Quality Improvement to Address the Opioid Epidemic in Missouri

Quality Improvement to Address the Opioid Epidemic in Missouri
Butler County Health Department

Goal To create a program offering structured technical assistance for quality improvement for local public health agencies and partnering stakeholder agencies through collaboration with a team at Johns Hopkins Bloomberg School of Public Health.

Objective To implement technical assistance on the topic of quality improvement in implementing projects to address the opioid epidemic in Region E

Counties Involved Bollinger Butler Cape Girardeau Dunklin Iron Madison
Mississippi New Madrid Pemiscot Ripley Scott Stoddard Wayne Perry St. Francis Ste. Genevieve Ozark St. Louis

Workshops Kickoff – (PLAN) Interim – (PLAN) Workshop 2 – (PLAN)
1. Kickoff Workshop (PLAN) How to ID projects PDCA and common tools 2. Interim (PLAN) Review and approve QI Plan Identify pilots, develop aim and baseline 3. Workshop 2 (PLAN) Workflow and fishbone ID solutions & develop theory of change 4. Interim (DO) Perform a "do" cycle and measure results 5. Workshop 3 (CHECK) Review solution and results measured Share results 6. Workshop 4 - Next Steps (ACT) Make presentations Prep for next cycle and orientation for new staff Kickoff – (PLAN) Interim – (PLAN) Workshop 2 – (PLAN) Interim – (DO) Workshop 3 – (CHECK) Workshop 4 – (ACT)

Naloxone Distribution
Partner with the MO-HOPE project with the goal of reducing opioid related deaths by providing access to prevention, public awareness, overdose education, and naloxone to individuals at risk of experiencing or witnessing an overdose. AIM: Increase the percentage of first responders who are trained to administer Naloxone from 0- 50% by January 2019, by providing training and education to qualified personnel and community members.

Strengths Weaknesses Opportunities Threats Internal Factors (Organizational or Program/Unit Level) External Factors (Outside program and/or organization) Political Already policy/legislation in place Board push back Lowering costs of Naloxone/Program Economic Time to send people to trainings Trainings are free Naloxone kits are free Money to send people to trainings Social “Mandatory Reporting” Awareness of opioid crisis Push back from community members Technological Train the Trainer Legal Naloxone administration is covered under the Good Samaritan Law Drug use is illegal-Community members may be nervous to report the need to naloxone education/training Frist responders will know LPHA will have naloxone kits available People who use drugs may not come to LPHA to receive training Environmental Having a place to distribute naloxone Having Naloxone available in a location that is conducive to people who need it. Potentially effective and saves lives/behavior change Training locations Transportation to LPHA

Projects biggest successes: In all of the communities at the table someone has a training set up or has been trained. 9 of 13 communities showed up for a training at New Madrid and provided continuing education hours

Issues that must be addressed/corrected Trainers availability to train Finding times for first responders to come Communication between community partners i.e. “politics” of certain areas

Next steps: Keep doing what we are doing.- Reaching out to community members, training new staff, etc Follow up with organizations that have not been trained yet Contact each other when we are having a training to share our trainings so more people can get trained

Prescription Drug Monitoring Program
Implement GIS mapping to analyze patterns of medical and nonmedical opioid misuse utilizing MO’s Prescription Drug Monitoring Program. Goals to include: identification of doctor shopping and decreased controlled substance availability by prescription AIM: By January 1, 2019, Butler, Reynolds, and Ozark County Health Departments will partner with Prescription Drug Monitoring Program to implement geospatial analysis regionally to identify and decrease controlled substances being prescribed by 50%.

