You can win a Pizza Party for your office!

Transcription

1 You can win a Pizza Party for your office! Geeta Patwa, MD and her staff from Chaparral Medical Group were the winners of the last InfoLink Pizza Party.

2 IMPROVING QUALITY OF LIFE: INTER VALLEY FOCUSES ON HEART FAILURE MANAGEMENT Because chronic heart failure (HF) is one of the top three chronic diseases diagnosed among individuals aged 65 years and older, Inter Valley is focusing on HF for its 2016 to 2018 quality improvement program (QIP) to promote effective management of chronic disease. Our goal is to lower rates of member mortality and to improve their quality of life. National HF Trends The 2015 American Heart Association (AHA) statistics on heart disease and stroke show that 5.7 million people in the United States have HF, with a projected increase to 8 million by Of the 870,000 individuals diagnosed with HF annually, 50% will die within 5 years. HF is one of the leading causes of hospitalization for those aged 65 years and older. Over 50% of those with HF are readmitted to the hospital within six months of hospital discharge. Inter Valley Health Plan HF Trends Members with HF represent 13% of Inter Valley Health Plan membership. Of members admitted to the hospital with HF, 9.4% are readmitted. Of the 2,893 members identified with HF, only 58% are receiving treatment with angiotensinconverting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or beta blockers. Physician Oportunities Improve your patients adherence to their thera peutic regimens with appropriate prescribing and optimization of ACE inhibitors, ARBs, and beta blockers. Promote clinical practice guidelines. Increase the average daily supply of ACE inhibitors, ARBs, or beta blockers to at least 180 days when patient compliance is at 50%. Increase the percentage of members who are receiving proper clinical treatment for HF. Heart Failure Management Implementation Detailed reports of which patients are not receiving treatment for HF will be available to physicians and provider groups. Physicians and their patients are encouraged to contact our dedicated Care Management team for assistance obtaining nurse interventions, developing treatment plans, and promoting behavioral changes to improve coping with HF. Clinical practice guidelines, educational materials, and other support tools will be made available in order to inform and engage physicians and members. Overall Outcome for the Heart Failure Management Program Reduce the risk of hospitalizations which may help mitigate readmission and improve overall management of members in the outpatient setting. Reduce the risk of nonfatal heart attacks in patients with HF. Improve the quality of life for patients with HF and increase patients satisfaction with their care. 2

3 GET YOUR OFFICE RUNNING SMOOTHLY When your office isn t running smoothly (exam rooms aren t stocked, nurses are running from patient to patient, patients are waiting too long, or the paperwork is piling up), it s the patients who suffer most. Most problems in a doctor s office can be traced back to inefficiency in processes rather than problems with staff. Here are some simple ideas to help you treat inefficiency in your office, so you can keep the focus on treating your patients. Map it out. Make a flow chart of the steps involved in each of your processes from beginning to end (eg, the steps for providing a patient referral or the steps for scheduling lab testing). Once you can see all the moving parts, it will be easier to determine improvements. Hold staff meetings. Have a brief staff meeting each morning to discuss the day s schedule and troubleshoot any potential problems. This will give you a chance to come up with a plan if you anticipate obstacles. Stay informed. Make sure both you and your staff have all the information you need about how various processes work. The more you know, the more successful you will be and the better able you will be to make any necessary adjustments as challenges arise. Manage patient expectations. Explain what you can about a process to your patients in advance, so they know what to expect. If they are prepared for what comes next, they will feel more comfortable and have more trust in you and your staff. Foster teamwork. A smooth-running office requires everyone s involvement, from the front desk to the exam room. Make sure you are fostering an environment of teamwork. TIMELY ACCESS TO CARE Every year Medicare members are asked to rate the Health Plan and their doctors on the members ability to obtain Access to Care in a timely manner. This rating system is one of the important scores that affect the health plans 5-Star Rating. URGENT APPOINTMENTS We understand that managing the expectations of Medicare members can be tricky, but California law requires that health plans provide timely access. This means that there are limits on how long patients should wait to get health care appointments. The purpose of the timely access law is to make sure patients get the care they need. Sometimes appointments may be needed even sooner than the law requires. In this case, the doctor should provide that appointment or direct the patient to Inter Valley so that we may help them obtain an appointment from another doctor if needed. NON-URGENT APPOINTMENTS Sometimes waiting longer for care is not a problem. You may offer longer wait times if it s not harmful to the health of the patient, but explaining the delay to the member is essential. On your right are guidelines from the Department of Managed Health Care. Inter Valley Health Plan requests that the office staff is aware so they can better meet the California law and manage the expectations of Inter Valley Health Plan members. 3

