Bree Collaborative Meeting

November 14, 2018 | Puget Sound Regional Council

Housekeeping

Web Access: listed throughout room

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Agenda

Chair Report September 26th Meeting MinutesAction Item: Approve minutes

Implementation Report Out: Qualis HealthDissemination for Public Comment: Lumbar Fusion Re-Review

Action Item: Approve Lumbar Fusion Bundle and Warranty for Dissemination for Public Comment

Dissemination for Public Comment: Collaborative Care for Chronic Pain Action Item: Approve Collaborative Care for Chronic Pain Report and

Recommendations for Dissemination for Public CommentTopic Update: AMDG Opioid Prescribing Guidelines Implementation Open Public Meetings Act Review | Conflict of InterestUpdate on New WorkgroupsNext Steps and Close

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September 26th Meeting Minutes

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Dissemination for Public Comment: Lumbar Fusion Re-Review.Kerry Schaefer, MSStrategic Planner for Employee Health, King County

Bob Mecklenburg, MDMedical Director, Center for Health Care Solutions, Virginia Mason Medical Center

November 14th, 2018 | Bree Collaborative Meeting

Members

Consumer Linda Radach, Patient Advocate

Providers and Surgeons Co-Chair: Robert Mecklenburg, MD, Virginia Mason Medical Center Jonathan Carlson, MD, PhD, Neurosurgeon, Inland Neurosurgery & Spine Associates Farrokh Farrokhi, MD, Neurosurgeon, Virginia Mason Medical Center Mark Freeborn, MD, Neurosurgeon, EvergreenHealth Spine & Neurosurgical Care Michael Hatzakis, MD, Physiatrist, Overlake Medical Center Andrew Friedman, MD, Physiatrist, Virginia Mason Medical Center

Administrators Sara Groves-Rupp, Asst Administrator, Performance Improvement, University of

Washington Medicine Purchasers

Co-Chair: Kerry Schaefer, King County Gary Franklin MD, MPH, Medical Director, Washington State Department of Labor

and Industries Marcia Peterson, Manager of Benefits Strategy and Design, Washington State

Health Care Authority Health Plans

Lydia Bartholomew, MD, Aetna 2

Today’s GoalDisseminate for public comment

Workgroup meeting since January 2018 Responding to requested changes from community and new evidenceScope. Expand inclusion criteria from single level lumbar fusion → current draft silent on levels of fusion Non-surgical care. Facilitate evidence-based, multidisciplinary non-surgical care to provide an alternative to inappropriate or unsafe surgery → doneExpand to outpatient → “facility” replaces “hospital”

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Cycle I: Disability Despite Non-Surgical TherapyReview: two changes

A) Specification of patient’s degree of functional impairmentDocument with PROMIS-10 and Oswestry Disability Index with additional optional measures including the following patient reported outcome measures: Roland-Morris Disability Scale, EuroQual-5 Dimensions (EQ-5D), Short Form 36 (SF-36), Therapeutic Associates Outcome Score, a similarly peer-reviewed and validated patient-reported outcome.B) Documentation of imaging findings confirming lumbar instability that correlate with patient’s symptoms and signsNeural foraminal stenosis as the result of loss of foraminal height, associated with nerve root compression and concordant radiculopathy.Previous decompressive surgery requiring significant facetectomies for foraminal decompression that are expected to create instability in the spinal segment. C) At least three months of structured non-surgical therapy delivered by collaborative teamD) Documentation of severe disability unresponsive to non-surgical therapy E) Shared decision making

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Cycle II: Fitness for SurgeryReview: Three changes

A) Requirements related to patient safetyPre-operative plan for management of opioid dependency, if patient has taken opioids for more than three preceding months as per Bree Collaborative Supplement to AMDG Guidelines.

