1. Welcome to the Team-Based Opioid Management Project!

2. University of Washington-Group Health Research Team
Michael Parchman, MD, MPH
Director, MacColl Center for Innovation
Group Health Research Institute
Laura-Mae Baldwin, MD, MPH
Professor, Department of Family Medicine
University of Washington
Brooke Ike, MPH
Project Manager and Practice Facilitator
University of Washington
David Tauben, MD
Chief of Pain Medicine
University of Washington

3. Agenda Introduction to the Project
Six Building Blocks to best practices for opioid management
Small group discussions of your clinic’s current approach to chronic opioid management and your priorities for change

4. Team-Based Opioid Management in Primary Care
A collaboration between 20 rural and rural-serving clinics in Washington and Idaho Goal: To lower the risks of death and drug overdose among patients who are taking opioid medications for chronic non-cancer pain.

5. Key Components of the Team Based Opioid Management Approach
Creation of an opioid quality improvement team at each site
Set up and use of an opioid registry
Implementation of selected best practices from the “Six Building Blocks” to manage patients using chronic opioids

6. Support for the Project
Direct FTE support for the clinician champion and a medical assistant/nurse/care coordinator to manage the registry
Reports from the registry that can be used:
By MAs, nurses, and clinicians at the point of care
By the quality improvement team
Study website
Examples of clinic opioid management policies
Tools to support patient care
Archived webinars about chronic pain management

7. Support for the Project
Monthly conference calls with QI improvement teams across the 6 organizations (first Tuesdays at 11am)
discuss progress
identify barriers
share potential solutions
Quarterly individual check-in calls with Practice Facilitator (Brooke Ike)
One-hour monthly learning webinars on chronic pain management beginning February 11 (2nd Thursdays & 4th noon)

8. Quality Improvement AND Research
This project is largely a quality improvement activity.
Some information that we collect from you to improve and assess the program will be used for research in collaboration with the UW and Group Health Research Institute
Information statement describes
the purpose of the research
the QI activities that will be used for research

9. Michael Parchman, MD, MPH February 2016
The Six Building Blocks of Team-Based Opioid Management: How did we get here?
Funded by AHRQ Grant # 1R18HS

10. Overview Background: do we have a problem? Experiences
The Group Health Opioid Initiative
Learning from Effective Ambulatory Practices (LEAP) Study
Six Building Blocks for Safer Opioid Prescribing

13. 77 opioids written for every 100 people.
In Washington state, there are
77 opioids
or prescription pain medications
written for every 100 people.

16. We have Dug a Deep Hole
Deaths due to prescription opioid overdose now 16,000 per year
More than cocaine and heroin overdose deaths combined
From 2009 to 2013 more than 1.3 million admits for Rx opioid overdose

17. Top five medicines prescribed in the U.S. in 2014 were:
Levothyroxine (120 million Rx)
Hydrocodone/acetaminophen (119 Million)
Lisinopril (104 million)
Metoprolol (85 million)
Atorvastatin (81 million)

18. NIH-funded research at Group Health, replicated elsewhere, found dose-related overdose risks among chronic pain patients

19. Group Health Actions Regarding Opioids Prescribing
Guidance recommending increased caution in COT
Multi-faceted COT risk mitigation initiative
An individualized, standardized COT care plan
Standardized tools for patient education and treatment again
Minimum standards set for monitoring visit and urine drug screening
Refill ordering processes modified
On-line education program for GH clinicians
Trescott, Beck, Seelig & Von Korff
Health Affairs, 2011

20. In Group Health clinics, the percent of patients on high COT doses was reduced by 63% from 2006 to 2014
Percent of COT patients receiving > 120 mg. morphine dose
Community physicians (GH contracted network)
GH group practice physicians

