Spokane Pain Initiatives

Alliance Consistent Care Program A community program aimed at addressing prescription drug abuse and overutilization of the emergency department

Alliance Consistent Care Program of South Eastern Washington Tri-Cities Pain Management NetworkMay 22, 2014 My name is Becky Grohs, RN, CM- I have been an RN for 23 years and a Case Manager for about 18 years. The majority of my career was spent working for a managed care organization as a CM. I did spend a lot of time providing CM services to our members, travelled into the community, visiting patients in the hospital, working with home health agencies, nursing home, etc.- I specifically focused on providing care for Special Needs kids, behavioral health and cd issues, end of life issues and complex cases, those with trauma or co-morbid chronic diseases. I come from a community of about 253 K people. We have 3 separate cities- 3 separate city govts, police, emergency services, city council, etc. but all 3 cities border each other and you can get across all 3 cities in about 20 minutes. I started working for Washington State University and the current ED that I serve back in January. I met Dr. Neven when he interviewed for my position and I have been running since. Im incredibly busyIm the program coordinator the CCP. We have essentially built this program from the ground up since January. Today I want to share with you my story of how we have built our program, give you some background about why were doing what were doing and hopefully, youre able to take back with you some ways in which you may be able to implement a similar program in your area. Next Slide1Objectives Learn more about the Alliance Consistent Care Program

Gain a better understanding of the drivers behind inappropriate ED visits

Understand the risk of prescription drug misuse

Learn about a CDC sponsored clinical trial

Learn the role Medicaid policy has had in driving better coordinated emergency department care in Washington State.

I hope that by the end of our hour together that you have a better understanding.of the need for..2What is the Consistent Care Program?A community program to reduce Inappropriate ED visitsFocus attention on preventing prescription drug misuse and overdose deathsIdentifies and coordinates care for patients that over utilize the ED at four hospitals-KRMC, Trios Health, LMC and PMHOne coordinated and shared system (EDIE) Primary methods used:Coordinate care with primary care physicianDevelop ED Care Guidelines for each patient that is accessible by emergency physicians Provide individualized patient-centered case management

2006- Spokane Consistent CareSeptember, 2011- A study to address prescription drug abuse and overdose deaths (CDC) August, 2012- Alliance Consistent Care Program of SE WA

3What we knowPatients frequent multiple EDs for many reasons, including: pain, multiple chronic diseases, mental illness, substance abuse issuesMany patients have multiple providers Most have concurrent mental health diagnosesMany report chronic painSome have a primary care physicianMost have one hospital they prefer to frequent, many visit several Most are not forthcoming with informationMost commonly have Medicaid, Medicare, or no insuranceThere is a lack of systems in place to coordinate care between EDs and multiple providersLack of education exists regarding alternatives to the EDThere is a high incidence of prescription drug abuse and deaths

Discuss some of these individually4Prescription Drug abuseAmount of opioid medications sold in the US has quadrupled since 1999.In 2007, Washington state opioid overdose rate exceeded the nations rate at 8.2 per 100,000 to 4.6 per 100,000 2013 showed a 27% reduction in WA. More deaths related to opioids than cocaine and heroin combined. Main cause of death in 17 US states. Nearly 1 in 12 high school seniors reported nonmedical use of Vicodin; 1 in 20 reported abuse of Oxycontin.There has been an increase in Heroin abuse- Half of those being treated for heroin report an opioid addiction to start.Now Americas fastest growing drug problem! Opioids are second only to Marijuana.

Centers for Disease Control. (2012). CDC grand rounds: Prescription drug overdoses-a U.S. epidemic [MMWR 61(10dCenters for Disease Control. (2009). Overdose deaths involving prescriptionopioids among Medicaid enrollees- Washington 2004-2007 [Morbidity and Mortality Weekly Report 58(42) 1171-1175].

Birnbaum, H. G., White, A. G., Schiller, M., Waldman, T., Cleveland, J. M., & Roland, C. (2011). Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Medicine, 12, 657-667.

