Presentation was originally done at Group Health Cooperative’s National Summit on Opioid Safety: http://www.ghinnovates.org/?p=3502 Presentation by, Grant Scull MD, associate director for Group Health Family Medicine Residency
This degree of support was and remains necessary for rapidly affecting such significant clinical practice change across a large delivery system.
RPIW was led by our medical director of primary care, facilitated by our Lean consultant team, with clearly defined goals and process. Leadership was explicit that the guideline itself was NOT to be modified.
Implementing chronic opioid therapy guidelines at Group Health Cooperative
National Summit on Opioid SafetyGrant Scull MDAssociate DirectorGroup Health Family Medicine Residency
Disclosures I have no financial relationships that may pose a conflict of interest.
Essential Elements of COT GuidelineImplementation - Clinical Key Points of Chronic Opioid Therapy - Practice climate prior to Group Health’s COT guideline initiative - GH Leadership Support - Careful, thoughtful guideline design, followed by guideline operationalization during the COT RPIW - Coordinated step-wise implementation of COT guideline across all GH integrated group practice - Tools used to promote guideline adoption by providers - Outcomes to date - Summary and Questions
Clinical Key Points of Chronic Opioid Therapy Providers are compassionate and do not want to harm their patients Patients want NOT to suffer and NOT to be harmed by medications COT is one small part of Chronic Pain Management Chronic pain is a common presentation for other issues Providers need better knowledge of the limitations of opioids in the management of chronic pain COT guidelines and decision support improves provider confidence in COT AND patient satisfaction and safety
Practice Climate Prior to Group Health’sCOT Guideline Initiative Tension for change was clear and present Large degree of practice variation locally within provider groups as well as regionally within Group Health No clear “best practice” on chronic opioid prescribing or monitoring National and local epidemic of prescription opioid abuse and associated harms High prevalence of provider AND patient dissatisfaction around chronic opioid therapy
GH Leadership Support Unified and unequivocal support and sponsorship of the COT guideline and its implementation from all levels of leadership in the organization.
Careful, Thoughtful Guideline Design • Developed in parallel with state • Patients stratified by dose and behavior • Care plan elements defined • Monitoring criteria defined (frequency of visits and urine drug screening) • Referrals of high dose patients required
Guideline Operationalized RPIW (Rapid Process Improvement Workshop) June 21-24, 2010 Involved leadership and experts representing all stakeholders in delivering COT care Explicitly intended to develop the tools and workflow to operationalize the Guideline, NOT to modify the Guideline itself
Coordinated Step-wise Implementation of COTGuideline Across all GH Integrated Group Practice Training •Each chief and champion trained for 8 hrs •Online course required for all clinicians 1.5 hours: MD, PA, RN, Clinical Pharmacist •New process and highlights of the training presented to whole team 2 hours •Coaches available for difficult conversations and in-clinic mentoring on COT management
Implementation Timeline Q4 Q1 Q2 Q3-4 2010 2011 2011 2011Populationverified by High riskpcp invited in All patients Care plan invited in completion COT tracked and code on incentiveproblem list payment at end of year
Implementation Timeline:Percent of COT Patients with Care Plans 100% 80% 60% 40% 20% 0% 0 1 1 0 1 0 1 10 11 11 -1 -1 -1 -1 -1 -1 -1 n- n- b- ct ct pr ug ug ec ec Ju Ju Fe O O A D D A A
COT Patients Receiving Urine Drug Screeningin a Year by Dose 80% 70% 64% 60% 50% 50% All COT patients 40% High dose COT patients 30% 21% 20% 15% 13% 10% 7% 0% Baseline Guideline Guideline (2008-9) Planning Implementation (2009-10) (2010-11)
COT Patients Receiving Average Daily Dose> 120 mg MED (%): Group Health IGP vs. Network25%20% Network15%10% 17.8 % > 120 mg. MED IGP 5% 9.4 % > 120 mg. MED 0% ep t ar p ar p ar p ar p ar p ar S 6 M Se 7 M Se 8 M Se 9 M Se 0 M Se 1 M 5 6 7 8 9 0 00 2 00 2 00 2 00 2 00 2 00 2 00 2 00 2 00 2 01 2 01 20 12 Guideline Guideline Planning Implementation Group Health Solutions for Transforming Care | Chronic Opioid Therapy
Current State with COT Guideline • Best rollout ever at Group Health • Decreased patient complaints • Decreased tension and inefficiency in the clinics • Fewer patients on high doses • Much more urine drug screening • Factors of success: sponsorship, methods and processes in place, met real problem, state mandates, clear practice parameters, financial incentives, transparency
Next Steps What would the ideal future state look like? Move from COT to true Chronic Pain Management -Continue standard practice around COT -Integrate behavioral health, physical therapy, substance abuse into primary care
Essential Elements of COT GuidelineImplementation Questions?