This webinar discussed implementing team-based opioid management in primary care. It covered the six building blocks for team-based opioid management, which include leadership and consensus, revising policies and workflows, tracking patients on chronic opioid therapy, preparing for patient visits, caring for complex patients, and measuring success. The webinar provided examples of how clinics engaged all members of the care team, including medical assistants, nurses, behavioral health providers, and chiropractors, in caring for patients with chronic pain and opioid use. It also discussed tools clinics can use for population management, such as a chronic opioid dashboard and provider reports on opioid prescribing practices.

1. Taking Team-Based Care to the Next Level
WEBINAR 4 :
Caring for Patients with Pain is a Team Sport
March 8, 2018
Presented by the
the Community Health Center, Inc.

2. Get the Most Out of Your Zoom Experience
• Use the Q&A Button to submit questions!
• Live tweet us at @CHCworkforceNCA and #primarycareteams
• Recording and slides are available after the presentation on our website within
one week
• CME approved activity; requires survey completion
• Upcoming webinars: Register at www.chc1.com/nca
Q&A

3. Learning Objectives
1. Participants will be able to identify two strategies for increasing
provider confidence and competence in managing and treating
chronic pain.
2. Participants will be able to describe the role of extended care
members such as chiropractors in caring for patients with chronic
pain
3. Participants will be describe the role of behavioral health
providers in caring for patients with chronic pain.
4. Participants will understand the 6 building blocks for team-based
opioid management.

4. Implementing Team-Based Opioid
Management in Primary Care
Michael Parchman, MD, MPH
Laura-Mae Baldwin MD, MPH
Brooke Ike, MPH
Mark Stephens, MA
David Tauben, MD
Funded by the Agency for Healthcare Research & Quality (R18HS023750)
Kaiser Permanente Washington Health Research Institute

5. Disclosures
No conflicts to disclose
March 15, 2018

6. The Kaiser Permanente WA Health Research Institute-
University of Washington Research Team
Michael Parchman, MD, MPH
Principal Investigator
Director, MacColl Center for Innovation
Kaiser Permanente WA Health Research Institute
Laura-Mae Baldwin, MD, MPH
Co-Investigator
Professor, Department of Family Medicine, University of Washington
Director, WWAMI region Practice and Research Network
Brooke Ike, MPH
Project Manager and Practice Facilitator
WWAMI region Practice and Research Network Coordinating Center
University of Washington
David Tauben, MD
Co-Investigator
Chief of Pain Medicine
University of Washington
Kari Stephens, PhD
Co-Investigator
Informaticist
University of Washington

7. Opioid Prescriptions Dispensed
 The amount of opioids prescribed in the United States
peaked at 782 morphine milligram equivalents (MME) per
capita in 2010 and then decreased to 640 MME per capita
in 2015.
 Despite significant decreases, the amount of opioids
prescribed in 2015 remained approximately three times as
high as in 1999 and varied substantially across the country.
7 March 15, 2018
-Vital Signs CDC MMWR July 7, 2017

8. We need a new approach: origin of the Six
Building Blocks
8 March 15, 2018

9. LEAP: 30 Innovative Primary Care Practice Models
for Improving Team-based Care
Learning from Effective Ambulatory Practices

11. Six Building Blocks
Building Block 1: Leadership and consensus
• Build organization-wide consensus to prioritize safe, more selective, and more
cautious opioid prescribing.
Building Block 2: Revise policies and standard work
• Revise and implement clinic policies, patient agreements and define standard
work for health care team members to achieve safer opioid prescribing and
COT management in each clinical contact with COT patients.
Building Block 3: Track Patients on COT
• Implement pro-active population management before, during, and between
clinic visits of all COT patients: safe care & measure improvement.

12. Six Building Blocks
Building Block 4: Prepared, patient-centered visits
• Prepare and plan for clinic visits of all patients on COT to ensure that care is
safe and appropriate. Support patient-centered, empathic communication for
COT patient care. (“Difficult Conversations”)
Building Block 5: Caring for complex patients
• Identify and develop resources for patients who become addicted to or who
develop complex opioid dependence. Mental/Behavioral Health Resources are
essential.
Building Block 6: Measuring success
• Select COT-specific quality measures, continuously monitor progress, and
improve with experience.

