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This document summarizes the challenges of managing chronic pain in primary care settings and describes strategies to address those challenges. It finds that 20% of patients seen in a large community health system have chronic pain. These patients tend to be older, female, have more visits and mental health diagnoses, receive more opioids and referrals. The system introduced a stepped care model for pain management and used data analytics to understand pain management patterns. It also implemented the Project ECHO model, which uses videoconferencing to connect primary care providers with pain specialists to discuss complex pain cases. Preliminary results found this intervention improved provider knowledge and confidence in pain management.

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Clinical  Track:   Taking  on  Prescrip2on  Drug  Abuse   Across  the  Care  Con2nuum   Daren  Anderson,  MD   VP/Chief  Quality  Officer,  Community  Health  Center,  Inc.   Director,  Weitzman  Quality  Ins?tute   Associate  Professor  of  Medicine,  Quinnipiac  University     Melissa  Lamer,  PharmD,  BCPP     Director  of  Behavioral  Health  Pharmacy  Solu?ons   Magellan  Rx  Management  
Disclosures   •  Daren  Anderson  has  disclosed  no  relevant,   real  or  apparent  personal  or  professional   financial  rela6onships.   •  Melissa  Lamer  PharmD,  BCPP  wishes  to   disclose  she  is  an  employee  and  is  paid  a   salary  form  Magellan.  She  will  present  this   content  in  a  fair  and  balanced  manner.  
Learning  Objec6ves   1.  Iden6fy  the  specific  provider  educa6on   interven6ons  that  can  play  a  role  in  decreasing   prescrip6on  drug  abuse.     2.  Evaluate  how  the  applica6on  of  advanced  health   care  data  analy6cs  enables  the  iden6fica6on  and   targe6ng  of  inappropriate  behaviors  related  to   prescrip6on  drug  abuse.     3.  Analyze  preliminary  results  of  CHCI’s  randomized   trial  of  ECHO  Pain  Management,  discussing  the   impact  of  the  interven6on  on  provider,  pa6ent  and   administra6ve  outcomes.  
Strategies for Improving the Quality and Safety of Chronic Pain Management in Primary Care Daren Anderson, MD VP/Chief Quality Officer Community Health Center, Inc. Director, Weitzman Quality Institute Associate Professor of Medicine Quinnipiac University
Goals of Presentation •  To discuss current challenges in managing pain in primary care, particularly in medically underserved populations •  To describe the Stepped Care Model for Pain Management •  To describe primary care system interventions to improve quality of chronic pain management •  To explore methods to measure quality in chronic pain management •  To understand the Project ECHO model and how it can be used to improve the quality and safety of pain management in primary care
Community Health Center, Inc. Our Vision: Since 1972, Community Health Center, Inc. has been building a world-class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes and building healthy communities. CHC Inc. Profile: "   Founding Year - 1972 "   Primary Care Hubs–13 "   No. of Service Locations-218 "   Licensed SBHC locations– 24 "   Organization Staff – 500 "   140,000 patients "   400,000 visits "   Medical, dental, behavioral health
Weitzman Quality Institute•  Established in 2013 by the Community Health Center, Inc. •  Named in honor of Gerald Weitzman, a community pharmacist, one of CHC’s founders, and a long-time board member •  Research Institute based in a large FQHC •  Promotes innovations in quality improvement science as well as critical investigation in primary care and systems redesign
Academic Partners
•  Chronic pain affects approximately 100 million Americans1 •  Annual cost of $635 billion in medical treatment and lost productivity1 •  Majority of patients with pain seek care in a primary care setting2 •  Primary Care Providers express low knowledge and confidence in pain management and receive little pain management education3 •  Opioids are heavily relied on for pain management in primary care4 •  Prescription opioid overdose is a major and growing public health concern5 Background
•  Increasing demand to identify and manage painful conditions •  Increasing rates of opioid abuse and diversion •  Limited training in pain management •  Limited access to specialists •  Limited access to pain management specialty centers The Challenge for the PCP
CHC’s Stepped Care Model for Pain Management STEP   1   STEP   2   STEP   3   Primary Care Medical Home Routine screening for presence & intensity of pain Comprehensive pain assessment and follow up Documentation of function status and goals Management of common painful conditions Primary care team-care: MA, RN Care managers Systematic Opioid Risk Assessment/Refill/Monitoring Complexity Treatment Refractory Comorbidities RISK   Tertiary Interdisciplinary Pain Centers Referrals to community partners
Chronic Pain in Primary Care: Baseline Data from a large health system Chart ReviewData warehouse Provider/Staff surveys Data sources:
Source: J Am Med Inform Assoc. 2013 Dec; 20 (e2):e275-80. doi: 10.1136/ amiajnl-2013-001856. Epub 2013 Jul 31.
EHR Data: Chronic Pain Algorithm •  All patients age 18 and older with at least one medical visit in the past year who met any of the criteria below: •  A visit with an ICD9 code specific for chronic pain (e.g. “chronic pain syndrome” 338.2X, 338.4) •  Two or more visits separated by 30 days or more with an ICD9 code for a painful condition •  Receipt of at least 90 days of opioid medication other than buprenorphine in one year •  One visit with an ICD9 code for a painful condition AND two or more pain scores greater than or equal to 4. Data warehous e Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.
Demographics   Pa2ents  with  Chronic   Pain  (20%  of  all   pa2ents)   Pa2ents  without     Chronic  Pain  (80%)   p-­‐Value  Two-­‐ Tail    Total Patients* 8152   %   32487   %   Sex   Male   2995   37%   13215   41%   <0.0002   Female   5156   63%   19266   59%   <0.0002   Age   Age  18-­‐29   856   11%   8679   27%   <0.0002   Age  30-­‐39   1483   18%   7163   22%   <0.0002   Age  40-­‐49   2319   28%   6758   21%   <0.0002   Age  50-­‐59   2243   28%   5644   17%   <0.0002   Age  60-­‐69   925   11%   2969   9%   <0.0002   Age  69+   326   4%   1274   4%   0.7482   Race   Caucasian   3624   44%   12433   38%   <0.0002   Black   1005   12%   4147   13%   0.2891   Hispanic   3138   38%   12866   40%   0.0667   Visits   Avg  Visits/Yr   6.54   2.72   <0.0002   Opioids   Any  Opioid  Rx   3280   40%   1870   6%   <0.0002   90+  Days  Opioid   1297   16%   0   0%   <0.0002   Mental  Hlth   Pts  w/  a  CHCI  BH  Visit   1991   24%   3329   10%   <0.0002   Pain  Referrals  Physical  Therapy   1655   20%   953   3%   <0.0002   Pain  Management   573   7%   94   0%   <0.0002   Physical  Med  and  Rehab   700   9%   346   1%   <0.0002   Orthopedic  Surgery   1347   17%   677   2%   <0.0002   Rheumatology   275   3%   159   0%   <0.0002   Insurance   Medicaid   5425   67%   15315   47%   <0.0002   Medicare   1302   16%   3094   10%   <0.0002   Uninsured   780   10%   7814   24%   <0.0002   Data warehous e •  >female •  Older •  More visits •  More opioids •  More BH Dx •  More referrals •  Less uninsured * All adult patients in 2011 with at least one medical visit Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.
