Primary Care Clinic Re-Design for Prescription Opioid Management

Michael L. Parchman; Michael Von Korff; Laura-Mae Baldwin; Mark Stephens; Brooke Ike; DeAnn Cromp; Clarissa Hsu; Ed H. Wagner

doi:10.3122/jabfm.2017.01.160183

Article Figures & Data

Tables

View popup

Table 1.

Primary Care Clinic Characteristics and Examples of Opioid Improvement Efforts

State	Clinic Type	Location	Payer Mix	Example Opioid Improvement	Building Block(s)
PA	FQHC, nurse-led	Urban	4% Medicare	Chronic pain group therapy	4,5
			58% Medicaid
			14% commercial
			23% uninsured
WV	FQHC, AHEC	Rural	17% Medicare	Chronic pain group visits	1,2,3
			25% Medicaid	Pain registry
			22% commercial	Chronic opioid prescribing policy and pathway
			30% uninsured	Chronic opioid prescribing policy and pathway
SC	FQHC	Rural	32% Medicaid	Standard care plans	2,3,4
			12% Medicare	Patient agreements
			15% Other	In house physical therapy
			40% uninsured	Suboxone
OR	FQHC, residency	Urban	20% Medicare	Chronic pain group visit	2,3,4
			50% Medicaid	In-house CAM therapy
			0% commercial	Revised policies
			30% uninsured	Random urine drug tests
				Patient agreements
				Suboxone
				28-day refills
NH	MMG	Rural	45% Medicare	Patient agreements	2,5
			2% Medicaid	Opioid QI team
			50% commercial	Revised policies
			3% uninsured
WA	MMG	Rural, Suburban	20% Medicare	Chronic pain re-design team	2,4
			9% Medicaid	Suboxone
			61.5% commercial	Pain registry
			9.5% uninsured	Patient agreements
				Random urine drug screens
				Workflow for refills
MA	MMG	Suburban	23% Medicare	Patient agreements	2,3,4
			5% Medicaid	Revised clinic policies
			70% commercial	Suboxone
			2% uninsured	Chronic pain group visits
				Random urine drug screens
NM	FQHC	Frontier/ Rural	28% Medicaid	Chronic pain group visits	3,4
			30% commercial	Behavioral health integration on teams
			19% Medicare	Mental health “first aid” training for staff
			17% Sliding Fee	Suboxone
			6% self pay
CO	FQHC	Rural	47% Sliding Scale	Revised policies	2
			17% Medicaid	Routine PDMP check with refills
			15% Medicare	Patient agreements
			18% commercial dental	No refills on Fridays
ME	MMG	Suburban	35% Medicare	Registry with chronic pain manager	2,3,4
			4.4% Medicaid	Registry with chronic pain manager
			45% commercial	Chronic pain group visits
			5.4% uninsured	Revised policies
CO	MMG	Urban, Suburban, Frontier/ Rural	20% Medicare	Patient agreements	2,3,4
			21% Medicaid	Pre-visit preparation in daily huddle
			50% commercial	Random urine drug test
			9% self-pay	Track PEG scores and PHQ-9
				Suboxone
OH	FQHC	Urban	50% Medicaid	Random urine drug test	2,3,4
			20% uninsured	State PDMP check with refills
			20% commercial	Clinic refill policies
			10% Medicare
PA	PVT	Suburban	90% commercial	Patient agreements	2
			8% Medicare	Revised policies
			1% uninsured
			1% Medicaid
ME	FQHC, residency	Suburban	26% Medicare	Provider support and learning group	2,4
			25% Medicaid	Provider support and learning group
			40% commercial	Suboxone
			9% uninsured	Revised policies
WA	MMG, residency	Suburban	10% Medicare	Chronic pain registry with dedicated MA registry manager	1,2,3,4
			50% Medicaid	Revised policies
			30% commercial	Patient agreement
			10% uninsured	Nurse intake for new patients on opioids
				Random urine drug test
				State PDMP check
				PEG scores
				Referral for high risk
WI	MMG	Rural	17.7% Medicare	Patient agreement	2
			5.5% Medicare	Revised refill policies
			73.8% commercial
			3% uninsured
MA	CHC (hospital network)	Urban	40% Public	Physical therapy assistant	2,4
			40% uninsured	Chronic pain group visits led by social worker
			20% private	Chronic pain group visits led by social worker
DC	FQHC	Urban	63% Medicaid	Chronic pain group visits	4
			6% Medicare	Massage therapy
			20% DC Alliance
			6% commercial
			5% uninsured
NY	AHC, residency	Urban	10% Medicare	Revised clinic policies	2,4
			50% Medicaid	Patient agreements
			30% commercial	Behavioral Health Social Worker
			8% uninsured
CA	FQHC	Rural	50% Medicaid	Chronic pain group visits	2,3,4
			17% Medicare	Revised clinic policies
			3% commercial	Pre-visit planning in daily huddle
			28% uninsured	Patient agreements