Centers for Disease Control. (2009). Overdose deaths involving prescriptionopioids among Medicaid enrollees- Washington 2004-2007 [Morbidity and Mortality Weekly Report 58(42) 1171-1175].

Prescription drug abuse and death is a huge driver of our work in reducing inappropriate ED use. In fact, deaths attributed to prescription drug abuse totals deaths by heroin and cocaine combined.

In 2007we have a significant problem here in WA state..5Commonly abused prescriptionsOpioids (used to treat pain): Addiction. Prescription opioids act on the same receptors as heroin and can be highly addictive. People who abuse them sometimes alter the route of administration (e.g., snorting or injecting) to intensify the effect; some even report moving from prescription opioids to heroin. NSDUH estimates about 1.9 million people in the U.S. meet abuse or dependence criteria for prescription opioids.Overdose. Abuse of opioids, alone or with alcohol or other drugs, can depress respiration and lead to death. Unintentional overdose deaths involving prescription opioids have quadrupled since 1999 and now outnumber those from heroin and cocaine combined.Heightened HIV risk. Injecting opioids increases the risk of HIV and other infectious diseases through use of unsterile or shared equipment. Noninjection drug use can also increase these risks through drug-altered judgment and decisionmaking.CNS Depressants (used to treat anxiety and sleep problems): Addiction and dangerous withdrawal symptoms. These drugs are addictive and, in chronic users or abusers, discontinuing them absent a physician's guidance can bring about severe withdrawal symptoms, including seizures that can be life-threatening.Overdose. High doses can cause severe respiratory depression. This risk increases when CNS depressants are combined with other medications or alcohol.Stimulants (used to treat ADHD and narcolepsy): Addiction and other health consequences. These include psychosis, seizures, and cardiovascular complications

Lack of Coordinated careMany patients frequent numerous hospital EDsLack of communication between EDs

Lack of consistent communication between hospital EDs and assigned Primary Care Providers (PCPs).

Patients are not forthcoming with medical information Leading to duplication in diagnostic studies- Radiation overexposureMedication overprescribingBarrier to communication with care providersHospital EDs have separate Medical record systems, many have providers that are owned by the individual hospital systems, but as patients move around, coordination is lost. Our hospitals are only about 7 miles apart. Forthcomingeither by choice, or they simply dont have the tools to organize their care.

7Cross-Domain Communication is DifficultInter-FacilityIntra-Facility

Kennewick General HospitalKadlec Regional Medical CenterLourdes Medical Center

Cross Channel

HospitalPrimary

Mental illness and emergency room useMajority (estimated at around 90%) of our clients have underlying MH needsEstimated that 53% of patients with drug use disorders have co-occurring mental illness Complicates the treatment of pain opioid abuse is as high as 32% in patients being treated for painPain potentiates depression, anxiety and other symptoms of mental illnessPresence of mental illness compromises patients ability to engage in coordinated care Lack of communication between behavioral health providers and medical providers

Horsfall, J., Cleary, M., Hunt, G. E., & Walter, G. (2009). Psychosocial treatments for people with co-occurring severe mental illness and substance use disorders (dual diagnosis): A review of empirical evidence. Harvard Review of Psychiatry, 17, 24-34.

Schindler, A., Thomasius, R., & Petersen, K. (2009). Heroin as an attachment substitute? Differences in attachment representations between opioid, ecstasy, and cannabis users. Attachment and Human Development, 11, 307-330.

Majority of our patients that have been identified have underlying behavioral health issues9Core Principles of Consistent CareDo what is best for the patient- not punitiveIdentify the driving force behind ED use Coordinate care among providers and hospitalsKeep the primary care provider in controlAssist in resource identification and application Provide skills and tools for patients to treat themselvesPrevent prescription overmedication, abuse and deathAddress community gaps leading to higher ED utilization