Data warehous e 100% 37% 9% 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 All CHCI Chronic Pain Cohort Chronic Opioid Subset Total Primary Care Medical Visits, 2012 . Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 3% 3% 4% 4% 4% 5% 5% 5% 5% 5% 5% 5% 6% 7% 7% 7% 8% 10% 11% 11% 11% 11% 0% 2% 4% 6% 8% 10% 12% Dudley MD, Robert-PD Farb MD, Alan-PD Kennedy APRN, Michelle Moemeka MD, Angela Seagriff APRN, Nicole Ayubcha MD, Soussan- FP Mohammadu MD, Fusaini Bravo MD, Teresa-FP Kobel PA, Cela Martin MD, Monique Quarles APRN, Kristie Wessling MD, Kathleen DeMarco APRN, Rachel-FP Weir MD, Lori Knoeckel APRN, Sarah Weischedel MD, Anne-Katrin Dresden APRN, Debra Gellrich MD, Gabriella-FP Doerwaldt MD, Hartmut-FP Wilson APRN, Laura Carden APRN, Pamela LOCUM Lau MD, Wai Lang- IM Barrow MD, Alvin Butler MD, Danielle-FP Lecce MD, Carl-FP Swan APRN, Amanda Kamat MD, Leena Manning DO, Lynne Rivera Godreau MD, Ivelisse--FP Patel DO, Dipak--FP Decker APRN, Patricia-FP Percent of Panel Prescribed 90 Days of Opioids by PCP Provider Names Data warehous e Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
Chart Review Results Baseline     2011   Chronic  Opioid   Cohort     Presence  of  pain  documented     65.3%   Provider's  func6onal  assessment  documenta6on   6.7%   Provider's  cause/source  documenta6on   64.0%   Diagnos6c    test  reviewed   4.7%   Pain  medica6on  ordered   100%     Pain  consult   10.7%   Documenta6on  of  treatment  plan   96%     Pa6ent  educa6on  provided   16.0%     Diagnos6c  Imaging  ordered   22.0%   Pain  reassessed   20.0%   Chart review .
Pain Survey Questions Item Statement   Mean   Baseline 2011   Skilled chronic pain management is a high priority for me.   3.74*   My management of chronic pain is influenced by experience with addicted patients.   1.15   My management of chronic pain is influenced by fear of contributing to dependence.   1.36   I have adequate time to manage most patients with chronic pain.   1.81   Fear of narcotic regulatory agencies/administration influences my decisions regarding chronic pain management.   2.04   Analgesic side effects hinder my efforts to treat patients with chronic pain.   2.17   Patients I treat become addicted to opioids.   2.55   I use an opioid agreement with my patients.   4.45   I use a pain assessment or monitoring tool.   3.77   I am confident in my ability to manage chronic pain.   2.77   I am satisfied with the quality of resources available to help me manage patients with chronic pain.   1.53   Provider/ Staff surveys Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
152.49 138 178 150 0.00 50.00 100.00 150.00 200.00 250.00 CHCI  Providers  (n=47)   Davis  et  al.  Valida6on  Cohort:   Internists  (n=84)   Davis  et  al.  Valida6on  Cohort:   Pain  Experts  (n=22)   Davis  et  al.  Valida6on  Cohort:   Academic  Physicians  (n=27)   Avg CHCI KP50 Baseline Score Comparison Provider/ Staff surveys . Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
Key Findings •  Chronic pain is extremely common (up to 37% of visits) •  Patients using opioids have >10 visits per year •  Documentation of pain care is poor •  Functional assessments are rarely documented •  Pain care knowledge is low •  Providers have low confidence in their pain management skills •  Providers feel that pain care is an important skill for them . Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
Problem   Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
Pain CME Options •  Conferences •  REMS training
CHCI Biannual Pain Management CME •  All PCP’s •  2 hours, biannually •  Virtual Lecture Hall® •  Group format: PCP, RN, BHP, PharmD
Action Plan Problem   Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
Chronic Pain Follow-Up Templates •  Click the HPI link and select the category Chronic Pain Follow Up to document the necessary information:
Pain Follow Up Assessment Forms
Pain Follow Up Assessment Forms
Pain Follow Up Assessment Forms
Pain Follow Up Assessment Forms
Action Plan Problem   Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
CHCI standard policy for chronic opioid therapy: •  All patients receiving COT* must have: –  Signed opioid agreement scanned and saved in the EHR –  Utox at least once every 6 months –  Follow up visit every 3 months *COT defined as receipt of 90 days or more of prescription opioid analgesic medication
Opioid Management Dashboard Provider Names
Opioid Review Committee •  Committee with oversight over opioid prescribing –  Formulary –  High dose opioid oversight –  Can require review before Rx –  Can review outliers –  Establish internal guidelines
Action Plan Problem   Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
•  University of Bridgeport •  Six CHC sites: 4 Chiropractors + students •  1-2 days per week •  Internal referral in ECW •  ECW custom HPI folders •  Collaborative management for pain/ musculoskeletal problems Results •  Number of Unique Patients Seen – 77 •  98.7% completely satisfied •  98% stated their condition was improved after treatment CHC-University of Bridgeport Integrated Chiropractic Care
Expanded Access to Chiropractic
Photo of acupuncture
Action Plan Problem   Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
Behavioral Health Integration for Pain Management •  Co-location of Behavioral health and primary care •  Warm handoffs •  Group therapy •  BH participation in Project ECHO
COGNITIVE-BEHAVIORAL THERAPY (CBT) •  GOAL: Move person from passivity, stress- reactivity and hopelessness to hopefulness, resourcefulness, and action
METHODS FOR IMPROVED COPING WITH PAIN –  Cognitive Restructuring –  Acceptance and Adaptation –  Reframing –  Distraction –  Repetitive movement –  Relaxation –  Imagery –  Motivation –  Planning and Pacing Daily Activities –  Goal Setting –  Medication Management
Action Plan Problem   Goal   Interven2on   Low  pain  knowledge/self  efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain  and   func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of  pain   care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference  form   (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid  monitoring/ high  varia6on  in  prescribing   paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for  opioid   agreements   •  Standard  policy/procedure   for  utox   •  Opioid  dashboard   •  Opioid  review  commihee   Limited  behavioral  health  co-­‐ management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on  of   chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to  specialty   advice     Project  ECHO  
NEJM 6/2011 •  Prospective cohort study comparing HCV Rx at UNM with Rx by primary care clinicians at 21 ECHO sites in rural areas and prisons in NM. •  407 patients with no previous treatment •  Primary endpoint was SVR. •  57.5% at UNM and 58.2% at ECHO sites achieved SVR. •  Serious adverse events occurred in 13.7% at UNM and 6.9% at ECHO sites.