B) Document patient engagementC) Optimal preparation for surgery

Perform pre-operative history and physical examination with additional testing as needed. Recommended guidelines2016 guideline from the National Institute for Health and Care Excellence (NICE), andAnesthesia consultation per American Society of Anesthesiology Guidelines

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Cycle III: Spinal Fusion ProcedureReview: Three items of note

A) General standards for a surgical team performing surgery30 fusions/surgeon/12 months; 60 fusions/facility/12 monthsNeurosurgeons must be board certified or board eligible and credentialed to perform spine surgery by their institution. Orthopedic surgeons must have completed a spine fellowship and credentialed to perform spine surgery by their institution.

B) Elements of optimal surgical processMinimize use of opioids according to both the 2015 Agency Medical Directors Guideline and the 2018 Bree Collaborative Post-Op Supplement

C) Participation in registries Hospitals must participate in a registry such as Spine COAP with results available to purchasers. Providers must maintain a registry of patients undergoing lumbar fusion and collect prospective patient reported outcome measures as part of an internal quality improvement program.

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Cycle IV: Return to Function

A) Standard process for rapid recovery post-operative careB) Standardized facility discharge process

Aligned with current WSHA toolkit with attention to home environmentFollow-up call aligned with Bree’s Potentially Avoidable Readmissions ReportPain management aligned with 2015 Agency Medical Director’s Guideline

and 2018 Bree Collaborative Post-Op Supplement

C) Arrange home health services as neededD) Schedule follow-up appointments

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Quality Standards

1. Standards for appropriateness 2. Standards for evidence-based surgery3. Standards for ensuring rapid and durable return to function4. Standards for the patient care experience

Proportion of patients with lumbar fusion surveyed using HCAHPS or OAS CAHPS.

5. Standards for patient safety and affordability

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WarrantyReview: two changes

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1. The facility performing the surgery must have an agreement with a hospital to manage complications following surgery. The facility will provide information and instructions to the patient to seek treatment at that designated hospital.

2. Definition of infection taken from Centers for Disease Control, 2018

7 days 30 days 90 days• Acute myocardial

infarction • Pneumonia • Sepsis/septicemia

• Pulmonary embolism• Surgical site bleeding• Superficial incisional

surgical site infection

• Deep incisional surgical site infection that may involve implant

• Mechanical complications

Evidence tableToward a community standard for quality

Facilitates transition from opinion-based to systems-based care delivery

1. Current draft has 117 citations2. Search strategy: formal methodology drives international lit search plus general submissions3. Evaluated and graded by two credentialed appraisers according to Strength Of Recommendation Taxonomy method4. Subject to public comment and in public domain5. Replaces high-variation institution-based medical policies

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Recommendation

Approve Lumbar Fusion and Warranty for Dissemination for Public Comment

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Disseminate for Public Comment: Collaborative Care for Chronic Pain

Leah Hole-Marshall, JDGeneral Counsel and Chief Strategist, Washington Health Benefit Exchange

November 14th, 2018 | Bree Collaborative Meeting

Workgroup Members

Chair: Leah Hole-Marshall, JD, General Counsel and Chief Strategist, Washington Health Benefit Exchange Ross Bethel, MD, Family Physician, Selah Family Medicine Mary Engrav, MD, Medical Director, Southwest WA, Molina Health Care Stu Freed, MD, Chief Medical Officer, Confluence Health Andrew Friedman, MD, Physiatrist, Virginia Mason Medical Center Lynn DeBar, PhD, MPH, Senior Investigator, Kaiser Permanente Washington Health Research Institute Mark Murphy, MD/Greg Rudolf, MD, President, Washington Society of Addiction Medicine Mary Kay O’Neill, MD, MBA, Partner, Mercer Jim Rivard, PT, DPT, MOMT, OCS, FAAOMPT, President, MTI Physical Therapy Kari A. Stephens, PhD, Assistant Professor - Psychiatry & Behavioral Sciences, University of Washington

Medicine Mark Sullivan, MD, PhD, Professor, psychiatry; Adjunct professor, anesthesiology and pain medicine,

