1. Rx for Drug-Seeking Patients in the ED The Monterey County Prescribe Safe Initiative 1

2. AIM: Catalyst Be the Catalyst for Change in your Community OBJECTIVES: Why change is important How we made change in Monterey County How to pitch the story in your community Provide practical tools and resources to get started 2

3. Tools and Resources 3 www.chomp.org/for-healthcare-professionals/prescribe-safe

4. Opiate use in the U.S. ▫ 80% of the world’s prescription opiate supply ▫ 99% of the world’s hydrocodone supply ▫ From 1997 to 2007, the milligram per person use of prescription opioids in the U.S. increased from 74 milligrams to 369 milligrams, an increase of 402% (enough to supply every American adult with 5mg of hydrocodone every 4 hours for a month) Scope of the Problem 4

5. 7 Million Americans use prescription drugs recreationally annually (2.3% of the U.S. population) 50 Million Americans have used recreationally at least once during their lifetime (16.1% of the U.S. population) Scope of the Problem 5

6. Increased adverse medication events related to prescription drug misuse ▫ Estimated > 700,000 ED visits per year related to prescription drug misuse alone Approximately 10% of all patients on chronic opiates account for 40% of all overdoses high daily doses ▫ Usually on high daily doses multiple prescribers ▫ Getting drugs from multiple prescribers 6

7. Scope of the Problem Death300% Death from opiate overdoses have increased 300% since the 1990s years of productive life We lose more years of productive life in the US to prescription drug overdose than motor vehicle accidents 29 states and Monterey County Prescription drug related deaths exceed motor vehicle- related deaths in 29 states and Monterey County Prescription drug related deaths now outnumber those from heroin and cocaine combined 7

8. Scope of the Problem Gateway: 1/3 by using a prescription Gateway: Nearly 1/3 of people aged 12 and over who used drugs for the first time in 2009 began by using a prescription medications non-medically 8

9. Street Value www.streetrx.com 9

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12. Selling drugs for consideration (sex, addicted physicians) Medicine cabinet parties Prescription fraud Insurance fraud MRI forgery black market DIVERSION 12

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14. An Experiment 14

15. An Experiment (circ. 2005) Frequent Users of the ED Group (FUG) The Team: ▫ ED physicians ▫ ED nurse ▫ Administration ▫ Addictionology ▫ Hospitalist ▫ Pain management physician ▫ Psychiatrist ▫ Behavioral health nurse ▫ Social worker 15

16. EDRVP Emergency Department Recurrent Visitors Program 2013 16

17. EDRVP Purpose Adequately meet the needs and improve the overall care of patients recurrently seeking care in the ED for chronic medical problems, including, but certainly not limited to, opiate or benzodiazepine addiction 17

18. Change Concept care management Apply care management concepts: ▫ Identifyengage ▫ Identify and engage recurrent visitors barriers ▫ Remove barriers to more appropriate care self-management  Barriers to self-management  Establish PCP  Establish PCP or referral to more appropriate specialist socioeconomic  Address socioeconomic barriers to care and refer to community resources payer  Engage payer in the process standards of care Apply evidence-based and safe standards of care 18

19. Criteria Frequency ▫ ≥ 4 visits in 1 month ▫ ≥ 6 visits in 3 months ▫ ≥ 12 visits in 12 months Using the ED as a PCP office for non-emergencies ▫ Chronic condition management ▫ Repeat imaging and laboratory ▫ Medication refills Seeking pain medication refills and/or + CURES test Abusive or out of control behavior Provider or outside referral ▫ Pharmacy ▫ Insurance company 19

20. Care Management Process Screen Screen all referrals using criteria Review Review (prior 6 month chart review) ▫ Utilization patterns ▫ Visit reason ▫ Diagnostics ▫ PCP ▫ Medications refills Engage Engage patient, family, providers, insurance 20

21. Care Management Process Plan of Care Draft Plan of Care (POC) Advisory Council Advisory Council review of POC (monthly meeting) Communication Communication with Patient ▫ Letter to patient and providers ▫ POC uploaded in electronic medical record (green dot) 21

22. Tracking Board “Green Dot” Alert 22

23. Advisory Council ED Physician Urgent Care Physician/Addictionologist ED Director CHI ED Transition Care Manager and Referral Coordinator Social Worker Clinical Specialist Behavioral Health Services Hospitalist Coordinator CCAH Care Management Supervisor CCAH Care Management Supervisor 23

24. Health Information Technology Enablers High utilizer reports Electronic referral process Auto-population of POC 24

25. Monterey County Prescribe Safe Initiative Launched in February 2014 Modeled after the San Diego Collaborative Aim: Develop a broad-based coalition representing those interested in dealing with the epidemic of prescription drug abuse in Monterey County 25

26. 26 County-Wide Engagement

27. Monterey County Prescribe Safe Initiative Strategic Objectives Establish county-wide ED Pain Medication Prescribing Guidelines Develop resource tools to support ED efforts Community physician education “CURES Party” 27

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33. CURES Report 33

34. Results 34

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39. Resources FUG: ▫ Periodic Committee meeting ▫ 0.2 FTE Assistant Director of ED ▫ Annual Cost: $50,000 EDRVP ▫ Advisory Council meeting ▫ 0.5 FTE TCM ▫ Annual Cost: $75,000 39

40. Future More More of the same for the CHOMP EDRVP County-wide County-wide EDRVP Program pharmacies Engage local pharmacies health plans Engage local health plans 40

41. Take Home Messages A national epidemic with local implications (including your community) Exhaust the behavior – push in the same direction ▫ Use CURES ▫ Countywide medical community prescribing practices ▫ Engage the neighborhood Do it because it is the right thing to do AND there is a return on investment You’re behind – catch up by visiting our website 41

42. QUESTIONS?

43. Thank you Anthony Chavis, MD 831-644-7466 Anthony.chavis@chomp.org Reb Close, MD 831-625-4900 Reb.close@gmail.com