Project ECHO University of New Mexico “The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.” Dr. Sanjeev Arora, University of New Mexico
Technological Infrastructure •  Video conferencing system for ECHO team •  Mobile teleconferencing platform (Vidyo©) •  Webcam/iPad/ smart phone for end-users •  EHR 60
•  2 hour weekly sessions •  Case submission form •  Expert specialty team •  ECHO Project Coordinator •  15-20 min didactic presentation •  Case presentations (2-10) •  Primary care providers join from anywhere Structural Features
Unique Features of CHCI Project ECHO •  Google Sites project page •  ECHO blog •  Twitter for questions/ comments from participants and observers •  Integration of behavioral health and primary care through co-presentation •  National participation
Project ECHO Pain Management
Project ECHO Buprenorphine Primary Care Marwan Haddad, MD, MPH Psychiatry Richard Feuer, MD Behavioral Health Cliff Briggie Psy.D, LADC, LCSW Nursing Jonathan Arocho, LPN Medical Assistance Omar Perez 65
Bup Case Presentation Form 66 Page 1 Page 2
Provider Comments •  The sessions are “fascinating”, with “great didactic” presentations and a “collegial feel” that provides “the opportunity to…inspect my own clinical reflexes”. -- ECHO Medical Provider •  Sessions are “informative and feature helpful information on the types of patients I see in everyday practice”. -- ECHO Medical Provider •  “I have learned a lot and want to find a way to share this knowledge with the other providers at my site.” -- ECHO Medical Provider
Connecticut Community Health Center, Inc. 13 primary care health centers across the state Over 130,000 medically underserved patients Arizona El Rio Community Health Center 16 practice locations in Tucson, AZ 73,000 patients 280,000 visits per year Delaware Westside Community Health Center 9 practices in Delaware 23,000 patients Affiliation with University of Delaware California Open Door Community Health Center 2 primary care sites Northern CA region Coming soon: 10 additional sites from Maine 7 additional sites from New Jersey
Study Findings
Improvements in Opioid Agreements and uTox Screening
2.7 2.7 2.7 2.7 5.4 14.6 14.6 2.7 13.5 5.4 5.4 10.8 10.8 20.6 20.6 18.9 83.8 91.9 91.9 86.5 83.8 64.7 64.7 78.4 0 20 40 60 80 100 spent enough time with me thoroughly explains the treatment(s) I receive treats me respectfully listens to my concerns answered all my questions advises me on ways to avoid future problems gives me detailed instructions regarding my home program Overall, I am completely satisfied with the services I receive Percent of Patients My chiropractor: Pt satisfaction with chiropractic services assessment tool Disagree Agree
92.1% 50.0% 21.1% 18.4% 18.4% 13.2% 7.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Back Neck Leg Arm Hand/ Wrist Other Foot/ Ankle PercentageofPatients CHCI Chiropractic Services General Area of Treatment
Decrease in average # of visits for patients with chronic pain
Decrease in severe pain
Chronic Pain Cohort Prescription of any opioid medication in patients with and without chronic pain
Decrease in Chronic Opioid Prescribing Prescription of 90+ days of any opioid medication in patients with and without chronic pain
Chronic Pain Cohort
Chronic Pain Cohort
Next Steps •  Combine system redesign work with Project ECHO –  QI Training –  IHI “Breakthrough Series Collaborative” •  Population level data •  Complete controlled trial of Project ECHO •  Expand access to ECHO
Summary of Pain Management Best Practices •  Required pain CME for all PCPs •  Structured Opioid Risk Assessment •  Pain management follow up and monitoring frequency based on risk assessment •  Routine review of state prescription drug monitoring website •  Standard opioid agreement for all patients receiving chronic opioids •  uTox q6 months minimum •  Multimodal care, onsite when possible: –  Co-management with Behavioral health –  Chiropractic –  Acupuncture –  Mindfulness
Conclusions •  Chronic pain is highly prevalent in primary care •  Knowledge and adherence to guidelines for management of pain is variable •  Health IT can be used to identify patients with chronic pain •  Use of an opioid management dashboard can improve safety and monitoring •  A multifaceted QI initiative aimed at improving pain management in primary care is improving quality at CHC
Comments or Questions? _________________________   Daren  Anderson,  MD     VP/  Chief  Quality  Officer   Community  Health  Center,  Inc.,   Director   Weitzman  Quality  Ins?tute   Daren@chc1.com   860.347.6971  ext.3740   _________________________  
References References: 1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academy Press, 2011. 2. Breuer B, Cruciani R, Portenoy R. Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: A National Survey. South Med J 2010;103:738-747. 3. Ponte C, Johnson-Tribino J. Attitudes and Knowledge About Pain: An Assessment of West Virginia Family Physicians. Fam Med 2005;37:477-480 4. Okie, S. 2010. "A Flood of Opioids, A Rising Tide of Deaths." The New England journal of medicine 363 (21): 1981-5. 5. Centers for Disease Control and Prevention. 2010. Emergency Department Visits Involving Nonmedical Use of Selected Prescription Drugs - United States, 2004–2008. Washington, DC: DHHS. Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
Taking  on  Prescrip6on  Drug  Abuse   Across  the  Care  Con6nuum   Melissa  Lamer,  PharmD,  BCPP     Director  of  Behavioral  Health  Pharmacy  Solu?ons   Magellan  Rx  Management  
Financial  Disclosures   •  Melissa  Lamer  PharmD,  BCPP  wishes  to   disclose  she  is  an  employee  and  is  paid  a   salary  form  Magellan.  She  will  present  this   content  in  a  fair  and  balanced  manner.  
Learning  Objec6ves   •  Iden6fy  the  specific  provider  educa6on  interven6ons   that  can  play  a  role  in  decreasing  prescrip6on  drug   abuse.   •  Evaluate  how  the  applica6on  of  advanced  health  care   data  analy6cs  enables  the  iden6fica6on  and   targe6ng  of  inappropriate  behaviors  related  to   prescrip6on  drug  abuse.  
Startling  Trends  in  Substance  Use  and   Abuse   Prescrip2on  drug  abuse  is  the   fastest  growing  drug  problem   •  From  2004-­‐2011  emergency  room  visits   due  to  the  use  of  non  medical  use  of   opioids  has  increased  183%1   •  Over  54%  of  pa6ents  were  sent  home;   only  2.4%  who  were  referred  to  detox  or   treatment  programs2   11th  consecu2ve  year  of   increasing  drug  overdose  deaths2   •  Higher  morphine  equivalent  dosing   greatly  increases  risk   •  Many  deaths  involve  combined  mental   health  medica6ons  use  such  as   benzodiazepines,  an6depressants,  and   an6psycho6cs2   1    Drug  Abuse  Warning  Network,  2011.   2  Pharmaceu?cal  Overdose  Deaths,  United  States,  2010.”  Journal  of  the  American  Medical  Associa?on.  2012.  