University of Washington Medicine David Tauben, MD, Chief of Pain Medicine, University of Washington Medicine Nancy Tietje, Patient Advocate Emily Transue, MD, MHA, Associate Medical Director, Washington State Health Care Authority Michael Von Korff, ScD, Senior Investigator, Kaiser Permanente Washington Health Research Institute Arthur Watanabe, MD, President, Washington Society of Interventional Pain Physicians

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Today’s GoalDisseminate for public comment

Workgroup meeting since January 2018 Responding to community and Bree member request to address gap in working with patients with chronic painContinues focus on opioid prescribing

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Built on existing Models

Collaborative care is a reaction to siloed model of care centered around clinical or provider need not patient needConceptually based on 2001 Chronic Care Model developed by Wagner and colleaguesOther models used in this report include:

VA Multi-Model Review four system components UW AIMS Center five principles Learning from Effective Ambulatory Practice six building blocks Bree Collaborative Behavioral Health Integration eight elements

Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving Chronic Illness Care: Translating Evidence into Action. Health Affairs 20(6):64–78.. Available: http://dx.doi.org/doi:10.1377/hlthaff.20.6.64.Wagner E. 1998. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice 1(August/September):2–4. Available: www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdm.pdf.Peterson K, Anderson J, Bourne D, Mackey K, Helfand M. Evidence Brief: Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain. VA Evidence-based Synthesis Program Evidence Briefs [Internet]. Washington (DC): Department of Veterans Affairs (US); 2011-. VA Evidence-based Synthesis Program Reports.2017 Jan.Advancing Integrated Mental Health Solutions. Principles of Collaborative Care. 2016. Accessed: November 2016. Available: https://aims.uw.edu/collaborative-care/principles-collaborative-careBehavioral Health Integration Workgroup. (2017). Behavioral Health Integration Report and Recommendations. Weir, V, ed. Seattle, WA: Dr. Robert Bree Collaborative. Available: www.breecollaborative.org/topic-areas/behavioral-health/. Parchman ML, Von Korff M, Baldwin L-M, et al. Primary Care Clinic Re-Design for Prescription Opioid Management. Journal of the American Board of Family Medicine : JABFM. 2017;30(1):44-51.

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http://dx.doi.org/doi:10.1377/hlthaff.20.6.64http://www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdm.pdfhttps://aims.uw.edu/collaborative-care/principles-collaborative-carehttp://www.breecollaborative.org/topic-areas/behavioral-health/

Five Focus Areas

Patient Identification and Population Management Care Team Care Management Evidence-Informed Care Supported Self-Management

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Goal: Patient at the heart of care

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Developed by Nancy Tietje, workgroup member

Centered on the patient Built on patient self-management in the

context of biopsychosocial modelGoals are improved function, increased

quality of life, and greater patient autonomy rather than primary focus on pain relief Ideally, both acute and chronic pain will be

managed and treated over time using a systems approach to allow patients to stay within primary care supported by the elements of collaborative care

Adapted from MultiCare’s vision mantra

1. Patient Identification and Population Management Identifying patients with persistent pain with life activity impactsPreventing the transition from acute to chronic pain with life activity impacts through screening with a brief, validated instrument for psychosocial barriers to recovery (e.g., STarT Back Tool for low back pain)Tracking patients in a registry and participating in performance improvement based on aggregation of data for collaborative care performanceUse of a dashboard for patient progressPatient-reported outcome measures at initial visit and follow-up

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2. Care Team

Defined roles for care team members, care team coordination, and communication expectationsAccess to specialty pain or behavioral health consultation, if neededPatient point of contact for care teamStandard workflow with planned interactionsSystem supports (e.g. technology, training) Identifying, supporting and enhancing what patients are already doing to manage chronic pain with life activity impacts