4 PSA LEVEL SCREENING: TEST OR NOT TO TEST population, regardless of age. They say the tests may find cancers that are so slow-growing and that routine intervention and the associated serious side effects offer no benefit, on a population-wide basis. So, what should be done about the issue of PSA testing? First, ask your male patients to do a little family history search to determine if there is a first-degree relative (father, brother, uncle, or grandfather), with a history of prostatic cancer. As you know, elevated PSA levels and the benefit of related interventions, have come into question in recent research reports. Inter Valley Health Plan has encouraged its members to talk to their doctors about the benefits, risks, and limitations of prostate cancer screening before deciding whether to be tested. The American Cancer Association (ACA) guidelines make it clear that prostate-specific antigen (PSA) testing should not occur unless this discussion happens. They recommend that most men at average risk for prostate cancer start the discussion at age 50 and those with higher risk for prostate cancer should start the discussion earlier. The U.S. Preventive Services Task Force (USPSTF) and the American Association of Family Practitioners (AAFP), however, don t recommend routine PSA screening for men in the general Second, determine if they have had the test in the past, as one of the important aspects of this test is not just the PSA level today, but that level in relationship to previous levels. Third, be prepared to answer a few questions for your patients about PSA screening and whether it is right for them. This will assure that your patients fully understand your answers, and ultimately that they are comfortable with your recommendation to test or not to test. 4

5 PHARMACY UPDATE Inter Valley Health Plan s Pharmacy and Therapeutics Committee continually reviews all drugs for formulary inclusion or exclusion. This information was accurate at the print date. For more up-to-date information about additions, limitations or exclusions on our Formulary please visit our website at Aspx or call Pharmacy Services, 7:30 am to 8 pm, 7 days a week, at or TTY/TDD SERVICE TO SENIORS & OC PREFERRED CHOICE ADDITIONS TO THE FORMULARY COVERED ALTERNATE TIER UTILIZATION DRUG NAME DRUG NAME DESCRIPTION LIMITS ALOSETRON TAB 0.5, 1MG LOTRONEX Generic Drugs PA, QL (60 per 30 days) BEXAROTENE TARGRETIN Generic Drugs PA BREO ELLIPTA INH LUTIACASONE & VILANTEROL Preferred Brand GLATOPA INJ 20MG/ML COPAXONE Generic Drugs PA, QL (30 per 30 days) DIGOXIN TAB 0.125MG DIGOXIN Generic Drugs DUTASTERIDE CAP 0.5MG AVODART Generic Drugs QL (30 per 30 days) LANTUS INJ 100/ML VIAL INSULIN GLARGINE Preferred Brand QL (30 per 30 days) LEVOTHYROXINE TAB 25, 50, 75, 88, 100, 112MCG LEVOTHYROXINE Preferred Generic LEVOTHYROXINE TAB 125, 137, 150, 175, 200, 300MCG LEVOTHYROXINE Preferred Generic KLOR-CON 8 TAB 8MEQ ER POTASSIUM CHLORIDE Preferred Generic KLOR-CON 10 TAB 10MEQ ER POTASSIUM CHLORIDE Preferred Generic KLOR-CON M20 TAB 20MEQ ER POTASSIUM CHLORIDE Preferred Generic LYRICA CAP 25, 50, 75, 100 MG PREGABALIN Preferred Brand LYRICA CAP 225, 300MG PREGABALIN Preferred Brand LYRICA SOL 20MG/ML PREGABALIN Preferred Brand MEMANTINE TAB HCL 5, 10MG NAMENDA Generic Drugs QL (60 per 30 days) MEMANTINE TITRA PAK 5-10MG NAMENDA Generic Drugs QL (60 per 30 days) MYCOPHENOLATE CAP 250MG CELLCEPT Generic Drugs PA MYCOPHENOLATE TAB 500MG CELLCEPT Generic Drugs PA OLOPATADINE DRO 0.1% PATANOL Generic Drugs PREDNISOLONE SUS 1% OP PREDNISOLONE Generic Drugs PREMARIN TAB 0.3, 0.45, 0.9, 1.25MG CONJUGATED ESTROGENS Preferred Brand XELJANZ TAB 5MG TOFACITINIB Specialty PA DESERT PREFERRED CHOICE ADDITIONS TO THE FORMULARY COVERED ALTERNATE TIER UTILIZATION DRUG NAME DRUG NAME DESCRIPTION LIMITS LEVOTHYROXINE TAB 25, 50, 75, 88, 100, 112MCG LEVOTHYROXINE Preferred Generic LEVOTHYROXINE TAB 125, 137, 150, 175, 200, 300MCG LEVOTHYROXINE Preferred Generic PA = Prior Authorization QL = Quantity Limits 5

