MINNESOTA FIERCE TACKLING MENTAL HEALTH AND OPIOIDS

Transcription

1 Session Code C26 MINNESOTA FIERCE TACKLING MENTAL HEALTH AND OPIOIDS Paul Goering, MD, Allina Health Tani Hemmila, MS, ICSI Claire Neely, MD, ICSI Charles Reznikoff, MD, Hennepin Healthcare December 11, 2018

2 Nothing to disclose Paul Goering, Tani Hemmila, Claire Neely, and Charles Reznikoff today have no relevant financial or nonfinancial relationship(s) within the services described, reviewed, evaluated, or compared in this presentation

3 Objectives Describe MN Health Collaborative goals and specific strategies for reducing the harm of opioids in the community, including postoperative prescribing, access to addiction care, and demystifying opioids for PCPs Identify strategies for developing shared standards to improve care for acute mental health needs in emergency departments (EDs) and across systems Employ strategies for convening multiple stakeholders towards collaborative action

4 Fierce

5 Commitment The success of this work requires our personal leadership and focused influence, as well as the commitment and resources of our respective organizations. We further commit to a constancy of purpose, to ensure that we achieve the aims we set out to accomplish together.

6 MN Health Collaborative Members Allina Health CentraCare Health Children s Minnesota Essentia Health Fairview Health Services HealthPartners Hennepin Healthcare Medica North Memorial Health Ridgeview Medical Center Sanford Health UCare University of MN Health /University of MN Physicians Hutchinson Health Mayo Clinic

7 Collaborative Commitment Focus on the patient Incorporate evidence and standardize best practice Define common goals Share information, ideas and wisdom Be open to others and testing new ideas Do the work

8 Working Group Qualities Open-mindedness Curiosity Generosity Integrity Commitment Persistence Honesty Respect Passion Courage

9 Move forward together Despite unknowns Push through disagreement Use (and reframe) passion Refuse to be paralyzed by perfection Know that setbacks are inevitable Maintain discipline Build trust

10 MN Health Collaborative Working Groups Acute Pain Prescribing Measurement Acute Needs in EDs Opioid Opioids Epidemic Mental Health Chronic Pain Mgmt & Addiction Communications Integrated Behavioral Health

11 MN Health Collaborative MN Health Collaborative members are changing the community of practice, designing practical, evidencebased and innovative approaches to shared problems.

12 TACKLING THE MENTAL HEALTH CRISIS PAUL GOERING, MD

13 Show of hands How many of you have identified a problem with systems around Mental Health, and then got stuck on what to do?

14 Acute Mental Health Needs in EDs In Minnesota, ED visits for mental health (including substance abuse) increased 75% from , while total ED visits increased 16.2%

15 Acute Mental Health Needs in EDs Improve the ED experience, including transitions, for people with mental health needs and those who serve them. Develop and implement shared standards including assessment, treatment and intervention, and transitions/referrals.

16 Approach as a Collaborative Assess issues and needs existing across organizations Determine shared goal and principles Conduct evidence review and environmental scan Develop recommendations, Calls to Action Commit to implement Test recommendations, iterate forward Adopt and spread

17 Shared Standards: Medical Stabilization Routine laboratory testing including UDS should not be required by facilities accepting patients for psychiatric treatment. Laboratory evaluation should be based on individual patient history and exam. Provides guidance on when further medical evaluation should be considered. If there is disagreement between the receiving facility and ED on evaluation and/or disposition of the patient with psychiatric complaints, the receiving psychiatry clinician and referring ED clinician should discuss the case via phone. Recommendations based on American College of Emergency Medicine (ACEP) guideline, American Academy of Emergency Psychiatry (AAEP), and working group consensus

18 Shared Standards: Medical Stabilization The real work: Building trusting partnerships between ED and inpatient between organizations

19 Shared Standards in Development Suicide Prevention and Intervention in the ED Conduct targeted screening to assess suicide risk If the screen indicates risk of suicide: conduct comprehensive assessment and intervention. Assess to treat and manage, NOT to predict. Use evidence-based protocols for clinical assessment and intervention

20 Florence Nightingale

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22 Allina Health - in progress A clinical pathway for Suicide Prevention across all services is consistent with what is typically done for all other patients who present in the ED

23 Allina Health - in progress Screen Columbia-Suicide Severity Rating Scale (C-SSRS) Ask Suicide-Screening Questions (ASQ) Intervene Linehan Risk Assessment & Management Protocol (LRAMP) Safety Planning Intervention (SPI) Refer Collaborative Assessment & Management of Suicide(CAMS)

24 Early results and successes at Allina Decreased ED LOS for MH patients by >1 hour (1.2 avg) Increased the number of ED MH discharge rate by 4% Decreased repeat visit from 13% to 9% ED 1:1 shifts decreased 52% or 16 hours per day 43% of patients are stratified as low risk and do not require full search, change out or segregation

25 Culture Transformation By engaging front line staff to solve their work flow problems and design the work - and equipping them to support and intervene with patients - our entire ED has been engaged in prioritizing and showing compassion towards people with mental health needs.