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3. Care Management

Coordination of the collaborative care process including facilitation of care team access Identifying diverse resources and interventions that patients can use in managing chronic pain with life activity impacts, depending on motivations and preferences.Facilitation of referrals, if neededManagement of medication Proactive outreach

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4. Evidence-Informed Care

Trauma-informed care Developing and improving pain management skills (e.g. relaxation)Conventional medical treatment options (e.g., NSAIDs as first line treatment rather than opioids, topical, heat and ice)Addressing pain amplifiers (e.g., sleep problems) Integrative health practices (e.g., massage, acupuncture)Movement and body awareness strategies

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5. Supported Self-Management

Helping patients identify goals for resuming life activities and addressing barriers to making progress toward goals Pain education including understanding of the cycle of pain Addressing anxiety and anger Removing barriers to physical activity Helping patients shift thoughts from being reactive to creative Focusing more on patient abilities, preferences, assets and existing efforts to

restore life activities, and less on deficits and dysfunctions Identifying and offering diverse resources to patients that may help them

develop and sustain multiple personally helpful ways of managing chronic pain and increase participation in affected life activities. See Enhanced Chronic Pain Care Resource Grid in Appendix E. May include educational resources (written, online, etc.), interventions that help

people become more active, diverse services that enhance chronic pain self-management skills within or external to health care settings, and care management services that help patients develop and implement a personalized plan to manage chronic pain and reduce impacts on life activities.

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Appendix E: Enhanced Chronic Pain Care Resource Grid – Health care resources

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Readily available in your setting?

If NO, what can be done to enhance availability?

Health care resources

Explanation

Mind-body therapies: Cognitive behavioral therapy (CBT), Acceptance and Commitment Therapy (ACT) for chronic pain, Mindfulness-Based Stress Reduction (MBSR)

CBT and ACT help people resume life activities, overcome fears and concerns related to chronic pain, and develop pain management skills such as relaxation, breathing, attention diversion and developing new ways of thinking about and experiencing pain.

MBSR helps participants learn to better manage pain through diverse techniques such as guided meditation, gentle yoga, and breathing exercises.

No Yes

CBT for insomnia (CBT-I)

Cognitive behavioral therapy addressing sleep difficulties. Improves restorative sleep among persons with chronic pain. Therapy can be provided in-person or via on-line programs that include expert guidance.

No Yes

Physical therapy (PT)

PT includes strengthening and flexibility exercises, manual therapy, posture awareness, and body mechanics instruction. PTs also help patients understand underlying causes of their pain. Some therapists offer MBSR therapy. PT’s gradually increase the intensity of active exercises and educate patients about how CNS hypersensitivity contributes to chronic pain.

No Yes

Occupational therapy (OT)

OT helps clients live and function productively. OT’s evaluate the pain’s impact on a client's desired activities and quality of life, and equips them with skills and strategies to manage the pain and resume normal activities, including work.

No Yes

Physiatry/Rehabilitation Medicine

Physiatrists evaluation patients and create individualized, nonoperative treatment plans, including PT and OT ,medications, and orthotic devices if likely to be beneficial. They develop a care plan for managing pain and resuming life activities.

No Yes

CAM therapies: Chiropractic, yoga, acupuncture, massage, hypnosis, tai-chi

Diverse therapies that seek to reduce pain, improve mood, enhance well-being, reduce stress, improve function and abilities to do life activities, provide a greater sense of control over life and pain.

No Yes

Care Manager for chronic pain

Care managers identify and work with chronic pain patients with major life activity impacts more likely to have unfavorable outcomes. The assess patient needs and work with patients to identify their personal goals and develop a care plan. The help connect patients with resources to implement their plan, including self-management support services, and coordinate care across providers. The follow-up with patients over time to assess progress, to adjust care plans as needed, and to help patients overcome barriers to achieving their goals.