Resource identification- beh health care, drug assessment and treatment, housing, in-home custodial support, equipment10Tools for consistent careCommunity CollaborationHospitals working together Care Guidelines Committee Organizational points of contact, go to peoplePrescription Monitoring ProgramPatient specific controlled-substance tracking Habitual access and use by ED providers and CM staffEmergency Department Information Exchange (EDIE)Communication among treating hospital EDs and PCPsDatabase for Case Management trackingPatient Centered Care Plan developmentCase ManagementProactive and available outside the emergency departmentSkilled in addressing BH/CD issuesPatient-CenteredOne Team across all hospitals

There are four main components or tools that are used by the CCP. They are..11Community collaborationHospitals working togetherHeld meetings with key leadership in Case Management, Health Information Technology, Compliance/Privacy and Emergency DepartmentCommunity effort

Care Guidelines CommitteeIdentified experts and organizations in the community vested in decreasing inappropriate ED use Create an opportunity to collaborate

Target and communicate with key go to people in clinics, hospitals, urgent cares, and community organizations

Went out and met with each hospitals CEO to discuss opportunity to implement to the program, lead to meeting with key leadership for buy-in12Care Guidelines Committee Mental Health & Chemical DependencyCrisis Response, Detox, Lourdes Counseling Center (jail), community providers, CWCMHHospital Case Management & Emergency PhysiciansDSHSCPSPublic HealthSafe Moms Safe Babies (BFHD)Community ResourcesAging and Long Term Care (ALTC)

Pastoral CareFire Departments-Pre Hospital Care PlansPharmacistConsistent Care Program StaffMedical Director- Dr. Darin NevenPrimary Care

Just added the Jail Services Supervisor- She is a DMHP that coordinates the MH and CD services for incarcerated individuals. Many of whom are the same patients that are in and out of the ED. Working closer together to coordinate care for individuals as they leave jail and return to the community. We work with her to obtain CD assessment and treatment, identify the need for and re-establish BH care while our patients are incarcerated.13Prescription monitoring Program (PMP)Controls prescription misuse by providing practitioners prescription historiesChanges the clinical management in 41% of the casesAccess to PMP for ED providers and ED Case Management staffPromote the use of PMP for other providers; dental, pain management specialists, PCPAbility to use PMP to assess provider prescribing behavior and identify areas of improvement/education

Executive Office of the President of the United States. (2011). Epidemic: Responding to Americas prescription drug abuse crisis [Policy Report]. DOH program14Emergency department information exchange (EDIE) Internet delivered tool that facilitates communication across hospitals and care providers2.5M ED visits going through EDIE (98%)Ability to identify high users across all service areasCreates a mechanism to re-insert the PCP as the center of care through automated notificationsAllows the automated delivery of individualized care guidelines to the treating ED 24/7 Notifications automatically trigger the delivery of Case Management services at the time of the ED visitHIPAA Compliant

How EDIE Notifications Work

NotificationsEDIE

HospitalPrimary Care ProviderClinic

Mental Health Provider

2.1.3.4.16Case managementPatient-Centered Establish PCM for every client

Face to Face or follow-up phone call following day

Care Guideline development Care Plan reflects a individualized plan for the patient

Promote clinical coordinationCommunicate with PCP, specialists, pain management, Health Homes, community resources

Proactive Case Management Chemical Dependency refer to substance abuse screening and treatmentBehavioral Health promote access to BHSCommunity resource needs- housing, transportation, medicationsAlternative plans and education to the use of the ED

Key to the effectiveness of this program is the case management. We are providing a proactive form of case management, were not waiting for the patient to show up in the er and deliver crisis mgt, we are contacting them in an effort to divert their care back to their PCP. Taking the time to learn their story, discover the gaps, provide the education.

Promote clinical coordination- facilitate the communication between providers, help identify the sole prescriber and notify the other providers, be the glue that links the care team together.

Face to Face interaction- provide that consistent message, consistent face that educates them about approp use of the ER, together we walk through decision making that lead to their decision to come to the ED, redirection, gap identification17Development of the care guidelines

Referral is called in 24 hour referral line

compiled and researched.

