1. Incorporating Best Practices through Practice Organization & EMRs in a Residency Practice Mathew Devine, D.O. Associate Medical Director Highland Family Medicine

2. Highland Family Medicine – Urban Family Medicine Residency History Founded 1967 Recent expansion to 12:12:12 Urban Health Clinic 261 bed Critical care hospital P4 Residency program 2007 60 providers in practice Total patient population over 19, 000 > 55,000 visits per year

3. Chronic Pain and Narcotic Use at Highland Family Medicine 2009

4. Objectives of this section Discuss contract and narcotics policy use in resident practices Identify importance of patient databases to support chronic pain management in residency practices Review audit document used for peer review in residency practices

5. Use of EMR for tracking of Chronic Pain Use of Patient lists in EMR to create Chronic Pain Database Placing identifier on medication list for those on chronic narcotics, “1-pain management agreement” Implementing peer review to audit charts of patients with chronic pain Collaboration through EMR with Pain management clinic in system, placing and tracking referrals

6. New Patient @ HFM Providers Follow CS Policy Patient Handout & Information Old Records - Bridge

10. Peer Review/Audit process and results Updated information to provided at live presentation

11. Use of urine toxicology in monitoring Urine should contain the prescribed drug/s: If not, the patient may be diverting or providing a fake sample to cover other substances, make sure you know what your UDS is capable of detecting Urine should be free of non-prescribed substances: If the patient is unable to relinquish alcohol / recreational drugs in order to receive treatment, either treatment is not very important or the other drugs are overly important, and addiction assessment/RX is needed.

14. Urine drug screening results from practice Updated information to provided at live presentation

15. Helping Patients Whose Pain is Not Relieved Through Group Visits and Emotional Support Mathew Devine, D.O. Associate Medical Director Highland Family Medicine

16. Objectives of this section Review the curriculum, patient selection, and data collection performed for chronic pain group visit interpret the data from chronic pain group visits in regards to improvement of functional status, depression, and identification of addiction Discuss the tenets of creating a successful group visit format in residency practices

17. Group Visits Available at Highland Family Medicine Chronic Pain Diabetes Pediatric Asthma Depression In the pipeline: Prenatal visits Tobacco

18. Group Visit Format Referrals from PCP/CCP to group Closed group of 8 sessions over 6 months Group size goal of 8-12 patients Team consists of 2 providers, psychologist, nurse, and resident(s)

19. Why Group Medical Visits? PCMH: AAFP; TransforMed Growing Literature supports benefits Improved clinical outcomes Patient satisfaction Provider satisfaction Cost-neutral Education

20. Group Visit Data 1. REALM 2. PHQ-9 3. DAST 4. AUDIT 5. PDQ – Functional assessment tool 6. Smoking and Anxiety history 7. Re-sign pain contract 8. Urine Drug Screen 9. Domestic Violence screen 10. How’s Your Health online survey

21. Functional Assessment - Data Review Used an evidence based assessment survey that checks functional and psychosocial components of the patient The higher functioning and emotional stable the individual is the lower the scores

22. PDQ data from Chronic Pain group regarding: Functional assessment

23. PDQ data from Chronic Pain group regarding: Psychosocial assessment

24. Depression Screening data Information to be provided at session

25. Addiction Regardless of referral source – resident, nurse practitioner, or attending, addiction was found to be heavily present in sample of patients selected Majority of patients coming to group female

26. Addiction results

27. Resident involvement in Group process Get to observe them in group setting in motivation interviewing and teaching to patients Work closely with them on EBM evidence for pain management Can follow their prescription habits Can provide more structure and an organized plan and improved historical information of patients for further individual management by providers using annual pain review assessment

28. Downsides of Group visit Billing If applicable patient has to be for each co-pay Increased time of session, planning, and calling/mailing to patients Patient difficulty with being on time to visit Identification of addiction early in process and losing individual from group due to treatment or patient refusal to return

29. What other services are available to patients with chronic pain? Physical therapy Adjunct treatment Acupuncture Chiropractor Osteopathic Manipulation Massage therapy Hypnosis Behavioral health therapy Family therapy Pain management evaluation Support groups

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