No Yes

Appendix F: Managing Complex Pain Infographic – Rewiring the Pain Neuromatrix

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Appendix G: Managing Complex Pain Infographic - Reversing The Persistent Pain Cycle

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Recommendation

Approve Collaborative Care for Chronic Pain Report and Recommendations for Dissemination for Public Comment

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Break

Topic Update: AMDG Opioid Prescribing Guidelines Implementation

Gary Franklin, MD, MPHMedical Director, Washington State Department of Labor and Industries

November 14th, 2018 | Bree Collaborative Meeting

Workgroup Members Gary Franklin, MD, MPH (Co-Chair), Medical Director, Washington State Department of

Labor and Industries Charissa Fotinos, MD, (Co-Chair), Deputy Medical Officer, Health Care Authority Andrew Saxon, MD, (Co-Chair), Director, Center of Excellence in Substance Abuse Treatment

and Education (CESATE), VA Puget Sound Health Care System Jane C. Ballantyne MD, FRCA, Professor (retired) of Anesthesiology and Pain Medicine,

Director, University of Washington Pain Fellowship Chris Baumgartner, Director Prescription Monitoring Program, Washington State

Department of Health David Buchholz, MD, Medical Director of Provider Engagement, Premera Blue Cross Pamela J. Davies MS, ARNP, ACHPN, BC, Teaching Associate, University of Washington

Medical Center Deborah Fulton-Kehoe, PhD, MPH, Senior Research Scientist, University of Washington Frances Gough, MD, Chief Medical Officer, Molina Dan Kent, MD, Chief Medical Officer, United Healthcare Kathy Lofy, MD, Chief Science Officer, Washington State Department of Health Jaymie Mai, PharmD, Pharmacy Manager, Washington State Department of Labor and

Industries Joseph O. Merrill, MD, MPH, Acting Assistant Professor, Internal Medicine Attending Physician, Adult Medicine Clinic, Harborview Mark Murphy, MD, Addiction Medicine, Multicare Health Yusuf Rashid, PharmD, Vice President, Community Health Plan of Washington Shirley Reitz, PharmD, Pharmacist, OmedaRx, Cambia Health Greg Rudolf, MD, Pain Services, Swedish Mark Stephens, Principal, CareSync Consulting, LLC Mark Sullivan David Tauben, MD, Chief of Pain Medicine, University of Washington Medical Center Gregory Terman MD, PhD, Professor, Department of Anesthesiology and Pain Medicine and

the Graduate Program in Neurobiology and Behavior-Co-Chair Peri-op Workgroup John Vassall, MD, FACP, Physician Executive, Qualis Health Michael Von Korff, ScD, Senior Investigator, Group Health Research Institute

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Postoperative Prescribing Supplement

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Completed formatting of the Prescribing Opioids for Postoperative Pain– Supplemental Guidance.Available on the AMDG website along with the Robert Bree Collaborative website.

Perioperative Guideline Summary

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Perioperative guideline summary drafted. Formatting pending feedback on content.

Review of October 10th Meeting

Review 2015 AMDG sections on tapering and treatment of opioid use disorderScopingAssessmentThe state of the screening tools to identify dependence and addiction. TaperingUse of adjunctive treatments including pharmacological and non-pharmacological treatmentsTreatment of opioid use disorder if tapering fails or if opioid use disorder is more definitely identified

Establish working subgroups, review workgroup membership

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Interim Steps

Key informant interviews of national experts for emerging best practicesCompleting the evidence review of taperingFunding and planning a state-of-the-are conference next fall

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Meeting December 5th

Data from Labor and Industries and Health Care Authority Jaymie Mai, PharmD, Pharmacy Manager, Washington State Department of

Labor and Industries Charissa Fotinos, MD, Deputy Chief Medical Officer, Washington State Health

Care Authority

Literature on Assessment Tools Michael Von Korff, ScD, Senior Investigator, Kaiser Permanente Washington

Research Institute

Literature on Tapering Michael Sullivan, MD, PhD, Professor, Psychiatry; Adjunct Professor,

