Community Care of North CarolinaCommunity and Practice Based Interventions

to Lessen Opioid Abuse and Opioid Overdoses

Credentials

Robert L “Chuck” Rich, Jr., MD

Medical Director for Community Care of the Lower Cape Fear, Medicaid network

Practicing MD in rural Bladen County, NC.

AAFP Commission member, Health of the Public and Science

Chairperson AAFP workgroup re Opioids and Pain Management

No industry connections or sponsorships

Problem:

Utilization of highly addictive opioid medications has risen 160% in last 10 years

NC death rate for unintentional poisonings is 11.4 per 100,000 citizens 22nd in the country

1140 such deaths occurring in 2011

Deaths by motor vehicle accidents and unintentional poisonings are almost equal in NC.

Solution:

A model of intervention in the chronic pain cycle based on a successful integrated care pilot in Wilkes County, NC, called Project Lazarus (PL) PL decreased unintentional overdose deaths in Wilkes County

by 69% from 2009 – 2011

Community Care of NC, supported by a $2.6 million grant from The Trust (Kate B Reynolds) and matching funds from the Office of Rural Health, is expanding the PL approach statewide through 3 interrelated initiatives:

Community-Based Coalitions

The Clinical Process

Program Outcome Goals

The Kate B. Reynolds Trust

NC Foundation for Advanced Health Programs

NC Office of Rural Health

CCNC

Governor’s Institute

$

1.3 Million Dollars

2.6 Million Dollars – Matched

Pass Through

Project Lazarus

$

UNC IPRC

$

Pfizer

$

14 CCNC Networks

$

PL Initiative – Community-Based Coalitions

Community-based Coalitions: Broaden awareness of extent and seriousness of

unintentional poisonings and chronic pain issues

Support community involvement in prevention and early intervention

Comprised of broad range of community partners Law Enforcement

Public Health

Schools

Hospitals

Faith-Based Organizations

Marketing Project Lazarus

PL Initiative –The Clinical Process

The Clinical Process: Focuses on medical assessment and treatment of

chronic pain

Provides education on assessment criteria for pain, safe opioid prescribing, use of CCNC’s Provider Portal, and registration and use of the Controlled Substance Reporting System (CSRS) information

Prescribers:

Primary Care Physicians, Emergency Medicine, DOs, PAs, NPs, Pain Management, Orthopedists, Dentists

Dispensers:

Pharmacists

Behavioral Health:

CCNC Network Psychiatrists

Community Psychiatrists

Addiction Medicine Physicians

Prescribers of Methadone/Buprenorphine (Suboxone)

LME/MCO Medical Directors

SA/MH Clinical Directors

Target Audience

Overview of Chronic Pain and Pathophysiology

Risk Assessment

Treatment Planning/Written Agreements

Legislative Changes: CSRS, Naloxone, Good Samaritan Laws

Documentation

Role of Pharmacists

Monitoring for aberrant use

Diagnosing Addiction

Intervening for Misuse and Addiction

Referring to Behavioral Health Specialists

Case Studies

Topics

40 trainings over next 2 years

20 trainings will offer 3 prescribed credits of CME AMA Category 1 (CME trainings)

20 trainings will offer the same content and agenda but will not be eligible for CME credit (Pfizer-sponsored, non-CME trainings)

Each network will receive at least 1 CME training and 1 Pfizer-sponsored, non-CME training

CPI Coordinators will assist in determining which geographical locations within the network would most benefit from CME vs. Pfizer-sponsored, non-CME training

Clinical Trainings

Agenda Evening Meeting:

5:30 - 6:00 Registration, Pre-Evaluation, and Dinner

6:00 - 6:10 Introduction to Seminar Objectives

6:10 - 6:30 Nature of Pain/Role of Opioids

6:30 - 7:00 Risk Stratification and Initiating Treatment

7:00 - 7:30 Case discussion 1: Getting started

7:30 - 7:45 Break – Sign up for the CSRS

7:45 - 8:15 Monitoring, Intervening & When to Stop

8:15 - 8:45 Case discussion 2: Monitoring/Adapting Treatment Plan

8:45 - 9:00 Wrap up/Next steps

*Turn in Post-Evaluation and get CME Certificate*

A Guide to Rational Opioid Prescribing

PL Initiative –The Clinical Process

The Clinical Process: Makes use of toolkits with decision support and

other tools developed for:

