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Dr. Robert Rich's 2013 SLC Presentation
1. Community Care of North Carolina
Community and Practice Based Interventions
to Lessen Opioid Abuse and Opioid Overdoses
2. 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
3. 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.
4. 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
5. The Kate B. Reynolds Trust
1.3 Million Dollars
NC Foundation for Advanced Health Programs
NC Office of Rural Health
Pass Through
2.6 Million Dollars – Matched
CCNC
Governor’s
Institute
UNC
IPRC
Project
Lazarus
14 CCNC
Networks
Pfizer
$
$
$
$
$
6. 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
8. 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
9. Target Audience
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
10. Topics
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
11. Clinical Trainings
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 Pfizersponsored, 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
12. A Guide to Rational
Opioid Prescribing
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*
13. 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
14. Toolkit Contents
Universal Precaution for
Prescribing & Algorithm for
Assessing and Managing Pain
Pain Treatment Agreement and
Informed Consent
Prescriber and Patient Education
Materials
Screening Forms and Brief
Intervention – list of Community
Resources
Format for Progress Notes
Naloxone Prescribing
Medication Flow Sheet
Controlled Substance Reporting
Personal Care Plan
System (CSRS) Application
Local Community Resources
15. Medical Director Leadership
Created educational
Advises Care Managers and
presentation for prescribers to
Quality Improvement Staff on
use with Toolkit distribution
“difficult” chronic pain
Conducting Lunch & Learns
with “Top 20” practices in
network with high chronic pain
patient volume and other
practices indicating interest in
chronic pain education
patients or practice-related
issues via “in person”
meetings, telephonic
consultation and use of CMIS
Presenting at CommunityCoalition stakeholder
meetings
16. 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 “lockin” procedures
Summary with Q&A
17. 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
18. Types of Practice Interventions
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
19. 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
20. 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
21. 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
22. 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
Sum of ED Visits
0%
-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 %
23. 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
24. 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
25. Advocacy- LegislaturesResources
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
26. 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