Dr. Robert Rich's 2013 SLC Presentation


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Dr. Robert Rich's 2013 SLC Presentation

  1. 1. Community Care of North Carolina Community and Practice Based Interventions to Lessen Opioid Abuse and Opioid Overdoses
  2. 2. Credentials  Robert L “Chuck” Rich, Jr., MD  Medical Director for Community Care of the Lower Cape Fear, Medicaid network  Practicing MD in rural Bladen County, NC.  AAFP Commission member, Health of the Public and Science  Chairperson AAFP workgroup re Opioids and Pain Management  No industry connections or sponsorships
  3. 3. Problem:  Utilization of highly addictive opioid medications has risen 160% in last 10 years  NC death rate for unintentional poisonings is 11.4 per 100,000 citizens 22nd in the country  1140 such deaths occurring in 2011  Deaths by motor vehicle accidents and unintentional poisonings are almost equal in NC.
  4. 4. Solution:  A model of intervention in the chronic pain cycle based on a successful integrated care pilot in Wilkes County, NC, called Project Lazarus (PL)  PL decreased unintentional overdose deaths in Wilkes County by 69% from 2009 – 2011  Community Care of NC, supported by a $2.6 million grant from The Trust (Kate B Reynolds) and matching funds from the Office of Rural Health, is expanding the PL approach statewide through 3 interrelated initiatives:  Community-Based Coalitions  The Clinical Process  Program Outcome Goals
  5. 5. The Kate B. Reynolds Trust 1.3 Million Dollars NC Foundation for Advanced Health Programs NC Office of Rural Health Pass Through 2.6 Million Dollars – Matched CCNC Governor’s Institute UNC IPRC Project Lazarus 14 CCNC Networks Pfizer $ $ $ $ $
  6. 6. PL Initiative – Community-Based Coalitions Community-based Coalitions:  Broaden awareness of extent and seriousness of unintentional poisonings and chronic pain issues  Support community involvement in prevention and early intervention  Comprised of broad range of community partners  Law Enforcement  Public Health  Schools  Hospitals  Faith-Based Organizations
  7. 7. Marketing Project Lazarus
  8. 8. PL Initiative – The Clinical Process The Clinical Process:  Focuses on medical assessment and treatment of chronic pain  Provides education on assessment criteria for pain, safe opioid prescribing, use of CCNC’s Provider Portal, and registration and use of the Controlled Substance Reporting System (CSRS) information
  9. 9. Target Audience Prescribers: Primary Care Physicians, Emergency Medicine, DOs, PAs, NPs, Pain Management, Orthopedists, Dentists Dispensers: Pharmacists Behavioral Health:  CCNC Network Psychiatrists  Community Psychiatrists  Addiction Medicine Physicians  Prescribers of Methadone/Buprenorphine (Suboxone)  LME/MCO Medical Directors  SA/MH Clinical Directors
  10. 10. Topics  Overview of Chronic Pain and Pathophysiology  Risk Assessment  Treatment Planning/Written Agreements  Legislative Changes: CSRS, Naloxone, Good Samaritan Laws  Documentation  Role of Pharmacists  Monitoring for aberrant use  Diagnosing Addiction  Intervening for Misuse and Addiction  Referring to Behavioral Health Specialists  Case Studies
  11. 11. Clinical Trainings  40 trainings over next 2 years  20 trainings will offer 3 prescribed credits of CME AMA Category 1 (CME trainings)  20 trainings will offer the same content and agenda but will not be eligible for CME credit (Pfizer-sponsored, non-CME trainings)  Each network will receive at least 1 CME training and 1 Pfizersponsored, non-CME training  CPI Coordinators will assist in determining which geographical locations within the network would most benefit from CME vs. Pfizer-sponsored, non-CME training
  12. 12. A Guide to Rational Opioid Prescribing Agenda Evening Meeting: 5:30 - 6:00 Registration, Pre-Evaluation, and Dinner 6:00 - 6:10 Introduction to Seminar Objectives 6:10 - 6:30 Nature of Pain/Role of Opioids 6:30 - 7:00 Risk Stratification and Initiating Treatment 7:00 - 7:30 Case discussion 1: Getting started 7:30 - 7:45 Break – Sign up for the CSRS 7:45 - 8:15 Monitoring, Intervening & When to Stop 8:15 - 8:45 Case discussion 2: Monitoring/Adapting Treatment Plan 8:45 - 9:00 Wrap up/Next steps *Turn in Post-Evaluation and get CME Certificate*
  13. 13. PL Initiative – The Clinical Process The Clinical Process:  Makes use of toolkits with decision support and other tools developed for:  Primary Care Physicians  Emergency Department Physicians  Care Managers
  14. 14. Toolkit Contents  Universal Precaution for Prescribing & Algorithm for Assessing and Managing Pain  Pain Treatment Agreement and Informed Consent  Prescriber and Patient Education Materials  Screening Forms and Brief Intervention – list of Community Resources  Format for Progress Notes  Naloxone Prescribing  Medication Flow Sheet  Controlled Substance Reporting  Personal Care Plan System (CSRS) Application  Local Community Resources
