AHRQ Final Project Report: Title: Connected Care for Improving Treatment of Chronic Headache (CCITCH)

Transcription

1 AHRQ Final Project Report: Title: Connected Care for Improving Treatment of Chronic Headache (CCITCH) Susan Baggaley, MSN, Nurse Practitioner: APRN- C: Principal Investigator Chief Value Officer, Neurology; Medical Director, Outpatient Neurology Clinic; Vice- Chair of Clinical Operations, Department of Neurology Terry Box, MD: Director, Project ECHO K.C. Brennan, MD: Headache Medicine Mentor Division Chief, Translational Neuroscience Kathleen Digre, MD Headache Medicine Mentor Chief, Division of Headache and Neuro- Ophthalmology; Director; Treasurer American Headache Society; Chair, Publications Committee American Headache Society; Director, Center of Excellence in Women s Health Lisa Gren, PhD, MSPH: Evaluation Specialist; Division of Public Health U of U Scott Junkins, MD: Pain Medicine Mentor Fellowship Director, Department of Anesthesiology; Medical Director, Pain Management Center; Vice- Chair Pain Medicine, Department of Anesthesiology Karly Pippitt, MD: Primary Care Headache Champion and Mentor Eric Yelsa, PhD: Faculty Pain Psychologist; Mentor Patricia Jarent, Pharm D: Pharmacist Mentor Leah Willis, MS: Project Manager, Business Operations Manager, Project ECHO Gregory Keough, MPH: Project Coordinator, Project ECHO Organization: University of Utah Health Sciences School of Medicine: Department of Neurology, Family and Preventive Medicine, Division of Pain Medicine, and Project ECHO Salt Lake City, Utah Dates of Project: March 1, 2015 through October 31, 2016 Agency Support: Pfizer through an Independent Grant for Learning and Change Engaging in Interdisciplinary and Interprofessional Teams in the Care and Management of Chronic Pain Patients Grant Award Number: ID:

2 1. Structured Abstract: Purpose: Migraine is the most common neurologic disorder affecting 36 million Americans. Twelve percent of patients have headache as a chief complaint in primary care. A statistical analysis confirmed clinical observation that too many opioids were prescribed for patients with non- specific headache coding. Limited resources to a tertiary headache center and over 25% of referrals from internal community clinics required action. Scope: Recruit case- based presentations from 10 University Community Clinics for bi- weekly sessions over the course of 15 months. PCP will present a case that would otherwise be referred to specialty clinic. Methods: Use of Project ECHO (Extension for Community Healthcare Outcomes) model providing headache experts and interprofessional team as resource to PCP. Each session had a 15 minute didactic in such topics as headache diagnosis and management, mindfulness, and physical therapy. A Tele- Edu note created in a shared Electronic Health Record (EHR) with diagnosis and recommendations. One hour CME. Implementation of a headache screening tool Migraine ID TM into the EHR. Data extraction from the EHR warehouse was used to measure changes in practice. Results: 26 ECHO sessions offered and 17 were attended with an average of 4 participants each session. Improving coding for headaches resulted in positive practice changes, we saw an increase in migraine specific therapy and reduction of opioid prescriptions. Despite perceived innovation, 35% of sessions were not attended. Key Words: Project ECHO, opioid, headache, migraine 2. Purpose While 350,000 Utahns suffer from migraine headache, primary care providers (PCPs) remain under- supported as the front line of chronic headache care. Even though headache is a very common chief complaint, PCPs experience barriers to success in managing headache including: lack of time to develop competence/short clinic visits average 15 minutes does not allow for comprehensive evaluation/comfort, lack of appropriate education and/or training, and lack of consistent access to specialist consultation. As a result, patients may be misdiagnosed, inappropriately treated, or forced to enter an over- crowded referral stream. The goal of the Connected Care for Improving Treatment of Chronic Headache (CCITCH) program is to improve and advance the standard of care for patients with migraine chronic headaches) by offering bi- weekly video- conferenced continuing medical education (CME) sessions lead by University of Utah specialists for front- line community- based primary providers. CCITCH will utilize the Project ECHO (Extension for Community Healthcare Outcomes) educational method. The mission of Project ECHO is to improve patient access to best- practice specialty care by enhancing primary providers capacity to

3 treat chronic, common, and complex diseases. In this model, an interdisciplinary, interprofessional team of headache specialists including embedded family practitioners at the University of Utah (U of U) will use videoconferencing technology to conduct bi- weekly sessions with primary providers (physicians and advanced practice clinicians) in the U of U s 10 community clinics across the Salt Lake Valley. The multipoint conferencing system allowed providers and staff at all 10 clinics to connect on a regular schedule simultaneously for the educational, consultative clinic from their home clinics. The bi- weekly sessions focused on case- based learning with cases being presented by community providers, in addition to including brief didactic presentations that help inform disease management. Specifically, the CCITCH program s goals are to: 1. create interdisciplinary and interprofessional knowledge networks focused on cost- effective, best- practice care of patients with chronic headache 2. increase primary providers competence and self- efficacy in diagnosing/treating headache and reduce referral patterns to tertiary care 3. increase use of a validated migraine diagnosis tool (ID Migraine ) 4. decrease opiate prescription rates for the treatment of headaches Scope: Headache is a massive public health burden in Utah. Based on national and international epidemiological work (Lipton et al Headache 2001), 36 million Americans suffer from migraine. This translates into 12% of the Utah population - 350,000 Utahns suffers from migraine this is more than those who suffer from diabetes and asthma combined. Moreover, there is an epidemic in post- traumatic headache, which affects more than half of blast- injured veterans (Theeler et al Headache 2013) exact numbers are not available for Utah but are likely substantial as the state has a large military and veteran population. Finally, opioid use, which is a significant determinant of headache chronification (Bigal et al Headache 2008) is a severe problem in Utah. We are the fourth highest state in the nation for opioid death. (Utah Dept of Health Violence & Injury Prevention Program 2015) Utilizing statistical analysis from the data warehouse of our 10 internal Community Clinics (135 providers), we realized that our clinical impression of inaccurate or symptom coding was a concern as it related to the prescribing patterns of our PCPs. Over 54,000 encounters were reviewed for diagnosis and medication management in the pre- grant phase ( ). Fifty eight percent of patients were given a symptom code for headache and 28% of encounters received opioids. Armed with granular statistics we gained letters of support from hospital administration and the Chair of Family and Preventive Medicine to embark on such

4 a process in order to provide feedback and opportunities for assistance in managing complex headache patients. The public health risk of headache management was both qualitative and quantitative. The University of Utah Neurology Department receives referrals from the entire state of Utah as well as the 5 intermountain states as a tertiary care center. The catchment area for referrals is 10% of the United States geography. Headache referrals comprise at least 20% of these referrals. The community clinics comprise 31% of Headache referral requests. Resources for diagnosis and treatment of headache have access limitations and average a 6 month wait to be seen for definitive care. Furthermore, the U of U is the only United Council for Neurologic Subspecialties (UCNS)- accredited headache program in the Mountain West. At any given time there are over 500 referrals waiting to be seen in the Headache Clinic. With only a total of 1.5 full- time equivalent (FTE) delivering specialty headache care in our system and a total capacity to see new patients a month placing a focus on diagnosis and management of headache puts it in the hands of our primary care partners to manage. However, delivering specialty headache care to such large numbers, using conventional models is not feasible. Leveraging technology and innovation is a possible solution to shorten the definitive diagnosis and treatment of a patient with headache. Another component to our interdisciplinary team is the advantage of a Pediatric neurologist in headache. She will also provide expertise to primary care clinicians as an expert. 4. Methods The first key innovation of CCITCH was to leverage the infrastructure and expertise of an already successful Project Echo to deliver connected headache care. ECHO has been operating at the University of Utah (U of U) since October It is part of a larger network of ECHOs (44 sites across the United States and around the world) that began at the University of New Mexico in Currently, Utah Echo (U ECHO) offers tele- conferences in several disciplines, including hepatitis B and C management, advanced liver care, immune disorders of the gut, and behavioral health. Each discipline s ECHO tele- conference is offered for Category 1 CME credit, is led by an interdisciplinary, interprofessional team of specialists, and is administratively managed by the U ECHO office. U ECHO is experienced in creating, marketing, implementing, and evaluating educational programs like CCITCH. U ECHO enjoys strong administrative support from the U of U Health Care group. It is financially supported by the U of U Hospital, the U of U Medical Group, and a Centers for Disease Control and Prevention grant (for the hepatitis tele- ECHO, specifically). Of note, U of U Health Plans, a University- based insurance payer, is

5 collaborating with U ECHO to develop a plan to allow eventual reimbursement of CCITCH activities for both specialists and primary providers. We are optimistic that if we demonstrate success with our proposal, insurance- based support could make CCITCH a scalable and self- sustaining program. The CCITCH model capitalizes on our existing administrative infrastructure for providing high- quality, maximally efficient educational experiences (Project ECHO), clinical expertise committed to connected care, and previous experience in collaboration between U of U specialists and primary providers to manage chronic headache. The guiding principles for success and attendance: minimal disruption to current workflow (e.g., early morning before clinic, lunch hour, during previously- scheduled administrative meeting times), utilize champion(s) at each clinic; train nurses/aides to assist with administrative components; flexible learning modules (recorded didactic sessions), practical, actionable knowledge dissemination conventional didactics only when necessary; prioritization of individual case based approaches with group discussion, and ongoing assessment, measurement, and revision to maximize outcomes Data Collection and Analysis: Using the exact parameters for data extraction in the Pre- Grant phase; we followed the behavior of diagnosing and treating headache. The graph below reflects the 10 Community Clinics, two time periods: baseline or pre- grant and secondly grant phase /31/2013 3/1/2015-8/31/2016 HEADACHE ENCOUNTERS: 54,794 11,794 MIGRAINE DX % ENCOUNTERS: 44.64% 56.73% NON- SPECIFIC DX % ENCOUNTERS: 58.05% 46.79% FLOWSHEET USE % 0.01% 11.02% OPIOIDS %: 27.53% 9.76% TRIPTANS % 14.40% 22.31% Most notable from baseline to end of grant is the dramatic reduction of opioid prescriptions as well as the increase in migraine specific therapy or triptans