Medicaid  is  One  of  the  Most  Vulnerable   Popula6ons  for  Abuse   •  Medicaid  recipients  are  prescribed  pain  killers  at  twice  the  rate  of  non-­‐Medicaid   recipients  and  are  at  six  6mes  the  risk  of  overdose1   •  Washington  study  iden6fied  that  45%  of  people  who  died  were  enrolled  in  Medicaid2   •  A  combina6on  of  4  variables  have  been  found  to  predict  increase  risk  for  opioid   dependence3   -­‐  Age   -­‐  Depression   -­‐  Psychotropic  Medica6ons   -­‐  Pain  Impairment   •  Medicaid  is  the  largest  payor  for  mental  health  services4   -­‐  This  will  con6nue  to  be  of  greater  importance  with  Medicaid  Expansion   1  CDC,  2011        2  Interagency  Guideline  on  Opioid  Dosing  for  Chronic  Non-­‐Cancer  Pain   3Pain  Physician,  2012  4CMS  Bulle?n,  2012  hXp://medicaid.gov/Federal-­‐Policy-­‐Guidance/Downloads/CIB-­‐12-­‐03-­‐12.pdf  
Tradi6onal  Management  Methods   •  Controlled  substance  monitoring  to   increase  awareness  of  pa6ent   u6liza6on  paherns   •  Leverages  a  pharmacist  driven   educa6onal  campaign  and  requiring   provider  registra6on  and  checking  for   certain  pa6ents   •  6  months  aper  implementa6on   -  Registra6on  up  from  4.4%  to   86.5%   -  Database  access  up  from  15.8%  to   58.9%   -  Last  quarter  247  unique  provider   ran  a  query  (45.2%)   •  Audits  iden6fy  pharmacies  and  providers   dispensing/prescribing  higher  quan66es  of   controlled  substances  than  peers   •  Medica6on  use  evalua6ons  iden6fy  use  of   medica6ons  with  addi6ve  effects   -­‐  Narco6cs  +  muscle  relaxants  +   psychotropic  medica6ons   •  Lock-­‐in  high  risk  individuals  to  one   prescriber  or  pharmacy  for  all  controlled   substances     -­‐  Prescrip6ons/pa6ent/month  dropped   15%  during  the  lock  and  38%  post-­‐lock   -­‐  Average  #  of  drugs/pa6ent  dropped   15%  during  and  36%  post-­‐lock   Prescrip2on  Drug  Monitoring   Program  Ini2a2ve  (PDMP)   Retrospec2ve  Medica2on   Reviews  
Ques6on  
While  Tradi6onal  Methods  Are  Needed   They  Are  Not  Enough   •  Despite  the  release  many   community  providers  are  not   accessing  these  important   databases   •  There  is  addi6onal   administra6ve  burden  on  the   providers  by  requiring  them   to  go  online,  register  and   frequently  revisit  the  site   •  Open  it  does  not  account  for   prescrip6on  in  other  states  
To  Best  Manage  Opioid  Abuse  We  Need  a   Smarter  Solu6on   •  Maximizes  knowledge  by  leveraging   evidence-­‐based  guidelines  to  create   ac6onable  recommenda6ons   •  Works  with  mul6disciplinary  teams   and  industry  leaders  to  iden6fy  high   profile  targets   •  Engages  providers  through  mul6-­‐ modal  communica6ons  techniques   including    face-­‐to-­‐face,  telephonic,   virtual  and  email   •  Push  data  out  to  providers  instead  of   pulling  them  in  to  get  it  saving  6me,   resources  and  increasing  ease  
Receipt  of     Medical,  Behavioral,  &   Rx  Data   Evidence-­‐Based   Algorithms   Clinical  Outreach   Outcomes   • Medical,   behavioral,  lab,   and/or  pharmacy   data  received  by   our  data  warehouse   • Extract  created,   data  scrubbed   • Leverages  expert   clinicians  to  create   ac6onable   informa6on   • Algorithms  iden6fy   non-­‐compliant   prescribing   paherns  and   stra6fy  others   • PCP  &  BH   Providers   - Mul6-­‐channel   consulta6on   - Educa6onal   materials   • Quality  indicator   monitoring   • Impact  analysis   • Ac6vity  tracking   Advanced  proprietary  clinical  algorithms  iden6fy  prescribing  paherns  that   are  inconsistent  with  evidence-­‐based  guidelines  resul6ng  in   personalized  provider  consulta6ons   Whole  Health  Rx SM   Integrated  Solu6on  for  Whole  Member  Health  Management  
To  See  the  Whole  Pa6ent,  Pharmacy  and   Medical  Claims  Systems  Must  be  Integrated   •  Mul6ple  opioid   prescrip6ons  from  mul6ple   doctors  and  pharmacies   •  High  dose  medica6ons   •  Over  use  of  short  ac6ng   analgesics  without  long-­‐ ac6ng  medica6ons   •  Early  refills   •  Hospital  admissions  for   overdoses  admissions   •  Diagnosis  claims  to   iden6fy  substance  abuse   •  Methadone  opioid   maintenance  claims  are   not  in  pharmacy  data   •  Cancer  diagnosis   requiring  higher  dosing   Pharmacy  Data   Medical  Data   Whole  Pa2ent   Management  
•  Suboxone®  u6liza6on  in   combina6on  with  other  opioid   medica6ons   •  High  cumula6ve  diazepam   equivalent  daily  doses   •  Concomitant  benzodiazepine  and   opioid  therapy   •  High  cumula6ve  morphine   equivalent  daily  dosing   •  Opioids  from  mul6ple   prescribers  and  pharmacies   •  Methadone  and  concomitant   medica6on    monitoring     •  Cumula6ve  early  refills   Repor2ng  and  Profiling   Early  Pa6ent  Iden6fica6on  and  Provider   Outreach  is  Cri6cal  to  Improving  Outcomes  
Cumula6ve  High  Risk  Report   Combining  mul6ple  ini6a6ves  is  key  to  addressing   poten6al  dangerous  behavior    

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Cl 1 anderson lamer

  • 1.
    Clinical  Track:   Taking  on  Prescrip2on  Drug  Abuse   Across  the  Care  Con2nuum   Daren  Anderson,  MD   VP/Chief  Quality  Officer,  Community  Health  Center,  Inc.   Director,  Weitzman  Quality  Ins?tute   Associate  Professor  of  Medicine,  Quinnipiac  University     Melissa  Lamer,  PharmD,  BCPP     Director  of  Behavioral  Health  Pharmacy  Solu?ons   Magellan  Rx  Management  
  • 2.
    Disclosures   •  Daren  Anderson  has  disclosed  no  relevant,   real  or  apparent  personal  or  professional   financial  rela6onships.   •  Melissa  Lamer  PharmD,  BCPP  wishes  to   disclose  she  is  an  employee  and  is  paid  a   salary  form  Magellan.  She  will  present  this   content  in  a  fair  and  balanced  manner.  
  • 3.