13. Study Setting: Six Rural-Serving Health Care
Organizations with 20 clinic sites within WPRN
 60 clinics across 29 organizations in 5 states
 20 clinics with electronic infrastructure to access EHR data

14. 14

15. Roadmap AND Team Support
 Our team supported clinics via:
– In-person site visit: Initial clinic team discussion and completion of building block
self-assessment to determine current status. Stimulate action plan.
– Quarterly phone call from a “practice coach” to support action plan and problem-
solve
– Support for chronic opioid management tracking system
– Monthly shared learning calls at which all clinics can share lessons learned
– Monthly webinars and difficult case presentations with pain specialist
– Shared resources: clinic policies, patient agreements, clinic workflows, patient
education materials, etc.

16. Six Building Blocks
Self-Assessment Tool
(20 items)
Study kick-off
consensus-building
team conversation

17. How did clinics engage in the work?
17 March 15, 2018
Phase 1
• Revise policies and agreements
• Develop tracking systems
Phase 2
• Redesign and implement workflows
• Develop patient outreach/education
Phase 3
• Gather and discuss tracking data
• Measure success

18. Look at what you’ve accomplished!
 Implemented pain visits
 Standardized the approach to MED calculation and recording
 Revised policies and treatment agreements
 Signed up for state drug monitoring database
 Developed a methodology to track patients on COT
 Provided dedicated staff time for data tracking
 Reduced providers and staff burnout
 Implemented standard work processes
 Had significant consensus-building conversations
 Prioritized the work at all levels
18 March 15, 2018

19. Primary Care Clinician:
–"Having a defined care pathway for an
emotionally charged and complex area of care -
to walk in with a plan. It's like walking into the
ER and someone having a cardiac arrest. Not
the most stressful things I do because we have
a clear plan. Now I have the same kind of
pathway for opioids. Having what we are going
to do defined."

20. www.improvingopioidcare.org

24. 24 March 15, 2018

25. Conclusions
25 March 15, 2018
Contact:
parchman.m@ghc.org
www.improvingopioidcare.org

26. Engaging Teams
MAs:
• Planned/Routine Care
• Routine PMP Checks (delegate status)
• Functional Assessment Questionnaire
• Coordinating DI/Referral tracking as needed
• Random/Routine Toxicology
• ED/UC Reports
• Liaise with the Pharmacy for any issues
• Controlled Substance Agreement Review

27. Engaging Teams (continued)

28. Engaging Teams (continued)
Nurses:
• Nursing Visits/Co-Visit with BH (in-between provider
visit surveillance)
• Routine PMP Checks (delegate status)
• Functional Assessment Questionnaire
• Med Rec/SE Surveillance
• Random/Routine Toxicology
• Controlled Substance Agreement
Review/Signing

29. Engaging Teams (continued)
Team Preparation:
• Understanding roles/responsibilities
• Accountability
• Addressing sensitivity issues/stigma
• De-escalation training
• Using the whole team

30. Pain Treatment & Behavioral Health
“So you’re telling me it’s all in my head?!”

31. Messaging
• For many patients pain is an invisible illness that
has not been taken seriously at times
• Suggesting a behavioral health solution often leads
people to feel attacked or like they’re not being
taken seriously
• Analogy as a way of explanation that minimizes
misinterpretation

32. Treatment
• Multiple behavioral health modalities have been shown to
be effective in the treatment of pain. Primarily:
– Mindfulness meditation
– CBT
• Group therapy makes sense as a modality for pain
treatment for multiple reasons
– Referrals from PCPs would likely quickly overwhelm individual
appoint slots
– Support and shared experience can help patients normalize their
experience
• Evidence shows long term improvement with even short
BH interventions (Miranda et al, 2012; Trafton et al, 2012)