6 5. Results AIM #1: Create Accessible inter- disciplinary and inter- professional approach to headache care leveraging Project ECHO model. We offered twice monthly video- conferenced (CME) sessions lead by University of Utah specialists for front- line community- based primary care providers. This program included 10 University of Utah Community Clinics. The providers in each clinic had access to consultative care via Project ECHO model. An interdisciplinary, interprofessional team of headache specialists in adult and pediatric headache medicine, a pharmacist, physical therapist and psychologist were part of the mentor team. We also had an embedded primary care specialist as part of the mentor team. We felt this was a crucial component to have buy- in from the clinics recognizing one of their own as part of the team. The multipoint conferencing system allowed providers and staff at all 10 clinics to connect on a regular schedule simultaneously for the educational, consultative clinic from their home clinics. We provided minute didactics at the beginning of every session. These were referred to as clinical updates to allow for reinforcing best practice in headache management. Video conferencing allowed for a living library of reference; including the didactic on power point and follow up s with clinical pearls after each conference. AIM # 2: Increase use of EMR- based tool ID Migraine TM to improve diagnosis specificity. Recognizing that busy PCP s may not know all the questions to ask in a short visit for a headache history, we wanted to have a validated tool implemented into our EMR (EPIC). The ID Migraine TM is available throughout the institution for use. It is a 3 question (yes/no) tool. If the patient has a score or 2 or greater; the probability for migraine diagnosis exceeds 80%. We essentially went from zero percent at start to a 12% adherence rate. AIM # 3: Increase headache diagnosis specificity and migraine specific therapy; reduce opioid prescribing and reduce non- specific headache coding for encounters. Results: Migraine diagnosis and triptans increased while non- specific diagnosis and opioids decreased. See Graph:

7 AIM #4: Reduce Community Clinic referrals to Headache Clinic via innovative approach with Project ECHO model. Results are reflected by 2 time points only: At Grant submission October 2014, 31% of Headache Clinic referrals were from Community Clinics and at close of grant October % of all referrals to Headache Clinic were from Community Clinic. The variability each month was not captured over time and therefore we can t say with certainty this happened. For the 2 points that are presented, a P value is =.021 AIM #5: Increase the confidence of primary care providers to diagnose and manage migraine The results of the study are limited to the number of responders to our pre and post test. Providers who attended were more likely to report having more resources to use when treating headache (chi- square, p=0.000). Providers who did not attend were more likely to report no change in referral pattern (chi- square p=0.000). Discussion Points: Provider Knowledge and Self Efficacy ECHO attendance did not result in statistically significant improvements in self- evaluated knowledge. self- efficacy regarding treatment of headache patients. When asked directly about the efficacy of the ECHO model, providers generally agreed that ECHO helped improve their treatment of headache. Attendance 35% of our sessions were unattended. 6 mentors:? Opportunity Costs Academic network; Unfavorable incentives.

8 Even in Salt Lake City a non University primary care provider consistently attended All attended sessions had 5 providers. Top reasons for non- attendance Did not have time to attend Inconvenient time of sessions offered Conflicted with financial/productivity expectations Discussion: Throughout the grant funding period, early on, we recognized barriers in recruitment to the sessions as well as changing patterns of opioid prescribing even with poor attendance (N>5/session). Significant changes in Federal law took place October 6, Hydrocodone became a schedule II narcotic. This meant no prescriptions could be phoned in and required hard copy prescription. Utah is the 4 th highest state in opioid death by 2015 Health Department Report. A culture shift in other non- opioid treatment for pain has been gaining ground and getting away from prescribing opioids as a treatment for pain. The 1996 mandate for pain as the 5 th vital sign was rescinded in September Conclusions: Headache is a complex problem to treat. It requires skill in history taking as well as time to obtain data/interpret and devise a plan of care. Much of this cannot be done in short minute appointments. Unfortunately, we did not experience a positive trend in collaborative practice model given the low attendance at the sessions offered. We also recognize that competence and confidence are not the same. Thirty percent of the patients presented in ECHO sessions were still seen in the Headache Clinic. A retrospective chart review of case presentations revealed that 50% of the recommendations from the ECHO mentors were not followed by the PCP after an ECHO session. We recognized that limitations in this model had the biggest impact related to geographic patterns. All 10 Community Clinics are within a 30 mile radius to the University. One theory is that the closer proximics to the University, the least likely to utilize Project ECHO model. On the contrary, we have seen an uptake of attendance with the continuation of this program from our rural healthcare partners. This is a valuable resource to access specialists, and the University Medical Group has committed funding for 4 mentors to continue Chronic Pain & Headache ECHO. We are now holding weekly sessions and have focused on the Outreach Network Community.

9 6. Publications and Products Baggaley, S. Improving Headache Care Within An Academic Health System Using Project ECHO Model. Abstract from the 58 th Annual Scientific Meeting American Headache Society; 2016 June 9-12; San Diego, CA. Volume 56, Issue S1 PS12 p 53.