26 TACKLING THE OPIOID EPIDEMIC CHARLIE REZNIKOFF, MD

27 Show of hands Who here has ever been prescribed an opioid?

28 Show of hands Who here has ever been prescribed an opioid? Who here got opioids they didn t use?

29 Show of hands Who here has ever been prescribed an opioid? Who here got opioids they didn t use? If you had unused opioids, did you. Keep the opioids? Or Bring to a disposal site? Or Flush down the toilet?

30 Opioid Aims Limit the excess supply of opioids Decrease prescribing and increase disposal Preventing transition to chronic opioid use Lower acute opioids, improve opioid tapering Reducing the risk of opioid-related adverse events Addiction resources and tips for chronic pain patients Not harming patients on opioids for chronic pain Mindful of unintended consequences

31 Approach as a Collaborative Assess issues and needs existing across organizations Many and varied needs Determine shared goal and principles Often driven by emotion (burn out) Conduct evidence review and environmental scan Evidence often lacking

32 Approach as a Collaborative (cont) Develop recommendations, Calls to Action Communication, coordination Commit to implement CEOs support Test recommendations, iterate forward Many hurdles and restarts Adopt and spread

33 Core Principles Managing Pain Pain is complex: sometimes normal, or signals harm, or neither Focus on function and quality of life Patient engagement and education One-size-fits-all approach not sufficient, individualized care Most patients don t require an opioid If prescribing opioids, give the the lowest dose possible Opioid use disorder is not a failing of patient or provider

34 Guidance / Constraints ICSI Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management, 2017 State of MN Department of Human Services Opioid Prescribing Guidelines, 2018 CDC Guideline for Prescribing Opioids for Chronic Pain, 2016 Additional deep literature dive

35 Opioid: Disposal Call to Action for organizations to elevate provider, staff and patient awareness of: The importance of disposing of medications Options for disposal clarified Organizations are working on a variety of activities More pharmacists are educating patients Kiosks added in ambulatory settings for disposal Inpatient disposal methods are being improved

36 Acute Pain Opioid Prescribing Ambulatory clinical settings (primary and specialty), urgent care, emergency departments, and dental clinics The first opioid prescription for acute pain should be the lowest possible effective strength of a short-acting opioid Do not prescribe long-acting opioids for acute pain

37 Postop Opioid Prescribing Goal: sustainable process, implemented broadly Reduce opioid prescription dose and variation while retaining patient-centered approach Initially: common procedure-specific, patient-centered benchmarks Multiple challenges Now: increased flexibility for institutions to examine their post-op prescribing internally Self-determining the QI projects

38 Sample Benchmark

39 Demystifying Opioids Many gaps in knowledge about opioids Demystifying opioids educational package for primary providers Problems identified by the working group Lack of systematic way of identifying opioid use disorder Access issues with medication assisted therapy Discomfort with offering and attempting opioid tapers

40 Tapering Opioid Use Disorder FAQs Guide on how (dose/interval), and when taper is not needed Patients on opioids and benzos Patients on short-acting and long-acting Withdrawal symptoms Created an algorithm to help providers learn to identify OUD and then treat (or refer to treatment) Preliminary discussions on increasing access to MAT Biggest pitfalls Case examples

41 Next Steps Goal: Understand what the collaborative can do to improve the care for patients with chronic pain who are on opioids. Visits to 1-2 primary care sites at each organization in the fall Elicit feedback on materials Learn their process/resources for chronic opioid therapy management

42 CLAIRE NEELY, MD

43 What does it mean to be a fierce collaborative?

44 Backbone organization Build common agenda Align activities Commitment and accountability Shared measures Relationship builder and mediator Manage risk (anti-trust)

45 Behind the Curtain

46 To be a Fierce Backbone: Maintain a disciplined Focus on Forward Movement Constantly use the Psychology of Change Change your Point of View

47 Focus on Forward Movement

48 Know where you are going Because it is not a straight path.

49 ICSI Collaborative Action Framework Systems Thinking Action Evaluation IMPACT Knowledge Sharing Dissemination Sustainability Aims & Goals Commitment

50 Commitment to Test & Spread Scoping & Design Action prototype test validate spread Shared Standards & Accountability Performance & Outcomes Embedding Practices Stakeholder Commitment Collaborative Arc Commitment to Scale Discovery Normalization ICSI

51 Backbone work complexity Commitment to Test & Spread Action prototype test validate spread Shared Standards & Accountability Embedding Practices Scoping & Design Performance & Outcomes Stakeholder Commitment Collaborative Arc Commitment to Scale Discovery Normalization ICSI Stakeholder work complexity

52 Pace the action Not too fast, but faster than they think they can.

53 Iteration is the norm Perfection is the enemy of action.

54 Use the Psychology of Change

55 Make it easy to decide Reduce cognitive burden.

56 Change the conversation Don t admire the problem.

57 Always engage Spread the passion.

58 Change is social It s the relationship.

59 Change your Point of View

60 See the water See the system.

61 See possibilities Even in siloes.

62 See the unexpected And be ready to use it.

63 Hold the vision

64 Questions?

65 THANK YOU