Reviewed for appropriateness

Case Manager does case prep

Case Manager calls patient and team

PCPRecommendationsED Care Guidelines Committee

ED Care GuidelinesED PhysicianCare guidelinesED Visit Summary: A table of all ED visits made by the patient in the metropolitan area for the past two years.Primary Care Provider: A statement identifying the patients primary care provider/clinic name including the phone number. Opioid Recommendation: A recommendation from the Care Guidelines Committee regarding administering or prescribing opioids in the ED when objective findings to substantiate complaints of pain are absentChronic Pain Medication: A statement identifying if the patient has entered into an opioid agreement with their provider or is receiving a scheduled supply of controlled substancesOpioid- No controlled substances should be administered in the ED or prescribed from the ED for subjective pain.19Care guidelinesPast Medical History: A compilation of diagnoses listed on medical records, summary of other pertinent psychosocial history factors obtained from hospital medical records including overdose historySecurity Summary: Statements regarding the security risk of the patient to ED staff and describing patterns of dangerous behavior demonstrated on prior visitsReferrals: A statement regarding the referrals recommended by the Care Guidelines Committee such as chemical dependency evaluation, psychiatric evaluation, or physical therapy evaluation CT Scan Statement: A statement summarizing number of CT scans the patient has received in the last year

What Does edie Look Like?Patient / Visit Summary SectionCare Guideline SectionInvestigation Section

Registration Reveals Patient on Consistent Care

Patients Care Guidelines placed on chart

EDIEAuto-NotificationAuto-NotificationED HUC is called ED case manager called/faxed/emailED Care Guidelines Faxed to ED Medical Director sent text messagePrimary Care Provider faxed

Physician reviews ED care guidelines

Patient Discharged

medical screening exam by ED physician

No controlled substances

ED case manager talks to patient prior to dischargeED Visit Process

Usual TriageThe next time the patient registers two things happen- the ED is faxed a copy of the care guidelines and the Auto- Notifications are sent.22Results

n=540 patients (enrolled from 2006-2011)Ed care coordination study (CDC)Began in September, 2011- February, 2014No informed consent requiredFocus on prescription drug abuse and preventing overdose deaths

165 Participants randomized into the TAU (control) and CCare (treatment) groupsScreened for those patients with > 50% visits related to pain complaints

All payer sources- Medicaid, Medicare, Commercial and uninsured

Collecting data Prescribing behavior- PMP and hospital data 80% less likely to receive a prescription for controlled substanceED visit utilization- EDIE>60% reduction in ED visitsFinancial indicators- hospital data

Replication of the program that has been in existence since 2006 in Spokane, metropolitan area- community with multiple hospital systems, across several communities.165 patients, TAU defined as what was a standard of care when study began, numerous changes across the board and CCare is the CCP program, measure effectiveness through a number of data sources24What weve learnedJust communicating with each other and having access to EDIE information has made huge impactMental health care is key-improving patient access and adherence We need to learn how better to communicate with the vulnerable- better skills in the ED around patient engagement and motivation for changeBeginning to access training for staffWe need around the clock or late hours access to Urgent CareBetter screening for Substance Abuse- SBIRT trainingWe need timely access to primary care appointments- Patients have PCPs, they just cant get into themEstablish relationships to open up slots for patients within our programIdentify complex patients that need regularly scheduled appointments

Mental health care- so many patients have ceased obtaining MH care, much of what we do is working to re-establish MH servicesBetter communication- this might also mean, less communication in the ED. Were learning from MH experts that promoting the victim role in the ED with some of our borderline patients is encouraging repeat ED use- instead we are educating ED providers how best to communicate, limit empathytreat quickly and release and were directed them back to their therapist where they can address these issues more appropriately. 25Final thoughtsIts important to slow the flow of controlled substances our family, neighbors, and children are dying!

Communication and collaboration with community stakeholders is critical- get to know your neighbors!

Over-utilization of the emergency room is a symptom of underlying disease, whether that is poor primary care access or prescription drug abuse, use your assessment skills and create a treatment plan. It cant be fixed overnight but you can go a long way in a short amount of time!

Questions?Becky Grohs, RN, BSN, CCM(509) 392-6964Becky@allianceconsistentcare.org Case examples27