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Chronic Pain Management Redesign Program: Palo Alto Medical Foundation Robert J. Romanelli, PhD, MPH; Sandra Wilson, PhD; Deborah Bronstein, MD Project Goals: To improve the management of chronic pain within a healthcare delivery system Project Activities: Healthcare provider education (“boot camps”) Electronic Health Record (EHR) tools Chronic Opioid Therapy (COT) report Opioid Shared Medical Appointment (SMA) This doesn’t work…. Lessons Learned: Resistance to change is significant No one-size-fits-all approach Lean methodology for rapid cycle revisions is appropriate Identify “carrots” and “sticks” to leverage influence A better approach Palo Alto Medical Foundation (PAMF): A part of Sutter Health 1 M patients seen annually Geographically dispersed Target Populations: 450 PAMF providers and 3800 COT Patients - 800 with high MED Educate on new paradigms: Shift culture to focus on treatment goals and functional restoration New Medical Board of California opioid prescribing guidelines New EHR tools for documentation of guideline compliance Provider Reach: 200 providers attended 4 boot camps in-person (or by WebEx) Outgrowth: “Mini boot camps” at department meetings preferred to evening meetings, even if no CME credit, focused on tools. Grand Rounds held on urine drug testing (UDT) 0 50 100 150 200 250 300 350 400 450 Opioid SMA Referrals Month Cummulative Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2017 0 20 40 60 80 100 120 140 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Prescription Drug Monitoring Database (CURES) Documentation 0 10 20 30 40 50 60 70 80 90 100 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Morphine Equavalent Dosing Documentation PROJECT OVERVIEW PROJECT SETTING PROVIDER Education BOOT CAMPS CHANGING CULTURE EHR TOOLS COT REPORT OPIOID SMA KEY FINDINGS Available Jan 2016 Documentation: MED Urine screening Risk assessment - ORT, CAGE CURES “link” PEG scoring Process Outcomes: Increase in urine drug screening (Fig 6A) with start of project and implementation of state regulations Increase in MED documentation (Fig 6B) and CURES consults (Fig 6C) with implementation of state regulations Providers interested in “how” to change chronic pain management, rather than “why” Providers have some insecurity around care of COT patients – want more specialist resources/support COT report can serve as a variation reduction tool Most COT patients are not using dangerously high opioids doses, but risk assessments are not complete Use of EHR tools and improved documentation of pain encounters followed state introduction of new regulatory scheduled substance prescribing guidelines and regulations The Opioid SMA fulfills informed consent per CDC guidelines; resulted in improved patient confidence; and patients were generally satisfied with the program. Introduced: Feb 2016 Purpose: Informed consent Educate on: Adverse effects Safe Rx disposal Referrals: ~ 20-50 referrals per month, with 436 patients in total referred at 3 clinic sites (Fig 3) Patient Outcomes: Immediate improvements in patient ratings of confidence in self- managing pain and healthcare providers ability to help manage pain (Fig 4) The majority of participants were satisfied with the SMA, although fewer reported likely behavioral change (Fig 5) ID’d patients & providers with 3 consecutive months of opioid Rx; and MED distribution (Fig 1) “Proto Dashboard” became actionable: providers can send pts to SMA; batch CURES checks; send high MED pts for consults Encourages variation reduction (GET THE RED OUT!) (Fig 2) 0 50 100 150 200 250 300 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Urine Drug Screen Orders CA Prescribers required to register with CURES CA Prescribers required to consult with CURES CA Prescribers required to register with CURES CA Prescribers required to consult with CURES CA Prescribers required to register with CURES CA Prescribers required to consult with CURES Figure 6. EHR Process Measures (counts) A B C Project Start Date Figure 2. Proto Dashboard Figure 3. SMA Referrals Figure 4. Pre-Post SMA Outcomes Figure 5. Post SMA Outcomes PROJECT HAS OPENED DOORS PAMF launched a Pain Consultation Service in Aug 2016 as a prototype of a fully-integrated service The Opioid SMA was a big win, generating more interest in group appointments. Coming soon…. - Buprenorphine SMA (May ‘17) - Experience of Pain SMA (Jul ‘17) led by a pain psychologist Neurobiology of Pain (TBD) led by a pharmacist Collaborations - California Health Care Foundation - Quest Diagnostics - Community addiction services DISSEMINATION ACTIVITIES Images curtesy of Dr. William Brose Figure 1. COT Patients by MED Risk Level Clinic Site Active Project Site Boot Camp Opioid SMA Pain Consult Service LEGEND Danville Center Freemont Center Palo Alto Center Mountain View Center Sunnyvale Center Los Gatos Center Blossom Hill Center Santa Clara Center Daily City Center San Carlos Center Burlingame Center Dublin Center West Valley Center Aptos Center Westside Center Scotts Valley Center Watsonville Center Santa Cruz Center High Risk Sutter: PAMF P&T to create policy regarding standards for pain management Collaboration with other affiliates on standards for UDT External: Health Care Systems Research Network (HCSRN) Annual Meeting; March 21-23, 2017 (San Diego, CA) Journal of Patient Experience. ePub May 8, 2017 From the Medical Board of California to PAMF This project was funded by an Independent Grant for Learning & Change from Pfizer, Inc. and CAFP-CAPG