    Learning  Objec6ves   1. Iden6fy  the  specific  provider  educa6on   interven6ons  that  can  play  a  role  in  decreasing   prescrip6on  drug  abuse.     2.  Evaluate  how  the  applica6on  of  advanced  health   care  data  analy6cs  enables  the  iden6fica6on  and   targe6ng  of  inappropriate  behaviors  related  to   prescrip6on  drug  abuse.     3.  Analyze  preliminary  results  of  CHCI’s  randomized   trial  of  ECHO  Pain  Management,  discussing  the   impact  of  the  interven6on  on  provider,  pa6ent  and   administra6ve  outcomes.  
  • 4.
    Strategies for Improvingthe Quality and Safety of Chronic Pain Management in Primary Care Daren Anderson, MD VP/Chief Quality Officer Community Health Center, Inc. Director, Weitzman Quality Institute Associate Professor of Medicine Quinnipiac University
  • 5.
    Goals of Presentation • To discuss current challenges in managing pain in primary care, particularly in medically underserved populations •  To describe the Stepped Care Model for Pain Management •  To describe primary care system interventions to improve quality of chronic pain management •  To explore methods to measure quality in chronic pain management •  To understand the Project ECHO model and how it can be used to improve the quality and safety of pain management in primary care
  • 6.
    Community Health Center,Inc. Our Vision: Since 1972, Community Health Center, Inc. has been building a world-class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes and building healthy communities. CHC Inc. Profile: "   Founding Year - 1972 "   Primary Care Hubs–13 "   No. of Service Locations-218 "   Licensed SBHC locations– 24 "   Organization Staff – 500 "   140,000 patients "   400,000 visits "   Medical, dental, behavioral health
  • 7.
    Weitzman Quality Institute•  Establishedin 2013 by the Community Health Center, Inc. •  Named in honor of Gerald Weitzman, a community pharmacist, one of CHC’s founders, and a long-time board member •  Research Institute based in a large FQHC •  Promotes innovations in quality improvement science as well as critical investigation in primary care and systems redesign
  • 8.
  • 9.
    •  Chronic painaffects approximately 100 million Americans1 •  Annual cost of $635 billion in medical treatment and lost productivity1 •  Majority of patients with pain seek care in a primary care setting2 •  Primary Care Providers express low knowledge and confidence in pain management and receive little pain management education3 •  Opioids are heavily relied on for pain management in primary care4 •  Prescription opioid overdose is a major and growing public health concern5 Background
  • 17.
    •  Increasing demandto identify and manage painful conditions •  Increasing rates of opioid abuse and diversion •  Limited training in pain management •  Limited access to specialists •  Limited access to pain management specialty centers The Challenge for the PCP
  • 18.
    CHC’s Stepped CareModel for Pain Management STEP   1   STEP   2   STEP   3   Primary Care Medical Home Routine screening for presence & intensity of pain Comprehensive pain assessment and follow up Documentation of function status and goals Management of common painful conditions Primary care team-care: MA, RN Care managers Systematic Opioid Risk Assessment/Refill/Monitoring Complexity Treatment Refractory Comorbidities RISK   Tertiary Interdisciplinary Pain Centers Referrals to community partners
  • 19.
    Chronic Pain inPrimary Care: Baseline Data from a large health system Chart ReviewData warehouse Provider/Staff surveys Data sources:
  • 20.
    Source: J AmMed Inform Assoc. 2013 Dec; 20 (e2):e275-80. doi: 10.1136/ amiajnl-2013-001856. Epub 2013 Jul 31.
  • 21.
    EHR Data: Chronic PainAlgorithm •  All patients age 18 and older with at least one medical visit in the past year who met any of the criteria below: •  A visit with an ICD9 code specific for chronic pain (e.g. “chronic pain syndrome” 338.2X, 338.4) •  Two or more visits separated by 30 days or more with an ICD9 code for a painful condition •  Receipt of at least 90 days of opioid medication other than buprenorphine in one year •  One visit with an ICD9 code for a painful condition AND two or more pain scores greater than or equal to 4. Data warehous e Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.
  • 22.
    Demographics   Pa2ents  with  Chronic   Pain  (20%  of  all   pa2ents)   Pa2ents  without     Chronic  Pain  (80%)   p-­‐Value  Two-­‐ Tail    Total Patients* 8152   %   32487   %   Sex   Male   2995   37%   13215   41%   <0.0002   Female   5156   63%   19266   59%   <0.0002   Age   Age  18-­‐29   856   11%   8679   27%   <0.0002   Age  30-­‐39   1483   18%   7163   22%   <0.0002   Age  40-­‐49   2319   28%   6758   21%   <0.0002   Age  50-­‐59   2243   28%   5644   17%   <0.0002   Age  60-­‐69   925   11%   2969   9%   <0.0002   Age  69+   326   4%   1274   4%   0.7482   Race   Caucasian   3624   44%   12433   38%   <0.0002   Black   1005   12%   4147   13%   0.2891   Hispanic   3138   38%   12866   40%   0.0667   Visits   Avg  Visits/Yr   6.54   2.72   <0.0002   Opioids   Any  Opioid  Rx   3280   40%   1870   6%   <0.0002   90+  Days  Opioid   1297   16%   0   0%   <0.0002   Mental  Hlth   Pts  w/  a  CHCI  BH  Visit   1991   24%   3329   10%   <0.0002   Pain  Referrals  Physical  Therapy   1655   20%   953   3%   <0.0002   Pain  Management   573   7%   94   0%   <0.0002   Physical  Med  and  Rehab   700   9%   346   1%   <0.0002   Orthopedic  Surgery   1347   17%   677   2%   <0.0002   Rheumatology   275   3%   159   0%   <0.0002   Insurance   Medicaid   5425   67%   15315   47%   <0.0002   Medicare   1302   16%   3094   10%   <0.0002   Uninsured   780   10%   7814   24%   <0.0002   Data warehous e •  >female •  Older •  More visits •  More opioids •  More BH Dx •  More referrals •  Less uninsured * All adult patients in 2011 with at least one medical visit Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.
  • 23.
    Data warehous e 100% 37% 9% 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 All CHCI ChronicPain Cohort Chronic Opioid Subset Total Primary Care Medical Visits, 2012 . Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
  • 24.
    0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 3% 3% 4% 4% 4% 5% 5% 5% 5% 5% 5% 5% 6% 7% 7% 7% 8% 10% 11% 11% 11% 11% 0% 2% 4%6% 8% 10% 12% Dudley MD, Robert-PD Farb MD, Alan-PD Kennedy APRN, Michelle Moemeka MD, Angela Seagriff APRN, Nicole Ayubcha MD, Soussan- FP Mohammadu MD, Fusaini Bravo MD, Teresa-FP Kobel PA, Cela Martin MD, Monique Quarles APRN, Kristie Wessling MD, Kathleen DeMarco APRN, Rachel-FP Weir MD, Lori Knoeckel APRN, Sarah Weischedel MD, Anne-Katrin Dresden APRN, Debra Gellrich MD, Gabriella-FP Doerwaldt MD, Hartmut-FP Wilson APRN, Laura Carden APRN, Pamela LOCUM Lau MD, Wai Lang- IM Barrow MD, Alvin Butler MD, Danielle-FP Lecce MD, Carl-FP Swan APRN, Amanda Kamat MD, Leena Manning DO, Lynne Rivera Godreau MD, Ivelisse--FP Patel DO, Dipak--FP Decker APRN, Patricia-FP Percent of Panel Prescribed 90 Days of Opioids by PCP Provider Names Data warehous e Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
  • 25.