33. Team-Based Opioid Management in Primary care -
Chiropractic
• Interdisciplinary communication and collaboration
• Diagnosis
– Evaluation and management
– Chronic and acute pain due to neuromusculoskeletal
conditions and comorbidities
• Treatment
– Patient Education
– Acute and chronic pain
• non-invasive & non-drug treatments
– Spinal manipulation
– Extremity joint manipulation
– Soft tissue treatments
– Myofascial trigger point release
– Graston Technique
– Pin and stretch
– Postural and neuromuscular reeducation exercises
– More

34. Team-Based Opioid Management in Primary care -
Chiropractic
• Patient response to care
– Reduction in pain medication usage
– Risk reduction of addiction and
overdose/use
– Improved mood and health outlook
• Active vs. Passive care
• Feel informed and empowered
– Increased and sustainable pain relief
• Evidence based appropriate pain
treatment
"Noninvasive Treatments for Acute, Subacute, and
Chronic Low Back Pain: A Clinical Practice Guideline
From the American College of Physicians." Qaseem, Amir,
Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. Annals of
Internal Medicine. April 04, 2017. Accessed March 04, 2018.
http://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-
chronic-low-back-pain-clinical-practice.

35. • The Report lives in our intranet and is available to all members of our care team
• Data pulled in from multiple sources into our data warehouse
• Clinical Data comes from eClinicalWorks (EHR)
• Appointment data pulled from Centricity (Practice Mgmnt Software)
00/00/00 35
Chronic Opioid Dashboard
-Provider Scorecard-
Provider/Agency totals and percentages
-Patient Analysis Report-
Details data for each patient

36. 00/00/00 36
Provider Scorecard: Provider/Agency totals and percentages

37. 00/00/00 37
Patient Analysis Report: Details data for each patient

38. Comprehensive Tools
to Tackle the Pain
and Opioid Crisis

39. Pain

40. • 2-3 Cases per
ECHO session
• Co-presented by
PCP and BH Provider
• Complex cases
• Multi-disciplinary
consultation available
• Valuable for discussion
and teaching
• Total time = 1.5 hours
Case Presentations
• 1 per session
• Focused and topical
• By expert faculty
• Total time < .5 hour
Didactic
Presentations
Key Elements of an ECHO Session

42. Buprenorphine

44. A Primary Care-Focused
eConsult Network
for Pain and Other Specialties

47. Opioid Review Committee
Committee with oversight over opioid prescribing
 Establish Formulary
 High dose opioid oversight and review
 2nd level review/authorization
 Review outlier providers (high pill counts, high MEQ,
dangerous combos)
 Establish internal guidelines
 Follow up directly with prescriber

48. Provider Specific Opioid Data Report (Pg. 1)

49. Provider Specific Opioid Data Report (Pg. 2)

50. Pain Documentation
Baseline 2011
N=108 (%)
Evaluation
2014 N=213 (%)
p-values
Documentation of Pain 69 (64) 174 (81) <0.001
Source or Cause of Pain 67 (62) 158 (74) 0.025
Functional Assessment 5 (5) 42 (19) <0.001
Review of Diagnostic Tests 6 (6) 37 (17) <0.003
Treatment Plan 99 (92) 209 (98) 0.006
Pain Med Ordered 102 (94) 182 (85) 0.017
Pain Consult Ordered 7 (7) 60 (28.2) <0.001
Patient Education 16 (15) 47 (22) 0.121
Diagnostic Imaging Ordered 25 (23) 59 (28) 0.379
Assessment of Treatment Effectiveness 18 (17) 83 (39) <0.001

51. Changes in Practice
Pre-ECHO Post ECHO
Functional assessment
documented*
14% 60%
Documented pain
re-assessment*
40% 65%
Visit with behavioral
health**
29% 34%
Prescribed any opioid** 49% 45%
Increase
knowledge
Change
practice *Source: Chart review
**Source: Follow up EHR data

52. Post ORC: Chronic Opioid Prescribing Practices

53. Post ORC: Opioid Prescribing Practices in 3 Month Period

54. Summary
• Policy on Prescribing Controlled Medication
• Multifaceted provider education
• Non-opioid Medications
• Alternative Services
• Team based approach
• Risk Mitigation Strategies
• Templated EHR visits
• EHR/clinical alerts and reports
• Monitoring , oversight, and Tracking
• Larger Action Plan

55. Questions