Primary Care Physicians

Emergency Department Physicians

Care Managers

Toolkit Contents

Universal Precaution for

Prescribing & Algorithm for

Assessing and Managing Pain

Pain Treatment Agreement and

Informed Consent

Format for Progress Notes

Medication Flow Sheet

Personal Care Plan

Prescriber and Patient Education

Materials

Screening Forms and Brief

Intervention – list of Community

Resources

Naloxone Prescribing

Controlled Substance Reporting

System (CSRS) Application

Local Community Resources

Medical Director Leadership

Created educational

presentation for prescribers to

use with Toolkit distribution

Conducting Lunch & Learns

with “Top 20” practices in

network with high chronic pain

patient volume and other

practices indicating interest in

chronic pain education

Advises Care Managers and

Quality Improvement Staff on

“difficult” chronic pain

patients or practice-related

issues via “in person”

meetings, telephonic

consultation and use of CMIS

Presenting at Community-

Coalition stakeholder

meetings

Medical Director Presentation

Typically 1 hour long

Discussion of NC Medical Board guidelines

Review of current NC data

Review of provider toolkit contents including useful forms, basic prescriber guidelines, CSRS, DMA “lock-in” procedures

Summary with Q&A

Chronic Pain Patient Care Management Activities

Provide support to patients identified by the ED Referrals to PCP or specialty services

Provide care management to CPI Priority Flag patients: Screenings and assessment Medication reconciliation

Ensure all prescribers have a medication list

Referral to DMA narcotic lock in program if appropriate

Counsel patient on living with chronic pain

Assist with appropriate referrals to behavioral health

Educate patient and caregiver re: signs and symptoms of overdose

Identification of ED and Hospital Utilization

Recommending and/or Assisting with: Timely follow-up PCP appointment post ED visit or hospital

admission, including home and practice visits

Pain assessment and behavioral health screenings

Narcotic Lock-In

Pain contract

Close collaboration with pain management specialist/clinic and/or Psychiatrist/MCO providers as a TEAM effort

CSRS registration

Medication reconciliations and pharmacist consultations

Types of Practice Interventions

PL Initiative – Program Outcome Goals

Program Outcome Goals: Measured through the Injury Prevention Research

Center and include:

Decreased mortality due to unintentional poisonings

Decreased inappropriate ED utilization for pain management

Decreased inappropriate ED utilization of imaging with diagnosis of chronic pain

Increased use of Provider Portal and CSRS

CCLCF Chronic Pain Activities Prior to Recent Funding

Identified 53 chronic pain patients to follow as a cohort group

32 practices represented

Survey Tool created to capture static data at baseline

Practice and patient ID blinded

Included data snapshot of key utilization stats

Pharmacy section

Case Management section

Practice section

Identified Top 20 practices with most patient volume associated with chronic pain

Cohort Data to Track

Sum of Inpatient Mental Health Admissions

Sum of Inpatient Non-Mental Health Admissions

Sum of Emergency Department Visits  

Sum of Total Medicaid Cost    

Average of Total Medicaid Cost    

Sum of Total Medicaid Drug Cost  

Average of Total Medicaid Drug Cost  

Sum of # of Pharmacies (All Fills, Not Just Opioids)

Sum of # of Opioid Fills in Past Year  

Sum of # of Benzo Fills in Past Year  

Sum of # of Hypnotic Fills in Past Year  

Cohort Data at Follow Up

Data Being Tracked Percent of Change

Sum of Inpatient Mental Health Admissions -14 %

Sum of Inpatient Non-Mental Health Admissions 0 %

Sum of ED Visits -30 %

Sum of Total Medicaid Cost 1 %

Average of Total Medicaid Cost 1 %

Sum of Total Medicaid Drug Cost -12 %

Average of Total Medicaid Drug Cost -12 %

Sum of Number of Pharmacies (All Fills) -22 %

Sum of Number of Opioid Fills/Past Yr -22 %

Sum of Number of Benzo Fills/Past Yr - 8 %

Sum of Number of Hypnotic Fills/Past Yr 33 %

Advocacy- Medical Boards

Often forgotten

2013 FSMB guidelines just released with emphasis on proper screening, documentation, treatment plans, monitoring

MB monitoring often preeminent in provider thought process compared to legislation

Advocacy avenues include MD testimony re proposed rules, membership on MBs, case reviews

Advocacy- Legislatures

Everyone wants the problem solved- “we just need more rules”

“Primary care MDs do not need to be prescribing these meds”

PCPs handle the bulk of prescribing and do so safely with guidelines

Advocacy / educational materials abundant

No need to reinvent the wheel

Advocacy- Legislatures- Resources

AAFP “Prescription Drug Monitoring Report”

AAFP position paper from OAPMWG workgroup

National conference of State Legislatures report of “Prevention of Prescription Drug Overdose and Abuse –State Laws”- updated 07/2013

FSMB policy guidelines re opioid prescribing

State level workgroups and position papers http://www.cdc.gov/homeandrecreationalsafety/Poisoning/laws/laws.html

www.projectlazarus.org

Pharma resources

Types of Laws- CDC Website

Laws requiring a physical examination before prescribing

Laws requiring tamper- resistant prescription forms

Laws regulating pain clinics

Laws setting prescription drug limits

Laws prohibiting “doctor shopping”/ fraud

Laws requiring patient identification before dispensing

Laws providing immunity from prosecution/ mitigation at sentencing for individuals seeking assistance during an overdose

Q&A

QUESTION AND ANSWER TIME