Strengths Weaknesses Opportunities Threats Internal Factors (Organizational or Program/Unit Level) External Factors (Outside program and/or organization) Political Existing policy in place via St. Louis County Local gov. push back Not state mandated Enact legislation piece to maintain funding over time Push back from local legislatures, physicians, or pharmacists Economic PDMP trained staff Cost to train staff Conduct periodic performance review for opportunity, improvement, and future funding No specific funding source Social Collaborate with health agencies Social Media education campaign Physicians may be resistant or hesitant to change prescribing practices Increases access or availability to treatment Technological Potentially links PDMP data to EHR for improved patient care Staff may not have the computer skills Data may not be received in a timely manner Links PDMP data to health care professional database for improved patient care and data collection Limited interstate sharing Legal Use PDMP data as outcome measure to evaluate program and policy effectiveness Increase law enforcement investigation of pill mills, doctor shopping, and diversion Crime rates surrounding opioid abuse does not change Environmental Geographically map plotting distances patients travel to obtain prescriptions Increased knowledge and understanding of opioid prescribing. Decrease doctor shopping Cross over from opioid to increased heroin use

Project’s biggest successes Health Literacy Media has agreed to help develop strategic media messaging increasing awareness and education. St. Louis County is developing a regional report MFH CQI LPHA’s have all passed county ordinances partnering with St. Louis County PDMP All regional and non-regional MFH CQI LPHA’s have passed county-wide ordinances enacting PDMP.

Issues that must be addressed/corrected Verbal pushback from staff internally and partnering organizations about PDMP information Lack of knowledge surrounding PDMP

Next Steps: Disseminate reports to partnering organizations with an executive summary Develop awareness campaign about what PDMP is Implement strategic media messaging, educating community members about PDMP findings. The PDMP team will also be presenting about the PDMP to providers and pharmacists in the coming months, as was requested through initiatives with CDC.

Overdose Fatality Collaborative
Primary goal is to reduce incidence of overdose deaths in the community; a comprehensive review of overdose and non-fatal overdose data, generates recommendations to identify opportunities reducing opioid related deaths and overdoses as well as raising community awareness. AIM: Expand current cause of deaths, including all substance abuse deaths as identified by coroner, ages 18 years and older, for data/statistics in Butler County by January 31, 2019.

Strengths Weaknesses Opportunities Threats Internal Factors (Organizational or Program/Unit Level) External Factors (Outside program and/or organization) Political Existing model (CFRP) No adult program who will have access to data Coroner has opportunity to be proactive Apathy personal regards to drug users Economic Little to no additional cost Time effort Long term- less cost funeral hospitals Cost- limited Social Bring players I room to discuss/awareness Recognition of severity of problem Awareness of problem Stigma of data Technological Allow data to be accessed once collected No specified collection site Create accessible data Deterrent to growth of community Legal Panel already exists Currently 18 years and under Expand current law If mandated, potential pushback Environmental Desire to know outcome of death Increased knowledge and understand of manner and location to overdose deaths

Project’s biggest successes Creation of the OFC Identified a legislator to serve as champion and sponsor for OFC s in Missouri General Assembly Established an OFC model that is replicable for other jurisdictions Secured funding for GIS software and training to geo map overdose incidents

Issues that must be addressed/corrected Engaging new Prosecuting Attorney Need to create a formal report process Create a format for community partners to share non-PHI data

Next Steps Branch out to surrounding counties

Safe Syringe Access / Harm Reduction
Exchange of needle, while providing rapid HIV testing anonymously, however, other health services, such as rapid testing for Hepatitis C, STDs, pregnancy tests, and immunizations will be available AIM: Implement a Safe Syringe Access Program by January 1, 2019 to reduce the rate of HCV and HIV co-infections by 50%.

Strengths Weaknesses Opportunities Threats Internal Factors (Organizational or Program/Unit Level) External Factors (Outside program and/or organization) Political Has worked in other areas. Local government does not support needle access program Missouri could be 34 state to implement access program Community or state reps not support Economic Education funding Funded by local tax payers (push back form community) Reduce the number of people seeking treatment No federal funding (consider drug paraphernalia) Social Having a rapport with people who use drugs Community viewing it as excepting or promoting drug use. Testing, referring to treatment, reducing HIV/Hepatitis C Cases Local community members feeling unsafe (drug use=social norms) Technological Education on social media and improving data collection Push back on social media and funding for staff Extracting data to use and send to DHSS/treatment centers Could be seen as demeaning on social media Legal Not yet legal- considered drug paraphernalia Community collaboration support on syringe access program. Parole officers, drug courts, judges and law enforcement Bill does not pass at the state level. Environmental Reducing risk of contaminated needle sticks User could be paranoid Increases knowledge and changes behavior No behavior change

Project’s biggest successes Paring with smart moves smart choices program County wide Narcan training

Project changes needed The change of syringe access

Next Steps Distribute harm reduction packets Safe Syringe cleaning Fentanyl testing strips to help decrease overdoses Still approaching everything from a harm reduction stand point. BCHD will be a guest speaker along side a highway patrol officer and a person who has been in recovery discussing harm reduction and Narcan use.