6 OPIOID DISCONTINUATION FAQs 6 With careful patient selection, education, and monitoring, opioids can be safe and effective tools to improve function and pain intensity in chronic non-cancer pain. However, discontinuation may become necessary, either because of inefficacy, adverse effects, or misuse. The table below provides information to help clinicians deal with this challenging patient care situation. CLINICAL QUESTION: What are some situations to which opioid tapering and/or discontinuation might be considered? Misuse Re-evaluate treatment 1 Educate patient 1 Increase frequency/intensity of monitoring 1 Involve addiction or mental health providers 1 Prescribe limited quantities 1 Egregious misuse (injecting tablets) will likely require discontinuation 1 Use of illicit drugs or non-prescribed opioids Refer, ideally to a specialized program that can provide directly-observed therapy. 1 Diversion Usually requires immediate discontinuation. 1,2 Alternative is to refer to a specialized program that can provide directly-observed therapy. 1 Non-adherence to opioid agreement Restructure therapy (more intense monitoring, opioid tapering, addition of non-opioid or psychiatric treatment). 1 Overdose Adverse effects (sleep apnea, low libido, nausea, constipation) 1,4 Consider opioid rotation (e,g, switching patient from one opioid to another). 1 Consider tapering to a safe dose and continuing. 2 True allergic reaction requires immediate discontinuation. 10 No progress toward therapeutic goals If there is no sustained clinically meaningful improve ment (> 30%) in pain AND function, compared to base line or dosage increase, using validated tools, then 2 Discontinue, 2 or Go back to previous dose if it provided some benefit. 3 Tools recommended to assess progress in this context include the Three Item PEG Assessment Scale and the Two Item Graded Chronic Pain Scale, available at Files/2015AMDGOpioidGuideline.pdf. Reduced analgesia Restructure therapy (e.g., more intense monitoring, opioid tapering, addition of non-opioid or psychiatric treatment) 1 Hyperalgesia Discontinuation probably necessary. 5 Repeated dose escalation or need for high doses 1 Assess risk/benefit: 1 Assess underlying diagnosis and concomitant condition. 1 Assess psychological issues and social situation. 1 Assess pain control, function, quality of life, and progress toward therapeutic goals. 1 Assess adverse effects. 1 Assess adherence. 1 Rule out misuse or diversion. 1 Restructure therapy (e.g. more intense monitoring, opioid tapering, addition of non-opioid or psychiatric treatment). 1 Consider opioid rotation. 1 Consider dose reduction rather than complete discontinuation if opioid is providing some benefit. 5 Consider prescribing naloxone for patients on high doses to keep patients and families safe CLINICAL QUESTION: How do I prepare patients for opioid discontinuation? When starting chronic opioid therapy, set clear expectations. This may help prevent opposition to discontinuation if it is indicated later. 2 Use motivational interviewing techniques to identify reasons for patient opposition to discontinuation. 2 Identify and treat depression to improve pain control and improve taper success. 2,9 Patient education points Chronic pain is complex, opioids are not a cure-all, and may not provide adequate pain relief long-term. 2,4 Side effects of chronic opioid therapy include low hormone levels leading to fracture risk, low libido, and low energy and mood; worsening sleep apnea, leading to fatigue, and constipation. 1,4 When opioids are no longer providing good pain relief, most people feel better without them. 4 Most patients do not experience increased pain. 1,3 You are not abandoning the patient, and will help them with their pain. 9 Pain will be addressed with non-opioid alternatives. 2,5,9 Withdrawal symptoms are uncommon if the dose is tapered slowly. 9 CLINICAL QUESTION: What can be expected if the opioid is tapered or discontinued? Patients being tapered due to lack of efficacy may or may not experience a worsening of pain. 1 In VA populations (n=50) being tapered for reasons other than aberrant behavior, 70% of patients had no change or less pain vs baseline despite a 46% average dose reduction. 1 Some insomnia and anxiety should be expected. 4 Patients should plan ahead for not feeling well. 4 Increased pain is an early symptom of withdrawal, pain with opioid dose reductions is not a sign that the

