Bree Collaborative Meeting. March 21 st, 2018 Puget Sound Regional Council

Transcription

1 Bree Collaborative Meeting March 21 st, 2018 Puget Sound Regional Council

2 Housekeeping Web Access: listed throughout room Slide 2

3 Agenda Chair Report and January 24 th Meeting Minutes Action Item: Approve minutes Implementation Report Out: Swedish Medical Group New Topic: Suicide Prevention Action Item: Adopt Suicide Prevention Charter and Roster Topic Update: LGBTQ Health Care Topic Update: Collaborative Care for Chronic Pain Topic Update: Lumbar Fusion Re-Review Topic Update: AMDG Opioid Prescribing Guidelines Implementation Supporting Adoption of the Recommendations Next Steps and Close Slide 3

4 January 24 th Meeting Minutes Slide 4

5 2018: A Look Ahead May 21 st Address from the Health Care Authority Director Looking Back, Looking Forward Reviewing Status of Previous Recommendations Discussing Topics for 2018 July 17 th Reviewing New Topic Proposals and Selecting New Topics Action Item: Select three four topics for 2019 Slide 5

6 New Topic: Suicide Prevention Hugh Straley, MD Chair, Bree Collaborative Chair, Suicide Prevention Workgroup March 21 st, 2018 Bree Collaborative Meeting

7 Workgroup Members Chair: Hugh Straley, MD, Chair, Bree Collaborative (invited) Susan Bentley, DO, Assistant Professor, University of Washington Medical Center Kate Comtois, PhD, MSW, Psychologist, Harborview Medical Center Karen Hye, PsyD, Clinical Psychologist, CHI Franciscan Health Matthew Layton, MD, PhD, FACP, DFAPA, Clinical Professor, Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University Neetha Mony, MSW, Statewide Suicide Prevention Plan Program Manager, Washington State Department of Health (invited) Greg Reger, PhD, Associate Investigator, VA Puget Sound Health Care System Seattle Division Julie Richards, MPH, Research Associate, Kaiser Permanente Washington Health Research Institute (invited) Julie Rickard, PhD, Program Director of Integrated Behavioral Services, Confluence Health Jennifer Stuber, PhD, Associate Professor, University of Washington School of Social Work Jeffrey Sung, MD, Member, Washington State Psychiatric Association Slide 2

8 Issue Suicide is a preventable, public health issue, not a personal weakness or family failure. The health care system plays an important role in the assessment, treatment and management of patients at risk. Over 75% of all WA violent deaths are suicides. Firearms are used in almost half of all suicides. Suicide is the second leading cause of death in ages 15 34, and the fourth leading cause of death in ages American Indians and Alaska Natives die by suicide at a higher rate than every other ethnic and racial group. The rate of suicide is increasing and is higher in WA than in the US, 15 versus 13 / 100,000 in 2014.

9 Results WA Measure Age-Adjusted Rate per 100, N=8 Washington Residents N= Results WA Goal 2020: 14.0 per 100, WA State DOH

10 Suicide Rate by Race/Ethnicity ( ) Age-Adjusted Rate per 100, n=1 n= n=1 01 n= 25 AIAN White Multi NHOPI Black Asian Hispanic n=1 19 n=2 05 n=2 53 AIAN: American Indian and Alaskan Native Multi: Multiracial NHOPI: Native Hawaiian/Pacific Islander WA State DOH Source: DOH death certificates

11 Method of Suicide ( ) Methods Percent Count Firearm 48.0% 2596 Suffocation 24.4% 1322 Poisoning 18.6% 1006 Fall/Jump 3.3% 177 Other 2.3% 125 Cut/Pierce 2.2% 119 Drowning 1.3% 68 Total 5413 Source: DOH death certificates WA State DOH

12 Background USPSTF does not currently recommend suicide risk screening in primary care but does recommend depression screening in primary care PHQ-9 (screen for depression) includes question about suicidality, as do others Aligned with behavioral health integration recommendations Sources: O Connor E, Gaynes B, Burda BU, et al. Screening for Suicide Risk in Primary Care: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Apr. (Evidence Syntheses, No. 103.) Available from: Siu AL, US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, et al. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA Jan 26;315(4): Slide 7

