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

1. National Summit on Opioid Safety
Grant Scull MD
Associate Director
Group Health Family Medicine Residency

2. Disclosures
I have no financial relationships that may pose a conflict
of interest.

3. Essential Elements of COT Guideline
Implementation
- 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

4. 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

5. Practice Climate Prior to Group Health’s
COT 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

6. GH Leadership Support
Unified and unequivocal support and sponsorship of the
COT guideline and its implementation from all levels of
leadership in the organization.

7. 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

8. 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

9. Opioid Management RPIW
June 21-24, 2010

10. Coordinated Step-wise Implementation of COT
Guideline 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

11. Implementation Timeline
Q4 Q1 Q2 Q3-4
2010 2011 2011 2011
Population
verified by High risk
pcp invited in All patients Care plan
invited in completion
COT
tracked and
code on
incentive
problem list
payment at
end of year

12. 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

13. COT Patients Receiving Urine Drug Screening
in 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)

14. COT Patients Receiving Average Daily Dose
> 120 mg MED (%): Group Health IGP vs. Network
25%
20% Network
15%
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
1
2
Guideline Guideline
Planning Implementation
Group Health Solutions for Transforming Care | Chronic Opioid Therapy

15. 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

16. 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

17. Essential Elements of COT Guideline
Implementation
Questions?