7 OPIOID DISCONTINUATION FAQs opioid is effective for the patient s pain. 4,9 Pain due to withdrawal should resolve after the first week. 4 Unmasking of psychiatric conditions may occur. 1 CLINICAL QUESTION: How should the opioid be tapered / discontinued? General Concepts High quality evidence to guide tapering is lacking, individualize. The reason for discontinuation and the amount of opioid being used will influence the rate of taper. At high doses, rapid taper may cause withdrawal or drug seeking. 1 Discontinuation immediately if there is diversion. 2 Adjust taper based on response, such as appearance of withdrawal symptoms. 2 Consider referral for patients who have risk factors for failure. High-dose, substance use disorder, active psychiatric disorder, previous outpatient taper failure, or benzodiazepine use. 2 If benzodiazepine discontinuation is indicated, discontinue opioids before discontinuing benzodiazepines. 2 Consider consolidating the patient s opioids into a single long-acting formulation. 4 Choose a product that offers small dose increments (e.g., morphine 10mg) to facilitate slow tapering. 3 A short acting formulation can be used once the lowest dose of the long-acting formulation is reached. 9 Fentanyl patch can be switched to a long-acting 9, 10 formulation, or tapered in decrements of 12 mcg/hr. Before constructing the taper, check for insurance coverage limitation, and availability of specific opioid products/strengths at your local pharmacy. Flexibility may be needed. Tapering Protocols Taper over two to three weeks in the event of severe adverse effects, overdose, or substance abuse disorder. 2 Otherwise taper by 10% or less of the original dose per week. 2 An even slower taper (e.g., 10% every two to four weeks) may be needed for patients who have been taking opioids for years. 9 High doses may be able to tapered rapidly (e.g., 25% to 50% every few days) until reaching 60 mg to 80 mg of morphine or its equivalent. Then the rate can be slowed (e.g., 10% of the original dose per week) to prevent withdrawal. 1 Keep in mind that a more rapid taper may be possible. The minimum dose to prevent withdrawal may be only 25% of the previous day s dose. 9 A sample Opioid Tapering Template is available at Opioid-Taper-Template.pdf. CLINICAL QUESTION: How should the patient be monitored during dose reduction or discontinuation Check pain control and functional status at each visit. 2 Managed increase pain with non-opioids. 2 Monitor for psychiatric disorder such as depression or panic disorder. 2 Monitor for withdrawal (e.g., flu-like symptoms, insomnia, anxiety, abdominal cramps and other GI symptoms, goose bumps, fatigue, malaise). 4 If withdrawal symptoms occur, managed the symptoms (see below) and slow the taper (e.g., to 5% per week) or suspend the taper, do not increase the dose (Don t backpedal). Warn patients that they are at risk of overdose if they try upping the dose on their own. Opioid tolerance is lost after a week or two of abstinence. 3 Consider prescri bing naloxone for use in an overdose emergency. CLINICAL QUESTION: What adjunctive medications may help with withdrawal symptoms? Acetaminophen or NSAIDs for malaise and myalgias. 5,6 Ondansetron 8 mg q 12 h for nausea and other symptoms. 6,8 Trazodone for insomnia (25 mg to 100 mg at bedtime). 5 Hydroxyzine 25 to 50 mg three times daily as needed for anxiety, lacrimation and rhinorrhea. 7 Loperamide for diarrhea (not usually needed for gradual taper). 5 Clonidine is not usually needed for gradual tapers. 3 References 1. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10: Washington State Agency Medical Directors Group. Interagency guideline on prescribing opioids for pain. 3rd edition, June wa.gov/files/2015amdgopioidguideline.pdf. (Accessed October 30, 2015). 3. Harden P, Ahmed S, Ang K, Wiedemer N. Clinical implications of tapering chronic opioids in a veteran population. Pain Med 2015;16: University of British Columbia. Squire P, Jovey R. Managing opioid withdrawalinformation for patients Patients-TCMP-2014-Managing-Opioid-Withdrawal.pdf. (Accessed October 31, 2015). 5. Saskatoon City Hospital. Rx Files. Opioid tapering. July rxfiles/uploads/documents/opioid-taper-template.pdf. (Accessed October 31, 2015). 6. Smithedajkul PY, Cullen MW. Managing acute opiate withdrawal in hospitalized patients. ACP Hospitalist. October archives/2009/10/residents.htm#sb1. (Accessed October 31, 2015). 7. Butt P, McLeod M, Becker-Irvine C. Saskatoon Health Region. Mental Health and Addiction Services: Brief/Social Detox unit. locations_services/services/mhas/documents/resources%20for%20professionals/ Opioidwithdrawalprotocol-finaldraftJan _000.pdf. (Accessed October 31, 2015). 8. Wakim JH. Alleviating symptoms of withdrawal from an opioid. Pain Ther 2012;1:4. 9. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc 2015;90: U.S. Department of Veterans Affairs/U.S. Department of Defense. Tapering and discontinuing opioids. May OpioidTaperingFactSheet23May2013v1.pdf. (Accessed November 1, 2015). PL Detail-Document, Opioid Discontinuation: FAQs. Pharmacist s Letter/Prescriber s Letter. December