13 WA Suicide Prevention Plan Strategic Direction 1 Prevent acute risk through cultural change, public discourse, upstream prevention and connectedness Strategic Direction 2 Put comprehensive suicide prevention programming in place, train the general public and health professionals, restrict access to lethal means, publicize resources Strategic Direction 3 Expand access to care for people at risk, improve continuity of care, involve the patient s chosen support network and engage in postvention Strategic Direction 4 Improve and better disseminate surveillance data, build collaborations between researchers and state agencies, evaluate programming WA State DOH Source: bs/ suicideprevplan.pdf

14 Strategic Direction #2 GOAL 3: Designated health professions are trained in suicide assessment, treatment and management. GOAL 4: Screening for and limiting access to lethal means is conducted to reduce suicide risk for people in crisis. Train primary care and behavioral health professionals to integrate lethal means counseling into routine and acute care and discharge procedures. GOAL 5: Community members are aware of local resources, including behavioral health services and crisis lines. Widely market existing local behavioral health resource guides and databases, and how to find and use them Display crisis line information and suicide prevention materials in primary care, behavioral health and emergency department settings. Give them to patients and their supporters at appointments or interventions relevant to suicide, including discharge after a suicide attempt. WA State DOH 20

15 Strategic Direction #3 GOAL 1: Access to mental healthcare, substance abuse treatment and crisis intervention services is expanded. Use systems approaches (such as case management, electronic health record alert systems and patient care coordinators) to improve timely and effective care for patients at risk. GOAL 2: Emergency departments and inpatient units provide for the safety, wellbeing and continuity of care of people treated for suicide risk. Continuity of care and peer support. GOAL 3: Families and concerned others are involved, when appropriate, throughout a person at risk s entire episode of care. Educate health and social service providers on involving a self-defined care network in suicide-related treatment. WA State DOH 21

16 DOH Action Alliance for Suicide Prevention Possible actions for year 2 priorities o Connecting resources Programmatic change in predominantly male services, ex. Substance abuse treatment, DV treatment, anger management, etc. o Restoring and expanding existing programs Close the gap between training for providers and what s being done at healthcare systems o Focusing on priority populations Priority populations include men in the middle years, veterans, foster care youth, elderly, American Indian/Alaskan Natives, LBGTQ, by occupation (focus on construction and agriculture), those in transition (high education, military, prisons/jails, continuity of treatment care), rural communities o Changing the framework o Creating and improving data WA State DOH 11

17 Aim To develop implementable standards integrating suicide prevention, assessment, management, treatment, and supporting suicide loss survivors into clinical care pathways. Slide 12

18 Specific Objectives To propose evidence-based recommendations for in- and outpatient care including care transitions, behavioral health, and specialty care for suicide to the full Bree Collaborative on: Comprehensive prevention. Assessment and recognizing risk factors. Crisis response planning, management, and treatment of suicide risk. Follow-up and support after a suicide attempt and/or support for suicide loss survivors after a death. Addressing barriers to integrating recommendations in care. Implementation pathway(s) with process and patient outcome metrics. Identifying other areas of focus or modifying areas, as needed. Slide 13

19 Recommendation Development Plan Have met twice February, March Continue to meet monthly Recommendations expected Winter 2018/2019 Slide 14

20 Recommendation Approve Charter and Roster Slide 15

21 Break

22 Topic Update: Collaborative Care for Chronic Pain Leah Hole-Marshall, JD Medical Administrator, Department of Labor & Industries March 21 st, 2018 Bree Collaborative Meeting

23 Workgroup Members Chair: Leah Hole-Marshall, JD, Medical Administrator, Washington State Labor and Industries Ross Bethel, MD, Family Physician, Selah Family Medicine Mary Engrav, MD, Medical Director, Southwest WA, Molina Health Care Stu Freed, MD, Chief Medical Officer, Confluence Health Andrew Friedman, MD, Physiatrist, Virginia Mason Medical Center Lynn DeBar, PhD, MPH, Senior Investigator, Kaiser Permanente Washington Health Research Institute Mark Murphy, MD/Greg Rudolf, MD, President, Washington Society of Addiction Medicine Mary Kay O Neill, MD, MBA, Partner, Mercer Jim Rivard, PT, DPT, MOMT, OCS, FAAOMPT, President, MTI Physical Therapy Kari A. Stephens, PhD, Assistant Professor - Psychiatry & Behavioral Sciences, University of Washington Medicine Mark Sullivan, MD, PhD, Professor, psychiatry; Adjunct professor, anesthesiology and pain medicine, University of Washington Medicine David Tauben, MD, Chief of Pain Medicine, University of Washington Medicine Nancy Tietje, Patient Advocate Emily Transue, MD, MHA, Associate Medical Director, Washington State Health Care Authority Michael Von Korff, ScD, Senior Investigator, Kaiser Permanente Washington Health Research Institute Arthur Watanabe, MD, President, Washington Society of Interventional Pain Physicians Slide 2

24 Recommendation Development Plan Have met three times January, February, March Continue to meet monthly Recommendations expected Fall 2018 Slide 3

25 MacColl Model Bree Behavioral Health Integration Peterson (VA Multi- Model Review) Unutzer Parchman Community - Mobilize community resources to meet patient need Health System - Create a culture, organization, and mechanisms that promote safe, high quality care Health System Requirements: Leadership Promote effective improvement strategies aimed at comprehensive system change. Leadership Support for system changed and continuous monitoring Provide incentives based on quality of care Incentives aligned to support intervention Clinical Information System - Organize patient and population data to facilitate efficient and effective care. Clinical Information System: Provide timely reminders for providers and CIS - Appropriate reminders patients Decision support Identify relevant subpopulations for proactive care. Facilitate individual patient care planning. Share information with patients and providers to coordinate care. Monitor performance of practice team and care system. Delivery System Design - Assure the delivery of effective, efficient clinical care and selfmanagement support Define roles and distribute tasks among team members Use planned interactions to support evidencebased care. Provide clinical case management services for complex patients Ensure regular follow-up by the care team Give care that patients understand and that fits with their cultural background Decision Support - Promote clinical care that is consistent with scientific evidence and patient preferences Embed evidence-based guidelines into daily clinical practice. Share evidence-based guidelines and information with patients to encourage their participation Use proven provider education methods. Integrate specialist expertise and primary care Self-Management Support - Empower and prepare patients to manager their health and health care Emphasize the patient's central role in managing their health. CIS - Population idenfication; risk assessment CIS - Support Patient and provider communication; telehealth CIS - Measure and monitor and feedback Delivery System Idenfify /Define roles for primary care provider; care manager; and expert consultation Standard workflow with CIS support for stepped, EBM protocols and care Care Manager See CIS See Patient Empowerment See Delivery System See Delivery system Patient Empowerment Operational Stystems and Workflows to support Population based care Accessiblity and Sharing of Patient Information Data for Quality Improvement Integrated Care Team Evidence Based Treatments Treatment planning Additional care coordination Population Registry Outcome Measures Practice Team Care manager Population registry Measurement Planned visits Complex patient resources Operational systems and workflows to support population based care Treatment Protocols Policy and Workflow patient access to behavioral health as a routine part of care; Practice access to Psychiatric services Increasing access to multi-modal care Increasing access to multi-modal care Increasing access to multi-modal care Improving Patient Education and Activation Slide 4

26 MacColl Center for Health Care Innovation Chronic Care Model Community - Mobilize community resources to meet patient need Health System - Create a culture, organization, and mechanisms that promote safe, high quality care Promote effective improvement strategies aimed at comprehensive system change. Provide incentives based on quality of care Clinical Information System - Organize patient and population data to facilitate efficient and effective care. Provide timely reminders for providers and patients Identify relevant subpopulations for proactive care. Facilitate individual patient care planning. Share information with patients and providers to coordinate care. Monitor performance of practice team and care system. Delivery System Design - Assure the delivery of effective, efficient clinical care and selfmanagement support Define roles and distribute tasks among team members Use planned interactions to support evidence-based care. Provide clinical case management services for complex patients Ensure regular follow-up by the care team Give care that patients understand and that fits with their cultural background Decision Support - Promote clinical care that is consistent with scientific evidence and patient preferences Embed evidence-based guidelines into daily clinical practice. Share evidence-based guidelines and information with patients to encourage their participation Use proven provider education methods. Integrate specialist expertise and primary care Self-Management Support - Empower and prepare patients to manager their health and health care Emphasize the patient's central role in managing their health. Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up. Slide 5 Source: Group Health Research Institute. The Chronic Care Model. Models&s=363

27 Bree Collaborative Behavioral Health Integration Integrated Care Team Patient Access to Behavioral Health as a Routine Part of Care Accessibility and Sharing of Patient Information Practice Access to Psychiatry Services Operational Systems and Workflows to Support Population-Based Care Evidence-Based Treatments Patient Involvement in Care Data for Quality Improvement Slide 6

28 Peterson (VA Multi-Model Review) Decision support: Enhance provider education and treatment planning Facilitate interaction between providers Primary care provider education, activation Case management meetings Pain specialist peer support Treatment planning Additional care coordination Active symptom monitoring frequency Addition of case manager into primary care Collect and share information Increasing access to multi-modal care Addition of previously unavailable services Centralization of services Improving patient education and activation Source: Peterson K, Anderson J, Bourne D, Mackey K, Helfand M. Evidence Brief: Effectivenessof Models Use d to Deliver Multimodal Care for Chronic Musculoskeletal Pain. VA Evidence-based Synthesis Program Evidence Briefs [Internet]. Washington (DC): Department of Veterans Affairs (US); VA Evidence-based Synthesis Program Reports.2017 Jan. Increasing breadth, intensity, frequency, duration, and active patient engagement Slide 7

29 UW AIMS Center Collaborative Care Patient-Centered Team Care / Collaborative Care Primary care and behavioral health providers collaborate effectively using shared care plans. It s important to remember that colocation does NOT mean collaboration, although it can. Population-Based Care Care team shares a defined group of patients tracked in a registry to ensure no one falls through the cracks. Practices track and reach out to patients who are not improving and mental health specialists provide caseloadfocused consultation, not just ad-hoc advice. Measurement-Based Treatment to Target Each patient s treatment plan clearly articulates personal goals and clinical outcomes that are routinely measured. Treatments are actively changed if patients are not improving as expected until the clinical goals are achieved. Evidence-Based Care Patients are offered treatments for which there is credible research evidence to support their efficacy in treating the target condition. Accountable Care Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided. Source: AIMS Center University of Washington Psychiatry and Behavioral Sciences. Principles of Effective Integrated Health Care. Slide 8

30 Parchman Leadership Population registry Measurement Planned visits Complex patient resources Policy and Workflow Slide 9

31 Next Steps Patient self-management at core Define best-practices Care coordinator role paramount Defined care team Need flexible but defined model For inclusion in contracts Slide 10

32 Topic Update: Lumbar Fusion Review. Kerry Schaefer, MS Strategic Planner for Employee Health, King County Bob Mecklenburg, MD Medical Director, Center for Health Care Solutions, Virginia Mason Medical Center March 21 st, 2018 Bree Collaborative Meeting

33 Members Consumer Linda Radach, Patient Advocate Providers and Surgeons Co-Chair: Robert Mecklenburg, MD, Virginia Mason Medical Center Jonathan Carlson, MD, PhD, Neurosurgeon, Inland Neurosurgery & Spine Associates Farrokh Farrokhi, MD, Neurosurgeon, Virginia Mason Medical Center Mark Freeborn, MD, Neurosurgeon, EvergreenHealth Spine & Neurosurgical Care Michael Hatzakis, MD, Physiatrist, Overlake Medical Center Andrew Friedman, MD, Physiatrist, Virginia Mason Medical Center Administrators Sara Groves-Rupp, Asst Administrator, Performance Improvement, University of Washington Medicine Purchasers Co-Chair: Kerry Schaefer, King County Gary Franklin MD, MPH, Medical Director, Washington State Department of Labor and Industries Marcia Peterson, Manager of Benefits Strategy and Design, Washington State Health Care Authority Health Plans Lydia Bartholomew, MD, Aetna 2

34 Suggested Changes from Community Scope. Expand inclusion criteria from single level lumbar fusion to increase clinical impact and to facilitate contracting. Non-surgical care. Facilitate evidence-based, multidisciplinary non-surgical care to provide an alternative to inappropriate or unsafe surgery. Spreading and scaling. Offer the option of consulting spine conferences at larger facilities to improve access to bundle for patients and providers in smaller communities.* * Bree s recently-updated joint replacement bundle also suggested the option of implementing the three non-surgical bundle cycles in local communities. Slide 3

35 Suggestions for Expanding Scope Drs. Friedman and Farrokhi 1. Lumbar fusion as a second spine surgery when previous spine surgery is unsuccessful 2. Multi-level fusion, specifically up to but not including six levels 3. Complex spinal fusions, specifically equal to or more than six levels Slide 4

36 Scope 2014: Limited to single-level fusion Although this bundle is limited to single level spinal fusion it could be used as a minimum standard for multi-level spinal fusion surgery. 2018: Applies to lumbar fusion in general Slide 5

37 Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Robert M. McLean, MD; Mary Ann Forciea, MD; for the Clinical Guidelines Committee of the American College of Physicians. 4 April Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation) 2. For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation) 3. In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence) Slide 6

38 Cycle I: Disability Despite Non- Surgical Therapy A. Document disability due to either neurologic symptoms and/or signs of back pain without neurological findings with at least one of the following: 1. Oswestry Disability Index (ODI) 2. Patient Reported Outcome Measuring System-10 (PROMIS-10 ) or other validated scale 3. Document standardized baseline physical function by physical therapist using the Therapeutic Associates Outcome Score. 4. Pain interference scale B. Document imaging findings of lumbar instability on a standard scale that correlates with symptoms and signs C. Document at least three months of structured non-surgical therapy delivered by a collaborative team D. Documentation of persistent disability despite non-surgical therapy Slide 7

39 Topic Update: AMDG Opioid Prescribing Guidelines Implementation Gary Franklin, MD, MPH Medical Director, Washington State Department of Labor and Industries March 21, 2018 Bree Collaborative Meeting

40 Opioid Mortality Source: hs/nvss/vsrr/dru g-overdosedata.htm

41 Workgroup Members Gary Franklin, MD, MPH (Chair), Medical Director, Washington State Department of Labor and Industries Chris Baumgartner, Director Prescription Monitoring Program, Washington State Department of Health David Buchholz, MD, Medical Director of Provider Engagement, Premera Blue Cross Charissa Fontinos, MD, Deputy Chief Medical Officer, Washington State Health Care Authority Frances Gough, MD, Chief Medical Officer, Molina Dan Kent, MD, Chief Medical Officer, United Healthcare Kathy Lofy, MD, Chief Science Officer, Washington State Department of Health Jaymie Mai, PharmD, Pharmacy Manager, Washington State Department of Labor and Industries Mark Murphy, MD, Addiction Medicine, Multicare Health Yusuf Rashid, PharmD, Vice President, Community Health Plan of Washington Shirley Reitz, PharmD, Pharmacist, OmedaRx, Cambia Health Greg Rudolf, MD, Pain Services, Swedish Mark Stephens, Principal, CareSync Consulting, LLC David Tauben, MD, Chief of Pain Medicine, University of Washington Medical Center Gregory Terman MD, PhD, Professor, Department of Anesthesiology and Pain Medicine and the Graduate Program in Neurobiology and Behavior Michael Von Korff, ScD, Senior Investigator, Group Health Research Institute Slide 3

42 Implementation of Focus Areas Opioid prescribing metrics adopted July 2017 Paper submitted to Pharmacoepidemiology and Drug Safety Poster presentation at the American Pain Society Scientific Summit, March 2018 L&I has incorporated metrics as best practices in COHE/Top Tier programs and HCA has implemented metrics in the Apple Health Opioid Prescribing Report DOH will be reporting these metrics as part of the Washington Tracking Network Other health clinics are incorporating metrics as part of tracking opioid prescribing in their population (e.g., The Everett Clinic) Dental prescribing guideline adopted September 2017 DSHS/AMDG/Bree co-sponsored 2 dental conferences, April 19 in Spokane and April 20 in Seattle L&I is scheduled to implement the dental guideline April 1, 2018 HCA has implement opioid policy for Medicaid (FFS & MCOs) in November 2017 and UMP in January 2018 Slide 4

43 Continuing Effort to Reduce Inappropriate Acute Prescribing Append perioperative section of AMDG Interagency Guideline on Prescribing Opioids for Pain Emergent new evidence on postoperative opioid prescribing needs for specific procedures Provide guidance to the DOH Opioid Prescribing Task Force working on rules for perioperative pain management HCA opioid policy did not address postoperative pain management Slide 5

