TSWF Chronic Opioid Therapy (COT) CPG AIM Form Training AMSUS Lecture 30 Nov 2016 Sep-Dec 2016 Form Version

Objectives Introduce you to the documentation format and content available to MHS providers and staff right now! Demonstrate practical application of the TSWF COT CPG AIM form

What Do We Know About documentation and the Use of Opioid Analgesics for Pain? Increased surveillance increases overall safety and decreases morbidity and mortality in this patient population Increased surveillance is strongly recommended for chronic pain patients using opioid analgesics due to the high risk of their misuse Increased surveillance cannot occur without consistent and standardized documentation!!!

How Will Using the COT Form Help You Manage Your COT Patients? Promote evidence-based management Identify critical decision points in management of patients with chronic pain who are candidates for opioid therapy Provide care congruent with local policies regarding referrals or consultations with substance abuse specialists Standardize treatment of COT patients across the MHS Presenter Notes: The form is used to manage the patient’s opioid use for their chronic pain, not to manage the source of their chronic pain.

What is Documented in the COT Form? Sole care provider Pain Assessment using the DVPRS Scale Functional Pain Scale using the supplemental questions using the DVPRS. Date, presence, and location of the Pain Care Agreement Acknowledgement of contraindications prior to initiation of COT

What is Documented in the COT Form? Appropriateness of referrals to specialists Documentation of date and results of Urine drug testing (UDT) Risk assessment using DIRE, ORT, etc. Past pain treatment history and results Evaluation of possible opioid side effects at each visit Comprehensive Care plan for your COT patient

Reasons for and Methods of Increased Monitoring of COT Patients The VA/DoD Clinical Practice Guideline (CPG) recommendations for patients requiring increased monitoring during Chronic Opioid Therapy (COT) are at the top of the TSWF COT CPG AIM form The CPG recommendations for increased monitoring methods are located at the top right of the form

DVPRS Scale is linked in form adjacent to Pain Assessment and Functionality fields on TSWF COT AIM form. Recommend clinic print a Pain and Functional scale (next slide) and place in a page protector for patient to indicate. Corresponding entry fields are on the 1st tab of COT AIM form.

DVPRS Supplemental Questions Presenter Notes: The supplemental questions to the DoD/VA pain score allow you to document and follow the patient’s pain management by understanding how their pain has affected their sleep, mood, stress and activity in the last 24 hours.

Documentation of DVPRS Supplemental Questions Documenting the effect of pain on quality of life is essential to managing pain levels The Defense and Veterans Pain Rating Scale and the associated Supplemental Questions standardize and quantify the patient’s responses for rating pain during the assessment

Contraindications to COT Patients with contraindications are NOT candidates for Opioid Therapy and should be referred to specialty care Contraindications are reviewed with the patient during each visit Presenter Notes: A location to document the ‘absolute contraindications’ at each visit is provided on the form. Clinical Staff should have and understanding of the questions when asking, have reviewed medications during copy forward and reviewed for other encounters out side of the Patient’s PCMH team. Patients on COT are frequently seen by multiple providers and are difficult to manage.

Side Effects of COT Adverse effects of opioid medications are manageable elements for COT patients’ treatment plans and should be reviewed during intake at each visit Providers should use clinical judgment to manage side effects and reactions Presenter Notes: A location to document the opioid-related adverse effects is located on the form. Side effects are the number one reason that patients do not adhere to their chronic pain medication management plan. 50% of patient discontinue therapies due to medication side effects. Link to clinical guidance link.

Pain Care Agreement (PCA) The Pain Care Agreement is an annual requirement Document the date and location where the original agreement can be obtained on the COT CPG form A link to an Example Pain Care Agreement is now included Presenter Notes: This form allows you to document the date and location of their last pain management agreement. In addition it provides a sample pain management agreement if the patient does not have one. Example of Care Agreement in located in CPG. No standardized service document currently identified within pain specialty or Primary care. MTF Restriction form link allows providers to limit patient access to a single pharmacy and or provider. Program is managed by TRICARE express scripts ® and is linked to patients Tri-Care benefits restricting retail utilization. Cash will function. Notification is sent to PCM if patient attempts to utilize undesignated pharmacy or is written a prescription by a non sole source provider.

MTF Prescription Monitoring Program https://www.express-scripts.com/TRICARE/tools/rxMonitoring.shtml

MTF Rx Restriction Request Form

COT Comprehensive Care Plan (CCP) Specific to COT Chronic Pain CCP Diagnosis Date therapy is initiated Sole prescribing provider Treatment regimen Baseline pain assessment Screening measures for COT and LBP Opioid Risk Tool & D.I.R.E. Date of last urine drug test Document pill count for increased monitoring (as needed) Presenter Notes:

Pain Treatment History The Pain Treatment History is separate from the Medical Conditions (PMHx) box, allowing additional text space for specific pain treatments recommended in the VA/DoD CPG Presenter Notes: The past pain treatment history is crucial in understanding the patient’s chronic pain management history. A location to document their pain treatment history is located on the COT CPG form. Be as specific as possible when describing prior treatments!

Behavioral Health Treatment History The Behavioral Health History is separate from the PMHx Focused Behavioral Health History elements are identified in the CPG clinical hints box for added support

D.I.R.E. and ORT Screenings (Form View) This is what you will see when you open the ribbon

COT ® Reference Tabs The TSWF COT-CPG AIM form contains five reference tabs (marked with a ®) with specific COT content from the VA/DoD CPG Reference tabs use flow diagrams, tables, and external links to guide providers through COT patient management COT-CPG reference tabs are included for guidance in medication administration as well as numerous possible drug-drug interactions Presenter Notes: Reference tabs on the form provide management algorithms for initial management, follow-up management, and medication discontinuation. They also provide guidance for prescribing short term, or long term narcotics and drug-drug interactions.

Initial Assessment Tab

Follow-Up Assessment Tab

OT Discontinuation Tab

Medication Guidance Tab

Dug Interaction Tab

TSWF Resource Material The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/

Comments or Feedback Contact Form feedback / discussion forums: https://www.milsuite.mil/book/groups/tswf TSWF resources / educational materials: www.tswf-mhs.com Local Clinical Systems Trainer (CST) COT Project Managers: Mark Kline mark.kline@ehrts.com Scot Ario scot.ario@ehrts.com

TSWF Service Leads ARMY – Dr. Rolando Merino NAVY – CDR Anja Dabelic AIR FORCE – Maj Matthew Barnes & Maj Thomas Mahoney TSWF Feedback https://www.milsuite.mil/book/groups/tswf