Anesthesiology and Pain Medicine, University of Washington Medicine

Next Steps Conference planning Workgroups

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Open Public Meetings Act Review

Conflict of Interest

November 14th, 2018 | Puget Sound Regional Council

Open Public Meetings Act

Required training every four years

https://youtu.be/9yTtVGToW1A

More information: http://www.atg.wa.gov/open-government-training

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http://www.atg.wa.gov/open-government-traininghttp://www.atg.wa.gov/open-government-training

Conflict of Interest Form

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Update on New Workgroups

Ginny Weir, MPHDirector, Bree Collaborative

November 14th, 2018 | Puget Sound Regional Council

New Workgroups

Opioid Prescribing (Continued)

Maternity BundlePalliative CareShared Decision MakingHarm to Self and Others (Volk)

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Maternity Bundle

Chair: Carl Olden, MD, Family Physician, Pacific Crest Family MedicineMembers:

Anaya Balter, RN, CNM, MSN, MBA, Clinical Director for Women’s Health, Health Care Authority David Buchholz, MD, Medical Director for Provider Engagement, Premera Angela Chien, MD, OB/GYN, EvergreenHealth Andrew Castrodale, MD, Family Medicine, Coulee Medical Center Neva Gerke, LM, CPM, MSM, Midwives Association of Washington Lisa Humes-Schulz, MPA, Planned Parenthood of the Great Northwest and

Hawaiian Islands Ellie Kauffman, MD, Medical Director, OB COAP Carolyn Kline, MD, OB/GYN, Overlake Dale Reisner, MD, OB/GYN, Swedish Janine Reisinger, MPH, Director, Maternal Infant Health Initiatives,

Washington State Hospital Association Vivienne Souter, MD, Research Director, OB COAP

Meetings: January 8th 3:00 – 4:30pm | second TuesdaysSlide 3

Maternity Bundle

Addressing racial and income disparities.Process and patient outcome metrics.Addressing preventable complications. Inclusion and exclusion criteria. Pre and post-natal care.

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Palliative Care

Chair: John Robinson, MD, SM Chief Medical Officer First Choice HealthMembers:

Lydia Bartholomew, MD, Senior Medical Director, Pacific Northwest, Aetna George Birchfield Mary Catlin, MPH, Senior Director, Honoring Choices, Washington State

Hospital Association Randy Curtis, MD, MPH Professor of Medicine, Director, University of

Washington Palliative Care Center of Excellence Leslie Emerick, Legislative Consultant, Home Care Association of Washington Kerry Schaefer, MS, Strategic Planner for Employee Health, King County Richard Stuart, DSW, University of Washington Cynthia Tomik, LICSW, Manager Palliative Care & Hospice, Evergreen Health Gregg Vandekieft, MD, MA, Medical Director for Palliative Care, Providence

St. Peter Hospital Hope Wechkin, MD, Hospice and Palliative Care Specialist, EvergreenHealth

Palliative CareMeetings: January 4th 10:00 – 11:30am | second Fridays Slide 5

Shared Decision Making

Chair: Emily Transue, MD, Associate Medical Director, HCAMembers:

David Buchholz, MD, Medical Director of Provider Engagement, Premera Dan Lessler, MD Sharon Gilmore, RN, Risk Consultant, Coverys Leah Hole-Marshall, JD, General Counsel and Chief Strategist, WA Health

Benefit Exchange Andrew Kartunen, Program Director, Virginia Mason Dan Kent, MD, Chief Medical Officer, Community Plan at United Health Care Karen Merrikin, JD, Consultant, Health Care Authority Randy Mosley, MD, Hospitalist, Confluence Health Martine Pierre Louis, MSW, Director, Interpreter Services, Harborview Jonathan Sugarman, MD

Meetings: TBDSlide 6

Harm to Self and Others (Volk)

