Background
Methods/design
Project aim
Settings/target population
Target population
Health System’s opioid policy and implementation efforts (“routine rollout”)
Item | Summary of the Policy-recommended Components |
---|---|
Recommended components of opioid therapy management | |
Problem List | 1. Document diagnosis of chronic pain and source of pain |
2. Document information related to relevant prescribed medications: | |
a. Details of opioid prescription, with allowed quantity per given time period b. Name and location of designated pharmacy c. Date when treatment agreement was most recently signed d. Urine drug testing findings | |
3. PDMP review: date of last review, finding summary, e.g., consistent or inconsistent with prescription record | |
4. Document care plan | |
5. Add comments helpful to other providers, e.g., those covering in your absence | |
6. Update at least annually and when any changes occur | |
Care Plan Components | 1. Treatment goals: pain severity (BPI), function (BPI/other) |
2. Treatment plan (medications, exercise, physical or occupational therapy, mental health related therapies, CAM therapies, specialty consults) | |
3. Contingency plan for care outside PCP office | |
4. Update at least annually and when any changes to care plan | |
Treatment Agreement | 1. Serves as informed consent to long-term opioid therapy |
2. Scan new or updated signed treatment agreement into the EHR | |
3. Update treatment agreement annually and when any changes to care plan | |
4. Deactivate treatment agreement after opioids are no longer prescribed | |
Urine Drug Testing | 1. Complete urine drug testing annually or more frequently as needed |
2. Perform confirmatory testing for unexpected results of a screening test | |
3. Document findings | |
Prescription Refills | 1. Prescription for controlled substances should be filled at one agreed upon pharmacy, which is noted in the treatment agreement |
2. Prescriptions for Schedule II medications can be mailed to pharmacy only | |
3. Patient may sign a release form to designate up to 2 appointees who can pick up prescriptions for Schedule II medications with photo ID | |
PDMP | 1. Document findings of the PDMP database review at least annually. |
Approach to treatment agreement violation | |
Minor Infractions | 1. Patient should be contacted by prescribing provider; discussion documented |
2. Reassess and update care plan and treatment agreement as needed | |
Major Infractions | Follow minor infraction steps above; in addition: |
1. If opioid therapy is discontinued, provide, when appropriate: a. opioid taper instructions and prescription(s) to accomplish the taper b. prescriptions for non-opioid medications for opioid withdrawal symptoms | |
2. Document reason for the discontinuation of opioid therapy | |
3. Deactivate treatment agreement when opioid treatment is completed | |
4. Communicate with other treating clinicians | |
5. Contact Patient Relations; discuss placing a flag, if needed, in medical record by the Department of Pharmacy | |
6. Continue non-opioid treatment | |
7. If all care is planned to be terminated, discuss “No further service” with Patient Relations | |
Suspected Misuse or Use Disorder | 1. Consider referring to addiction medicine specialist |
2. If safe, continue modified or current opioid therapy until plan is in place with addiction specialist | |
3. Consider following the steps as for major violation of the treatment agreement |
Design
Overall design
QI intervention
QI Intervention Component | Description |
---|---|
Academic Detailing | A single on-site educational meeting between a content expert (project team member) and the clinicians and staff from the enrolled clinic wishing to improve the quality of care for their opioid-treated patients. |
Two Online Educational Modules, delivered via email: 1) Responsible Opioid Prescribing 2) Shared Decision Making | Brief, straightforward, and easily accessible educational tools delivered via the web or mobile devices. A set of 20–21 multiple-choice questions with instant feedback allows learners to assess and validate their current knowledge of the targeted content, which is presented in the context of a given health system setting. These modules were developed by the project team members, content area experts, and reviewed by the health system and external experts (content can be made available upon request). |
Practice Facilitation | An evidence-based method of assisting clinical practices in changing and optimizing the process of care. External facilitators (project team members) assist practices in implementing their prioritized goals and changing practice workflow, typically using the Plan, Do, Study, Act cycle model, ([21]) with the ultimate goal of improved patient care and outcomes. |
Two Patient Education Modules: 1) Opioids for Chronic Pain 2) Agreement for Using Opioids | Brief, online educational tools for patients, professionally developed by Emmi Solutions, LLC (https://www.my-emmi.com/SelfReg/PAIN). |
Outcome measures
Evaluation Component | Clinic-Level Measures |
---|---|
Clinically-Relevant Outcomes | |
EHR-based Measures (aggregate clinic-level data) | |
Treatment Agreement | Percent of eligible patientsa with signed treatment agreement in the past 12 months. |
Urine Drug Testing | Percent of eligible patientsa with the health system-recommended urine drug testing completed in the past 12 months. |
Opioid Therapy Risk Assessment | Percent of eligible patientsa with documented screening using the health system-recommended D.I.R.E. opioid misuse risk tool. |
Depression Screening | Percent of eligible patientsa with documented screening using the health system-recommended PHQ-2 or − 9 depression screening tool. |
Co-prescription of Opioids and Benzodiazepinesb | Percent of eligible patientsa with presence of active prescriptions for both opioids and benzodiazepines. |
PDMP Check | Percent of eligible patientsa with documented PDMP database check in the past 12 months. |
Process Measures (aggregate clinic-level data) | |
Clinic Team Surveys | Pre- and post-participation surveys will elicit: 1) ordinal responses as well as semi-qualitative comments to questions about current practice patterns; 2) comfort level with selected aspects of care for patients with opioid-treated chronic pain; 3) usefulness of the QI intervention components (post-participation). |
Clinic Team Member Participation in the Intervention Components | Percent of clinicians and clinical staff per clinic who: - participated in the academic detailing session - enrolled in and completed each of the two online educational modules - participated in the practice facilitation sessions |
Data from Practice Facilitators | Practice facilitator notes and experiences will enable identification of themes relevant to the implementation of the opioid policy (barriers and facilitators). |