    Chart Review Results Baseline     2011   Chronic  Opioid   Cohort     Presence  of  pain  documented     65.3%   Provider's  func6onal  assessment  documenta6on   6.7%   Provider's  cause/source  documenta6on   64.0%   Diagnos6c    test  reviewed   4.7%   Pain  medica6on  ordered   100%     Pain  consult   10.7%   Documenta6on  of  treatment  plan   96%     Pa6ent  educa6on  provided   16.0%     Diagnos6c  Imaging  ordered   22.0%   Pain  reassessed   20.0%   Chart review .
  • 26.
    Pain Survey Questions ItemStatement   Mean   Baseline 2011   Skilled chronic pain management is a high priority for me.   3.74*   My management of chronic pain is influenced by experience with addicted patients.   1.15   My management of chronic pain is influenced by fear of contributing to dependence.   1.36   I have adequate time to manage most patients with chronic pain.   1.81   Fear of narcotic regulatory agencies/administration influences my decisions regarding chronic pain management.   2.04   Analgesic side effects hinder my efforts to treat patients with chronic pain.   2.17   Patients I treat become addicted to opioids.   2.55   I use an opioid agreement with my patients.   4.45   I use a pain assessment or monitoring tool.   3.77   I am confident in my ability to manage chronic pain.   2.77   I am satisfied with the quality of resources available to help me manage patients with chronic pain.   1.53   Provider/ Staff surveys Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
  • 27.
    152.49 138 178 150 0.00 50.00 100.00 150.00 200.00 250.00 CHCI  Providers  (n=47)   Davis  et  al.  Valida6on  Cohort:   Internists  (n=84)   Davis  et  al.  Valida6on  Cohort:   Pain  Experts  (n=22)   Davis  et  al.  Valida6on  Cohort:   Academic  Physicians  (n=27)   Avg CHCI KP50 Baseline Score Comparison Provider/ Staff surveys . Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
  • 28.
    Key Findings •  Chronicpain is extremely common (up to 37% of visits) •  Patients using opioids have >10 visits per year •  Documentation of pain care is poor •  Functional assessments are rarely documented •  Pain care knowledge is low •  Providers have low confidence in their pain management skills •  Providers feel that pain care is an important skill for them . Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
  • 29.
    Problem   Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
  • 31.
    Pain CME Options • Conferences •  REMS training
  • 32.
    CHCI Biannual PainManagement CME •  All PCP’s •  2 hours, biannually •  Virtual Lecture Hall® •  Group format: PCP, RN, BHP, PharmD
  • 33.
    Action Plan Problem  Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
  • 34.
    Chronic Pain Follow-UpTemplates •  Click the HPI link and select the category Chronic Pain Follow Up to document the necessary information:
  • 36.
    Pain Follow UpAssessment Forms
  • 37.
    Pain Follow UpAssessment Forms
  • 38.
    Pain Follow UpAssessment Forms
  • 39.
    Pain Follow UpAssessment Forms
  • 40.
    Action Plan Problem  Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
  • 41.
    CHCI standard policyfor chronic opioid therapy: •  All patients receiving COT* must have: –  Signed opioid agreement scanned and saved in the EHR –  Utox at least once every 6 months –  Follow up visit every 3 months *COT defined as receipt of 90 days or more of prescription opioid analgesic medication
  • 44.
  • 45.
    Opioid Review Committee • Committee with oversight over opioid prescribing –  Formulary –  High dose opioid oversight –  Can require review before Rx –  Can review outliers –  Establish internal guidelines
  • 46.
    Action Plan Problem  Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
  • 47.
    •  University ofBridgeport •  Six CHC sites: 4 Chiropractors + students •  1-2 days per week •  Internal referral in ECW •  ECW custom HPI folders •  Collaborative management for pain/ musculoskeletal problems Results •  Number of Unique Patients Seen – 77 •  98.7% completely satisfied •  98% stated their condition was improved after treatment CHC-University of Bridgeport Integrated Chiropractic Care
  • 48.
    Expanded Access toChiropractic
  • 50.
  • 51.
    Action Plan Problem  Goal   Interven2on   Low  pain  knowledge/self   efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain   and  func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of   pain  care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference   form  (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid   monitoring/high  varia6on  in   prescribing  paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for   opioid  agreements   •  Standard  policy/ procedure  for  utox   •  Opioid  dashboard   •  Opioid  review   commihee   Limited  behavioral  health   co-­‐management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐ loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on   of  chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to   specialty  advice     Project  ECHO  
  • 52.
    Behavioral Health Integration forPain Management •  Co-location of Behavioral health and primary care •  Warm handoffs •  Group therapy •  BH participation in Project ECHO
  • 53.
    COGNITIVE-BEHAVIORAL THERAPY (CBT) • GOAL: Move person from passivity, stress- reactivity and hopelessness to hopefulness, resourcefulness, and action
  • 54.
    METHODS FOR IMPROVEDCOPING WITH PAIN –  Cognitive Restructuring –  Acceptance and Adaptation –  Reframing –  Distraction –  Repetitive movement –  Relaxation –  Imagery –  Motivation –  Planning and Pacing Daily Activities –  Goal Setting –  Medication Management
  • 55.
    Action Plan Problem  Goal   Interven2on   Low  pain  knowledge/self  efficacy   Increase  knowledge  and  self   efficacy   Online,  team-­‐based  CME   Poor  documenta6on  of  pain  and   func6onal  status   Poor  documenta6on  of  pain   reassessment   Improve  documenta6on  of  pain   care/func6onal  status   •  EHR  templates  for  pain   management  visits   •  SF8  Pain  interference  form   (PROMIS  tool)   •  Opioid  Risk  Tool   •  COMM®  form   Low  rates  of  opioid  monitoring/ high  varia6on  in  prescribing   paherns   Reduce  opioid  prescrip6on   varia6on  and  increase  use  of   opioid  agreements  and  u-­‐tox   monitoring   •  Standard  policy  for  opioid   agreements   •  Standard  policy/procedure   for  utox   •  Opioid  dashboard   •  Opioid  review  commihee   Limited  behavioral  health  co-­‐ management   Increase  BH-­‐Primary  care  co-­‐ management   •  Behavioral  health  co-­‐loca6on   •  Pain  group  therapy   •  Project  ECHO   Low  use  of  CAM   Increase  access  to  CAM   Improved  access/Co-­‐loca6on  of   chiroprac6c,     mindfulness  program   Limited  access  to  specialty   consulta6on   Increase  PCP  access  to  specialty   advice     Project  ECHO  
  • 57.