  15. 15. Medical Director Leadership  Created educational  Advises Care Managers and presentation for prescribers to Quality Improvement Staff on use with Toolkit distribution “difficult” chronic pain  Conducting Lunch & Learns with “Top 20” practices in network with high chronic pain patient volume and other practices indicating interest in chronic pain education patients or practice-related issues via “in person” meetings, telephonic consultation and use of CMIS  Presenting at CommunityCoalition stakeholder meetings
  16. 16. Medical Director Presentation  Typically 1 hour long  Discussion of NC Medical Board guidelines  Review of current NC data  Review of provider toolkit contents including useful forms, basic prescriber guidelines, CSRS, DMA “lockin” procedures  Summary with Q&A
  17. 17. Chronic Pain Patient Care Management Activities  Provide support to patients identified by the ED  Referrals to PCP or specialty services  Provide care management to CPI Priority Flag patients:  Screenings and assessment  Medication reconciliation  Ensure all prescribers have a medication list  Referral to DMA narcotic lock in program if appropriate  Counsel patient on living with chronic pain  Assist with appropriate referrals to behavioral health  Educate patient and caregiver re: signs and symptoms of overdose
  18. 18. Types of Practice Interventions  Identification of ED and Hospital Utilization  Recommending and/or Assisting with:  Timely follow-up PCP appointment post ED visit or hospital admission, including home and practice visits  Pain assessment and behavioral health screenings  Narcotic Lock-In  Pain contract  Close collaboration with pain management specialist/clinic and/or Psychiatrist/MCO providers as a TEAM effort  CSRS registration  Medication reconciliations and pharmacist consultations
  19. 19. PL Initiative – Program Outcome Goals Program Outcome Goals:  Measured through the Injury Prevention Research Center and include:  Decreased mortality due to unintentional poisonings  Decreased inappropriate ED utilization for pain management  Decreased inappropriate ED utilization of imaging with diagnosis of chronic pain  Increased use of Provider Portal and CSRS
  20. 20. CCLCF Chronic Pain Activities Prior to Recent Funding  Identified 53 chronic pain patients to follow as a cohort group  32 practices represented  Survey Tool created to capture static data at baseline  Practice and patient ID blinded  Included data snapshot of key utilization stats  Pharmacy section  Case Management section  Practice section  Identified Top 20 practices with most patient volume associated with chronic pain
  21. 21. Cohort Data to Track            Sum of Inpatient Mental Health Admissions Sum of Inpatient Non-Mental Health Admissions Sum of Emergency Department Visits Sum of Total Medicaid Cost Average of Total Medicaid Cost Sum of Total Medicaid Drug Cost Average of Total Medicaid Drug Cost Sum of # of Pharmacies (All Fills, Not Just Opioids) Sum of # of Opioid Fills in Past Year Sum of # of Benzo Fills in Past Year Sum of # of Hypnotic Fills in Past Year
  22. 22. Cohort Data at Follow Up Data Being Tracked Percent of Change Sum of Inpatient Mental Health Admissions -14 % Sum of Inpatient Non-Mental Health Admissions Sum of ED Visits 0% -30 % Sum of Total Medicaid Cost 1% Average of Total Medicaid Cost 1% Sum of Total Medicaid Drug Cost -12 % Average of Total Medicaid Drug Cost -12 % Sum of Number of Pharmacies (All Fills) -22 % Sum of Number of Opioid Fills/Past Yr -22 % Sum of Number of Benzo Fills/Past Yr - 8% Sum of Number of Hypnotic Fills/Past Yr 33 %
  23. 23. Advocacy- Medical Boards  Often forgotten  2013 FSMB guidelines just released with emphasis on proper screening, documentation, treatment plans, monitoring  MB monitoring often preeminent in provider thought process compared to legislation  Advocacy avenues include MD testimony re proposed rules, membership on MBs, case reviews
  24. 24. Advocacy- Legislatures  Everyone wants the problem solved- “we just need more rules”  “Primary care MDs do not need to be prescribing these meds”  PCPs handle the bulk of prescribing and do so safely with guidelines  Advocacy / educational materials abundant  No need to reinvent the wheel
  25. 25. Advocacy- LegislaturesResources  AAFP “Prescription Drug Monitoring Report”  AAFP position paper from OAPMWG workgroup  National conference of State Legislatures report of “Prevention of Prescription Drug Overdose and Abuse – State Laws”- updated 07/2013  FSMB policy guidelines re opioid prescribing  State level workgroups and position papers  http://www.cdc.gov/homeandrecreationalsafety/Poisoning/laws/laws.html  www.projectlazarus.org  Pharma resources
  26. 26. Types of Laws- CDC Website  Laws requiring a physical examination before prescribing  Laws requiring tamper- resistant prescription forms  Laws regulating pain clinics  Laws setting prescription drug limits  Laws prohibiting “doctor shopping”/ fraud  Laws requiring patient identification before dispensing  Laws providing immunity from prosecution/ mitigation at sentencing for individuals seeking assistance during an overdose