Abbreviations: AHC, Academic Health Center; AHEC, Area Health Education Center; CHC, community health center; FQHC, Federally Qualified Health Center; MMG, Multi-specialty Medical Group or part of large system; PVT, Private Practice; RHC, Rural Health Centerl THC, Teaching Health Center.

View popup

Table 2.

Six Building Blocks to Guide Management of Chronic Opioid Therapy

Building Block	Description	Examples of Action Steps
1. Provide Leadership Support	Leadership can build organization-wide consensus to prioritize safe, more selective, and more cautious opioid prescribing	Identify clinical champions to spearhead COT practice change initiatives.
1. Provide Leadership Support		Provide protected time and space for providers and staff to discuss and agree upon short and long-term goals for COT practice change initiatives
2. Revise Policies, Patient Agreements and Workflows	Revise and implement clinic policies and define standard work for health care team members to achieve safer opioid prescribing and COT management in each clinical contact with COT patients.	Convene a team from each area of the clinic to revise existing policies or write new ones
		Review patient agreement and revise to ensure alignment with clinic policies.
		Discuss with all staff and clinicians and modify roles, responsibilities and workflows accordingly
3. Implement a Registry for Population Management	Implement pro-active population management before, during, and between clinic visits of all COT patients to ensure that care is safe and appropriate and provide measure to track COT improvement activities.	Enter all existing COT patients and their relevant enrollment data into a COT registry.
		Assign each COT patient to a single provider responsible for managing their opioid use and.
		Assign a team member in each clinic with responsibility and protected time for managing and updating the registry.
		Use the registry to track data for prescription management (e.g., COT dose, PEG scores to monitor function and pain, date of state prescription database checks)
4. Conduct Planned Patient-Centered Visits	Conduct pre-visit planning and support patient-centered, empathic communication for COT patient care.	Review COT registry reports prior to the visit to identify care gaps
		Monitor and adjust management based on function and quality of life rather than pain scores (the PEG scale)
		Offer organizational support for clinic staff and providers to preview charts and do team huddles about COT patients
		Support staff training, to encourage the use of empathic communication techniques that
5. Identify Resources for Complex Patients	Develop resources to ensure that patients who develop complex opioid dependence, are identified and provided with appropriate care	Identify addiction referral resources and other mental/behavioral health resources, and ensure they are readily available, setting-up referral protocols or agreements as necessary.
6. Measure Progress	Continuously monitor progress and improve with experience.	Identify key process and outcome measures to monitor practice change implementation.
6. Measure Progress	Continuously monitor progress and improve with experience.	Monitor agreed upon COT patient care data, providing and discussing data with clinic staff and medical providers at monthly meetings.

COT, chronic opioid therapy.

View popup

Table 3.

Examples of Common Clinic Policies to Support Management of Chronic Opioid Therapy

New patients currently on COT

All new patients require a urine drug test and copies of prior medical records prior to an opioid prescription

Standard elements of a pain assessment on all new patients

Established Patients COT Management

No refills on Monday and Fridays

No early refills for lost or stolen prescriptions or or a police report for such a refill

Face-to-face visit intervals required for a refill based on level of risk

28-day supply only (to avoid running out on weekends)

Advanced notification period (e.g. 4 business days) for a refill request to be processed

Random urine drug screening frequency

Frequency of required PDMP check and who is responsible

Frequency and documentation of screening for depression and post traumatic stress disorder

Monitoring for co-prescribing of sedatives

Others:

No initiation of opioids to treat headaches, fibromyalgia or chronic low back pain

Standards for when a referral is required to a pain specialist or mental/behavioral health specialist (e.g., aberrant behaviors, high dose such as >100 morphine medication equivalent)