    NEJM 6/2011 •  Prospectivecohort study comparing HCV Rx at UNM with Rx by primary care clinicians at 21 ECHO sites in rural areas and prisons in NM. •  407 patients with no previous treatment •  Primary endpoint was SVR. •  57.5% at UNM and 58.2% at ECHO sites achieved SVR. •  Serious adverse events occurred in 13.7% at UNM and 6.9% at ECHO sites.
  • 58.
    Project ECHO Universityof New Mexico “The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.” Dr. Sanjeev Arora, University of New Mexico
  • 60.
    Technological Infrastructure •  Video conferencing systemfor ECHO team •  Mobile teleconferencing platform (Vidyo©) •  Webcam/iPad/ smart phone for end-users •  EHR 60
  • 61.
    •  2 hourweekly sessions •  Case submission form •  Expert specialty team •  ECHO Project Coordinator •  15-20 min didactic presentation •  Case presentations (2-10) •  Primary care providers join from anywhere Structural Features
  • 62.
    Unique Features ofCHCI Project ECHO •  Google Sites project page •  ECHO blog •  Twitter for questions/ comments from participants and observers •  Integration of behavioral health and primary care through co-presentation •  National participation
  • 64.
  • 65.
    Project ECHO Buprenorphine Primary Care MarwanHaddad, MD, MPH Psychiatry Richard Feuer, MD Behavioral Health Cliff Briggie Psy.D, LADC, LCSW Nursing Jonathan Arocho, LPN Medical Assistance Omar Perez 65
  • 66.
    Bup Case PresentationForm 66 Page 1 Page 2
  • 67.
    Provider Comments •  Thesessions are “fascinating”, with “great didactic” presentations and a “collegial feel” that provides “the opportunity to…inspect my own clinical reflexes”. -- ECHO Medical Provider •  Sessions are “informative and feature helpful information on the types of patients I see in everyday practice”. -- ECHO Medical Provider •  “I have learned a lot and want to find a way to share this knowledge with the other providers at my site.” -- ECHO Medical Provider
  • 68.
    Connecticut Community Health Center, Inc. 13 primary carehealth centers across the state Over 130,000 medically underserved patients Arizona El Rio Community Health Center 16 practice locations in Tucson, AZ 73,000 patients 280,000 visits per year Delaware Westside Community Health Center 9 practices in Delaware 23,000 patients Affiliation with University of Delaware California Open Door Community Health Center 2 primary care sites Northern CA region Coming soon: 10 additional sites from Maine 7 additional sites from New Jersey
  • 69.
  • 70.
    Improvements in OpioidAgreements and uTox Screening
  • 71.
    2.7 2.7 2.7 2.7 5.4 14.6 14.6 2.7 13.5 5.4 5.4 10.8 10.8 20.6 20.6 18.9 83.8 91.9 91.9 86.5 83.8 64.7 64.7 78.4 0 20 4060 80 100 spent enough time with me thoroughly explains the treatment(s) I receive treats me respectfully listens to my concerns answered all my questions advises me on ways to avoid future problems gives me detailed instructions regarding my home program Overall, I am completely satisfied with the services I receive Percent of Patients My chiropractor: Pt satisfaction with chiropractic services assessment tool Disagree Agree
  • 72.
    92.1% 50.0% 21.1% 18.4% 18.4% 13.2% 7.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Back NeckLeg Arm Hand/ Wrist Other Foot/ Ankle PercentageofPatients CHCI Chiropractic Services General Area of Treatment
  • 73.
    Decrease in average# of visits for patients with chronic pain
  • 74.
  • 75.
    Chronic Pain Cohort Prescriptionof any opioid medication in patients with and without chronic pain
  • 76.
    Decrease in ChronicOpioid Prescribing Prescription of 90+ days of any opioid medication in patients with and without chronic pain
  • 77.
  • 78.
  • 80.
    Next Steps •  Combinesystem redesign work with Project ECHO –  QI Training –  IHI “Breakthrough Series Collaborative” •  Population level data •  Complete controlled trial of Project ECHO •  Expand access to ECHO
  • 81.
    Summary of PainManagement Best Practices •  Required pain CME for all PCPs •  Structured Opioid Risk Assessment •  Pain management follow up and monitoring frequency based on risk assessment •  Routine review of state prescription drug monitoring website •  Standard opioid agreement for all patients receiving chronic opioids •  uTox q6 months minimum •  Multimodal care, onsite when possible: –  Co-management with Behavioral health –  Chiropractic –  Acupuncture –  Mindfulness
  • 82.
    Conclusions •  Chronic painis highly prevalent in primary care •  Knowledge and adherence to guidelines for management of pain is variable •  Health IT can be used to identify patients with chronic pain •  Use of an opioid management dashboard can improve safety and monitoring •  A multifaceted QI initiative aimed at improving pain management in primary care is improving quality at CHC
  • 83.
    Comments or Questions? _________________________   Daren  Anderson,  MD     VP/  Chief  Quality  Officer   Community  Health  Center,  Inc.,   Director   Weitzman  Quality  Ins?tute   Daren@chc1.com   860.347.6971  ext.3740   _________________________  
  • 84.
    References References: 1. Institute ofMedicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academy Press, 2011. 2. Breuer B, Cruciani R, Portenoy R. Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: A National Survey. South Med J 2010;103:738-747. 3. Ponte C, Johnson-Tribino J. Attitudes and Knowledge About Pain: An Assessment of West Virginia Family Physicians. Fam Med 2005;37:477-480 4. Okie, S. 2010. "A Flood of Opioids, A Rising Tide of Deaths." The New England journal of medicine 363 (21): 1981-5. 5. Centers for Disease Control and Prevention. 2010. Emergency Department Visits Involving Nonmedical Use of Selected Prescription Drugs - United States, 2004–2008. Washington, DC: DHHS. Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.
  • 85.
    Taking  on  Prescrip6on  Drug  Abuse   Across  the  Care  Con6nuum   Melissa  Lamer,  PharmD,  BCPP     Director  of  Behavioral  Health  Pharmacy  Solu?ons   Magellan  Rx  Management  
  • 86.
    Financial  Disclosures   • Melissa  Lamer  PharmD,  BCPP  wishes  to   disclose  she  is  an  employee  and  is  paid  a   salary  form  Magellan.  She  will  present  this   content  in  a  fair  and  balanced  manner.  
  • 87.
    Learning  Objec6ves   • Iden6fy  the  specific  provider  educa6on  interven6ons   that  can  play  a  role  in  decreasing  prescrip6on  drug   abuse.   •  Evaluate  how  the  applica6on  of  advanced  health  care   data  analy6cs  enables  the  iden6fica6on  and   targe6ng  of  inappropriate  behaviors  related  to   prescrip6on  drug  abuse.  
  • 88.