21. Learning from Effective Ambulatory Practices
PRIMARY CARE TEAMS:
Learning from Effective Ambulatory Practices

22. LEAP: 31 innovative primary care practices models for improving team-based care

23. LEAP Key Findings: COT
Leadership support and continual updating and revising of clinic policies & guidelines
Teams continually evaluated and modified workflows to implement policies
Use of a registry to pro-actively monitor patients and identify care gaps between visits
Monitored patient function, NOT PAIN, as guide for adjusting treatment plan

24. Registry Data 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
Categorical (yes/no)
Random Urine Drug Screen
All new patients; prn per policy
Categorical (positive: yes/no)
PEG Scale (Function and Pain)
State Prescription Registry Check
Every 6 months
Prescription Opioid Misuse Index (POMI) survey
PHQ-2

25. Roles and Tasks COT Clinical Champion
COT Improvement Team (from all areas of clinic)
COT Registry manager with protected time each week to update and do outreach
Huddles for pre-visit preparation

26. Six Building Blocks Building Block 1: Leadership and consensus
Build organization-wide consensus to prioritize safe, more selective, and more cautious opioid prescribing.
Building Block 2: Use a registry
Implement pro-active population management before, during, and between clinic visits of all COT patients: safe care & measure improvement.
Building Block 3: Revise policies and standard work
Revise and implement clinic policies and define standard work for health care team members to achieve safer opioid prescribing and COT management in each clinical contact with COT patients.

27. Six Building Blocks
Building Block 4: Prepared, patient-centered visits
Prepare and plan for clinic visits of all patients on COT to ensure that care is safe and appropriate. Support patient-centered, empathic communication for COT patient care.
Building Block 5: Caring for complex patients
Identify and develop resources for patients who become addicted to or who develop complex opioid dependence.
Building Block 6: Measuring success
Continuously monitor progress and improve with experience.

30. Where are we now? A time for reflection & discussion
Brooke Ike, MPH
February 2016
Where are we now? A time for reflection & discussion

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.
The first step in beginning quality improvement change is to really get an accurate understanding of where you are now with chronic opioid patient management. We know that depending on your role and clinic, you might have a different perspective than another person in the room. It is essential to get a sense of these different understandings to help build consensus and inform the first steps of the quality improvement initiatives.

32. Self-assessment activity directions
Divide into groups
Two tasks:
For each item, circle the description that best matches your clinic. If your group cannot agree, write that down too.
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 me at or call me at

33. Small-group baseline self-assessment results

34. Building Block 1: Leadership & Consensus
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
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
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. Building Block 2: Use a registry to proactively manage patients
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
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. Building Block 3 (first three questions): Revise policies and standard work
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
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
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. Building Block 3 (second three questions): Revise policies and standard work
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
10. Formal written policies and standard work for periodically checking the PDMP for COT patients…
…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
11. Patient education materials that include explanation of the risks, and limited benefits of long-term opioid use…
…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. Building Block 4 (first two questions): Prepared, patient-centered visits
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
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. Building Block 4 (last three questions): Prepared, patient-centered visits
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
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
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. Building Block 5: Caring for complex patients
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
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. Building Block 6: Measuring Success
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
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.

42. QI team meeting

43. Introductions & roles

44. QI processes Quarterly check-ins Monthly multi-site calls
How often will your QI team meet?
Tell us more about your QI experience

45. What are they key areas you want to address?
Your greatest needs for caring for chronic opioid patients?
What do you want to get out of this project?
How will you know?

46. Project aims & measures:
Building
Blocks
Brainstorm changes we want to make
(Review the Six Building Blocks high-impact 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. Steps List the steps necessary to achieve this aim (what)
Goal 1:
List the steps necessary to achieve this aim (what)
Person responsible (Who)
When
Where 1. 2. 3. 4. 5. 6.

48. Steps List the steps necessary to achieve this aim (what)
Goal 2:
List the steps necessary to achieve this aim (what)
Person responsible (Who)
When
Where 1. 2. 3. 4. 5. 6.

49. Project resources Registry Reports
Website:
Webinars
Shared Learning Calls & Check-In Calls