Chair: Kim Moore, MD, Associate Chief Medical Officer, Franciscan Health SystemMembers:

Ann Allen, Member, Washington Chapter of the National Association of Social Workers G. Andrew Benjamin, JD, PhD, ABPP, Psychologist, University of Washington

Medical Center Kate Comtois, PhD, MPH, Professor, Department of Psychiatry and Behavioral

Sciences, Harborview Medical Center (Member Suicide Care Workgroup) Laura Groshong, LICSW, Psychotherapist and mental health advocate Ian Harrel, MSW, Chief Operating Officer, Behavioral Health Resources Lucy Holmans, JD, LMHC, Member, Washington State Psychological Association Kelli Nomura, Behavioral Health Administrator, King County Mary Ellen O'Keefe, ARNP, MN, MBA, Clinical Nurse Specialist - Adult

Psychiatric/Mental Health Nursing, President Elect of Association of Advanced Psychiatric Nurse Practitioners Jennifer Piel, MD, JD, Psychiatrist, Department of Psychiatry, University of

Washington Medical Center Julie Rickard, PhD, Program Director, American Behavioral Health Systems –

Parkside (Member Suicide Care Workgroup) Jeffery Sung, MD, Member, Washington State Psychiatric Association (Member

Suicide Care Workgroup)Meetings: January 17th 3:00 – 4:30pm | Second or Third Thursdays Slide 7

Next Meeting:

Wednesday, January 23rd, 2018 12:30 – 4:30

Puget Sound Regional Council5th Floor Board Room1011 Western Avenue, Seattle WA

1.Intro-18-1114Bree Collaborative MeetingHousekeepingAgendaSeptember 26th Meeting Minutes

3.Meck-Schaefer-APM-18-1114Slide Number 1MembersToday’s Goal�Disseminate for public commentCycle I: Disability Despite Non-Surgical Therapy�Review: two changesCycle II: Fitness for Surgery�Review: Three changesCycle III: Spinal Fusion Procedure�Review: Three items of noteCycle IV: Return to Function�Quality StandardsWarranty�Review: two changes Evidence table�Toward a community standard for qualityRecommendation

4.Hole-Marshall-Chronic-Pain-18-1114Disseminate for Public Comment: �Collaborative Care for Chronic Pain ��Leah Hole-Marshall, JD�General Counsel and Chief Strategist, �Washington Health Benefit ExchangeWorkgroup MembersToday’s Goal�Disseminate for public commentBuilt on existing ModelsFive Focus AreasGoal: Patient at the heart of care1. Patient Identification and Population Management 2. Care Team 3. Care Management 4. Evidence-Informed Care 5. Supported Self-Management Appendix E: Enhanced Chronic Pain Care Resource Grid – Health care resourcesAppendix F: Managing Complex Pain Infographic – Rewiring the Pain NeuromatrixAppendix G: Managing Complex Pain Infographic - Reversing The Persistent Pain Cycle Recommendation

5.BreakBreak

6.Franklin-Opioid-Prescribing-18-1114Topic Update: AMDG Opioid Prescribing Guidelines Implementation��Gary Franklin, MD, MPH�Medical Director, Washington State Department of Labor and IndustriesWorkgroup MembersPostoperative Prescribing SupplementPerioperative Guideline SummaryReview of October 10th Meeting Interim Steps Meeting December 5th

7.OPMA-18-1114�Open Public Meetings Act Review��Conflict of Interest�Open Public Meetings ActConflict of Interest Form

8.New-Topics-Weir-18-1114Update on New Workgroups��Ginny Weir, MPH�Director, Bree CollaborativeNew WorkgroupsMaternity BundleMaternity BundlePalliative CareShared Decision Making Harm to Self and Others (Volk)

9.End-18-1114Next Meeting:��Wednesday, January 23rd, 2018 �12:30 – 4:30 ��Puget Sound Regional Council�5th Floor Board Room�1011 Western Avenue, Seattle WA