8 INTER VALLEY HEALTH PLAN 300 South Park Avenue PO Box 6002 Pomona CA PRESORTED STD U.S. POSTAGE PAID PERMIT #108 CLAREMONT CA Info-Link CONTRIBUTING EDITORS Kenneth E. Smith, MD, MBA Chief Medical Officer Cyndie O Brien Communications Emma Adarkwa Communications Fidel Valenzuela, Pharm D Pharmacy Susan Tenorio, BSN, RN Plan Operations Reynaldo Whitt, RN Health Services EDITOR S NOTE: We value your opinion. If you have any comments on this issue or have a topic suggestion for future issues, please contact Cyndie O Brien at or cobrien@ivhp.com. Inter Valley Health Plan is a not-for-profit HMO with a Medicare contract. Enrollment in Inter Valley Health Plan depends on contract renewal WIN A PIZZA PARTY ON US! Inter Valley is proud of their providers and all the great work they do. As a token of our appreciation we are rewarding one lucky physician and their entire staff with a pizza party, delivered directly to their office. Geeta Patwa, MD and her staff from Chaparral Medical Group are the most recent winners of our Physician Pizza Party. Their office is located in Pomona. Your staff provide exceptional care to patients, and essential support to you every day. Show them how much you appreciate all they do by entering them for a chance to win. Fill in the information below and mail to Inter Valley Health Plan, Attn. Pharmacy Dept, 300 South Park Ave, PO Box 6002, Pomona CA , or fax to Entries must be post-marked by April 22, Encourage your patients to make their as far in advance as possible. 2. Give your patient as much as you can. 3. If a patient has undergone and the results are, and. 4. Encourage your patient to become or stay, and suggest. 5. Ask about all the your patient takes in order to avoid with other. Physician: Phone: Office Address: Zip: