse,
diversion, abuse, addiction
and for recognizing complex
opioid dependence…
1
…is not done
routinely.
Behavioral Health Resources
1
18. Behavioral health (mental
health and chemical
dependency) services…
…are difficult
to obtain
reliably.
2
…is sometimes
done.
2
…are available
from behavioral
health specialists
but aren’t timely
or convenient.
3
…is usually done, but
follow-up when
problems are identified
is inconsistent.
3
…are available from
behavioral health
specialists and are
usually timely and
convenient.
4
…is consistently done, with
consistent follow-up when
problems are identified.
4
…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.
Monitoring Progress
19. A system to measure
and monitor progress in
COT practice change…
Assessing and Modifying
20. Adjustments to achieve
safer opioid prescribing
based on monitoring data…
1
…has not been
developed.
1
…are not being
made.
2
3
4
…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.
2
3
4
…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.
BUILDING
BLOCKS
Leadership &
consensus
Use a registry to
proactively
manage patients
Revise policies
and standard
work
Prepared, patientcentered visits
Caring for
complex patients
Measuring
success
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
GOAL 1:
LIST THE STEPS NECESSARY PERSON RESPONSIBLE
TO ACHIEVE THIS AIM
(WHO)
(WHAT)
1.
2.
3.
4.
5.
6.
WHEN
WHERE
GOAL 2:
LIST THE STEPS NECESSARY PERSON RESPONSIBLE
TO ACHIEVE THIS AIM
(WHO)
(WHAT)
1.
2.
3.
4.
5.
6.
WHEN
WHERE
www.improvingopioidcare.org