SBIRT / IPV Screening Tool
Create an opioid screening tool attachment for the Electronic Health Records system, specially assessing / screening women of child bearing years and male family planning clientele for opioid misuse. AIM: By January 2019, increase # of LPHA’s from 0% to 100% utilizing an electronic screening tool assessing substance use/abuse and intimate partner violence by screening all adult clients seeking family planning, pregnancy testing, and/or STD/HIV services.

Strengths Weaknesses Opportunities Threats Internal Factors (Organizational or Program/Unit Level) External Factors (Outside program and/or organization) Political Assessment tool used across the board to measure opioid abuse Push-back from local public health officials Continuation of funding sources Political push-back Economic 1.Financial Benefits (billable) 2.Available for low- income clients to receive substance abuse care Timely mental health services 1.Continuation of funding 2.Immediate treatment or referral for mental 1.High upfront acquisition /maintenance cost 2.Limited mental health services locally Social Improves patient/health professional trust New form of assessing clients for substance abuse 1.Network/partner with subject matter experts 2.Improves population health/knowledge 1.New program 2.Limited client trust Technologi cal Improves data storytelling 1. Staff openness to change 2. Timing 3.Workflow disruption 1.Improves ability to conduct research/data storytelling 2.Increased funding 1.Ongoing maintenance 2.Potential Hacking Legal 1.Better documentation 2.Reduces medical or clinical errors 1.Wrong medical entry 2.Visibility for off-site client services Better safeguard measures Privacy concern (hacking) Environmen tal 1.Private spaces already available; allows for trust to be established 1.Stigma surrounding health department 1.Change the stigma 2.Increase staff knowledge surrounding addiction 3. Create behavior change 1.No current security measures for IPV clients

Project’s biggest successes All counties are live on EHR Increased cooperation and communication between counties

Issues that must be addressed/corrected At this time nursing staff has to go to a separate report in order to screen client. Automatic population of questions vs. having to go to a separate report. Generate a score based on client’s response to questions.

Next Steps: Meet with other counties to streamline with all seven counties that are using the template. Work with Patagonia on re-vamping the SBIRT/IPV templates.

Smart Moves Smart Choices
Partner with Smart Moves Smart Choices, a national awareness program designed to inform parents, teens, and educators about the risk of middle school and teen prescription drug abuse and misuse and to empower them to address this serious problem AIM: By March 29, 2019, 20% of school aged children will participate in awareness of prescription medication abuse and safety program.

Strengths Weaknesses Opportunities Threats Internal Factors (Organizational or Program/Unit Level) External Factors (Outside program and/or organization) Political Provides awareness Push back from school board/parents School board not permitting curriculum Not enough time to implement curriculum Economic Program/educatio n material is free Staff, time, and budget constraints Decreasing the # of students misusing opioids Not enough funding for public health crisis Social Building better relationships with school districts Community may not view curriculum as necessary Referring to treatment, reducing possible school aged children addicted to opioids Avoidance of possible problems of misuse Technological Education or social media already available (improves data collection) Push back on social media and funding for staff Extracting data to use and sharing with stakeholders/partne rs Dependent on internet, projector, etc. Legal Evidence-based Parents may opt child out of education program Community collaboration and support with prevention May increase risky behavior Environmental Proper disposal of medications Resistance to change behaviors Increases knowledge and changes behavior No behavior change

Project’s biggest successes Pre and Post Test Scores; Pre Test and Post Test increase in scores The students were very receptive The Feedback provided by the student

Issues that must be addressed/corrected Funding Issues Changing the length of curriculum

Next Steps Implementation in more Counties Schools to take on program

Where are we going

Contact Emily Goodin Community Planner Butler County Health Department

Quality Improvement to Address the Opioid Epidemic in Missouri

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