    Startling  Trends  in  Substance  Use  and   Abuse   Prescrip2on  drug  abuse  is  the   fastest  growing  drug  problem   •  From  2004-­‐2011  emergency  room  visits   due  to  the  use  of  non  medical  use  of   opioids  has  increased  183%1   •  Over  54%  of  pa6ents  were  sent  home;   only  2.4%  who  were  referred  to  detox  or   treatment  programs2   11th  consecu2ve  year  of   increasing  drug  overdose  deaths2   •  Higher  morphine  equivalent  dosing   greatly  increases  risk   •  Many  deaths  involve  combined  mental   health  medica6ons  use  such  as   benzodiazepines,  an6depressants,  and   an6psycho6cs2   1    Drug  Abuse  Warning  Network,  2011.   2  Pharmaceu?cal  Overdose  Deaths,  United  States,  2010.”  Journal  of  the  American  Medical  Associa?on.  2012.  
  • 89.
    Medicaid  is  One  of  the  Most  Vulnerable   Popula6ons  for  Abuse   •  Medicaid  recipients  are  prescribed  pain  killers  at  twice  the  rate  of  non-­‐Medicaid   recipients  and  are  at  six  6mes  the  risk  of  overdose1   •  Washington  study  iden6fied  that  45%  of  people  who  died  were  enrolled  in  Medicaid2   •  A  combina6on  of  4  variables  have  been  found  to  predict  increase  risk  for  opioid   dependence3   -­‐  Age   -­‐  Depression   -­‐  Psychotropic  Medica6ons   -­‐  Pain  Impairment   •  Medicaid  is  the  largest  payor  for  mental  health  services4   -­‐  This  will  con6nue  to  be  of  greater  importance  with  Medicaid  Expansion   1  CDC,  2011        2  Interagency  Guideline  on  Opioid  Dosing  for  Chronic  Non-­‐Cancer  Pain   3Pain  Physician,  2012  4CMS  Bulle?n,  2012  hXp://medicaid.gov/Federal-­‐Policy-­‐Guidance/Downloads/CIB-­‐12-­‐03-­‐12.pdf  
  • 90.
    Tradi6onal  Management  Methods   •  Controlled  substance  monitoring  to   increase  awareness  of  pa6ent   u6liza6on  paherns   •  Leverages  a  pharmacist  driven   educa6onal  campaign  and  requiring   provider  registra6on  and  checking  for   certain  pa6ents   •  6  months  aper  implementa6on   -  Registra6on  up  from  4.4%  to   86.5%   -  Database  access  up  from  15.8%  to   58.9%   -  Last  quarter  247  unique  provider   ran  a  query  (45.2%)   •  Audits  iden6fy  pharmacies  and  providers   dispensing/prescribing  higher  quan66es  of   controlled  substances  than  peers   •  Medica6on  use  evalua6ons  iden6fy  use  of   medica6ons  with  addi6ve  effects   -­‐  Narco6cs  +  muscle  relaxants  +   psychotropic  medica6ons   •  Lock-­‐in  high  risk  individuals  to  one   prescriber  or  pharmacy  for  all  controlled   substances     -­‐  Prescrip6ons/pa6ent/month  dropped   15%  during  the  lock  and  38%  post-­‐lock   -­‐  Average  #  of  drugs/pa6ent  dropped   15%  during  and  36%  post-­‐lock   Prescrip2on  Drug  Monitoring   Program  Ini2a2ve  (PDMP)   Retrospec2ve  Medica2on   Reviews  
  • 91.
  • 92.
    While  Tradi6onal  Methods  Are  Needed   They  Are  Not  Enough   •  Despite  the  release  many   community  providers  are  not   accessing  these  important   databases   •  There  is  addi6onal   administra6ve  burden  on  the   providers  by  requiring  them   to  go  online,  register  and   frequently  revisit  the  site   •  Open  it  does  not  account  for   prescrip6on  in  other  states  
  • 93.
    To  Best  Manage  Opioid  Abuse  We  Need  a   Smarter  Solu6on   •  Maximizes  knowledge  by  leveraging   evidence-­‐based  guidelines  to  create   ac6onable  recommenda6ons   •  Works  with  mul6disciplinary  teams   and  industry  leaders  to  iden6fy  high   profile  targets   •  Engages  providers  through  mul6-­‐ modal  communica6ons  techniques   including    face-­‐to-­‐face,  telephonic,   virtual  and  email   •  Push  data  out  to  providers  instead  of   pulling  them  in  to  get  it  saving  6me,   resources  and  increasing  ease  
  • 94.
    Receipt  of     Medical,  Behavioral,  &   Rx  Data   Evidence-­‐Based   Algorithms   Clinical  Outreach   Outcomes   • Medical,   behavioral,  lab,   and/or  pharmacy   data  received  by   our  data  warehouse   • Extract  created,   data  scrubbed   • Leverages  expert   clinicians  to  create   ac6onable   informa6on   • Algorithms  iden6fy   non-­‐compliant   prescribing   paherns  and   stra6fy  others   • PCP  &  BH   Providers   - Mul6-­‐channel   consulta6on   - Educa6onal   materials   • Quality  indicator   monitoring   • Impact  analysis   • Ac6vity  tracking   Advanced  proprietary  clinical  algorithms  iden6fy  prescribing  paherns  that   are  inconsistent  with  evidence-­‐based  guidelines  resul6ng  in   personalized  provider  consulta6ons   Whole  Health  Rx SM   Integrated  Solu6on  for  Whole  Member  Health  Management  
  • 95.
    To  See  the  Whole  Pa6ent,  Pharmacy  and   Medical  Claims  Systems  Must  be  Integrated   •  Mul6ple  opioid   prescrip6ons  from  mul6ple   doctors  and  pharmacies   •  High  dose  medica6ons   •  Over  use  of  short  ac6ng   analgesics  without  long-­‐ ac6ng  medica6ons   •  Early  refills   •  Hospital  admissions  for   overdoses  admissions   •  Diagnosis  claims  to   iden6fy  substance  abuse   •  Methadone  opioid   maintenance  claims  are   not  in  pharmacy  data   •  Cancer  diagnosis   requiring  higher  dosing   Pharmacy  Data   Medical  Data   Whole  Pa2ent   Management  
  • 96.
    •  Suboxone®  u6liza6on  in   combina6on  with  other  opioid   medica6ons   •  High  cumula6ve  diazepam   equivalent  daily  doses   •  Concomitant  benzodiazepine  and   opioid  therapy   •  High  cumula6ve  morphine   equivalent  daily  dosing   •  Opioids  from  mul6ple   prescribers  and  pharmacies   •  Methadone  and  concomitant   medica6on    monitoring     •  Cumula6ve  early  refills   Repor2ng  and  Profiling   Early  Pa6ent  Iden6fica6on  and  Provider   Outreach  is  Cri6cal  to  Improving  Outcomes  
  • 97.
    Cumula6ve  High  Risk  Report   Combining  mul6ple  ini6a6ves  is  key  to  addressing   poten6al  dangerous  behavior