University of Washington-Group Health Research Team

Michael Parchman, MD, MPHDirector, MacColl Center for InnovationGroup Health Research Instituteparchman.m@ghc.org

Laura-Mae Baldwin, MD, MPHProfessor, Department of Family MedicineUniversity of Washingtonlmb@uw.edu

Brooke Ike, MPHProject Manager and Practice FacilitatorUniversity of Washingtonbike2@uw.edu

David Tauben, MDChief of Pain MedicineUniversity 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.

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

• Hydrocodone/acetaminophen (119 Million)

0

2

4

6

8

10

Group Health 2010 VHA 2011

Od

ds

Ra

tio

Re

lati

ve t

o L

ow

Do

se C

OT

<20 mg. MED 20 to < 50 mg. MED 50 to <100 mg. MED 100+ mg. MED

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

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

% R

ece

ivin

g h

igh

do

se (

≥ 1

20m

g)

GH group practice physicians

Community physicians (GH contracted network)

Learning from Effective Ambulatory Practices

PRIMARY CARE TEAMS:

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

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 bike2@uw.edu or call me

at 206-685-1052.

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 &

Guidelines1 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.

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

Established1 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.

Polices & Standard

Work1 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.

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.

Prepared COT Patient

Visits1 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 Visits1 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.

Empathic

Communication1 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.

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.

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.

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

GOAL 1:

LIST THE STEPS NECESSARY

TO ACHIEVE THIS AIM

(WHAT)

PERSON RESPONSIBLE

(WHO)WHEN WHERE

1.

2.

3.

4.

5.

6.

GOAL 2:

LIST THE STEPS NECESSARY

TO ACHIEVE THIS AIM

(WHAT)

PERSON RESPONSIBLE

(WHO)WHEN WHERE

1.

2.

3.

4.

5.

6.

www.improvingopioidcare.org