44 Guidelines: Johns Hopkins Source: risis.org/bestpractices Slide 6

45 Guidelines: Michigan Surgical Quality Collaborative Source: Michigan Surgical Quality Collaborative. Opioid Prescribing Recommendations for Opioid-naïve Patients. September m/static/598c503737c e7cc9/t/59ee43d29f8dce62 23ef2af6/ /Opi oid+prescribing+recommenda tions+for+opioids+web b.pdf Slide 7

46 DRAFT: Supplemental Guidance on Prescribing Opioids for Postoperative Pain Supplement provides further guidance on the postoperative period to augment the best practices from the 2015 AMDG Interagency Guideline on Prescribing Opioids for Pain and the AMDG/Bree Dental Guideline on Prescribing Opioids for Acute Pain Management. Although opioids are often indicated to manage severe acute postoperative pain, recent studies show that patients often receive more opioids than are necessary for their procedure. This may result in dangerous and illegal diversion of opioids to those for whom opioids were not prescribed. Increased duration of initial opioid prescription has been associated with increased incidence of chronic opioid use, abuse and overdose. There is no optimal number of pills for a given procedure, but recommendations in table 1 are based on the best evidence to date regarding analgesic needs for the listed procedures and should guide postoperative pain management for procedures with similar pain burden. Slide 8

47 DRAFT: Table 1. Duration of Opioid Treatment for Postoperative Discharge Type I Dental procedures such as third molar or wisdom tooth extraction, graft, implant Procedures such as hernia repair, laparoscopic appendectomy, carpal tunnel release, laparoscopic cholecystectomy, biopsy, meniscectomy Type II Procedures such as anterior cruciate ligament (ACL) repair, rotator cuff repair, discectomy, laminectomy Type III Procedures such as lumbar fusion, knee replacement, hip replacement Patients on Chronic Opioid Therapy Elective surgery in patients on chronic opioid therapy Prescribe a nonsteroidal anti-inflammatory drug (NSAID) or combination of NSAID and acetaminophen for mild to moderate pain as first line therapy If opioids are necessary, prescribe 3 days (e.g., 8 to 12 pills) of short-acting opioids in combination with an NSAID or acetaminophen for severe pain Prescribe non-opioid analgesics (e.g., NSAIDs, acetaminophen) and nonpharmacologic therapies as first line therapy If opioids are necessary, prescribe 3 days (e.g., 8 to 12 pills) of short-acting opioids for severe pain Prescribe non-opioid analgesics (e.g., NSAIDs, acetaminophen) and nonpharmacologic therapies as first line therapy Prescribe 7 days (e.g., up to 42 pills) of short-acting opioids for severe pain. For those exceptional cases that warrant more than 7 days of opioid treatment, the surgeon should re-evaluate the patient before refilling opioids and taper off opioids within 6 weeks after surgery Prescribe non-opioid analgesics (e.g., NSAIDs, acetaminophen) and nonpharmacologic therapies as first line therapy Prescribe 14 days of short-acting opioids for severe pain. For those exceptional cases that warrant more than 14 days of opioid treatment, the surgeon should re-evaluate the patient before refilling opioids and taper off opioids within 6 weeks after surgery Follow the recommendations above for the appropriate surgery type Resume chronic regimen if patients are expected to continue postoperatively Slide 9

48 Accomplishments and Plan Bree workgroup has submitted comments to DOH Opioid Prescribing Task Force on perioperative period Bree workgroup is working to complete the supplement to the AMDG Interagency Guideline on Prescribing Opioids for Pain and the AMDG/Bree Dental Guideline on Prescribing Opioids for Acute Pain Management Anticipate presentation of final draft at July meeting to begin public comment period prior to final vote to adopt at September meeting Develop a one-page summary of the best practices from both the 2015 AMDG guideline and the AMDG/Bree supplement Slide 10

49 Next Steps AMDG will meet to discuss whether an update to the 2015 AMDG guideline is needed by If so, which sections will need updating, which format should be used and who will be involved (Advisory group PLUS Bree)? If Bree is involved, this may need to be prioritized by Bree or Bree could endorse the guideline update as before Leverage efforts to address cohort of patients on longterm, high dose opioid therapy by increasing access and coordinating services (e.g., multimodal intervention, taper, MAT) Slide 11

50 Supporting Adoption of the Recommendations March 21, 2018 Bree Collaborative Meeting

51 Next Meeting: Wednesday, May 23 rd, :30 4:30 Puget Sound Regional Council 5th Floor Board Room 1011 Western Avenue, Seattle WA