Saving & Changing Lives: Ochsner s Opioid Stewardship Program

Transcription

1 Saving & Changing Lives: Ochsner s Opioid Stewardship Program What Sparked our Interest How common opioid dependency was becoming How worrisome the morbidity and mortality in becoming in patient populations How disruptive Opiod patients were in the hospital (contributing to burn-out of providers and nurses, as well as therapeutic uncertainty) 1

2 Starting Out As we began our work, our approach was 1. Preventing Opioid Dependency 2. Treating It It became clear we needed a small army As we began to recruit participants, we found a plethora of professionals who were extremely engaged with the issues themselves, and our ability to make a difference Building the Right Team Identified Executive Sponsor: Chief Quality Officer Allocated Resources: Project Management Support Initial Goal to Change Provider Behavior Enlisted Provider Participants: Representatives from Each Campus Who Expressed Interest Supplemented Team with Pharmacy, Nursing, Legal, Compliance and Security Initially Identified 3 Components for Project Strategy: Education for MDs and Patients Data Transparency, Practice Improvement, Patient Resources Subsequent Work Groups Developed 2

3 Opioid Stewardship Org Structure Team Lead Strategic Program Manager Opioid Stewardship Hospital Opioid Stewardship Clinic Opioid Stewardship ED Opioid Stewardship Pain Treatment Dependency Treatment and Recovery Opioid Management Support Diversions Our First Big Win: ED Data Transparency Provided Blinded, and Eventually Un-Blinded, Data to Each ED Leadership Team: Prescription Volumes and Rates by Provider and Unit The Average Prescription Morphine Equivalent (MEQ) of Each Provider- Converted More Than 200 Opioids to Normalize the Potency Across Different Drugs Information on What Drugs Each Provider and Unit Were Prescribing Also: Established Guidelines and defaulted quantities in Epic prescribing function 3

4 Patient Experience Mean Score 7/6/ Initial Resistance: HCAHPS Physicians Who Prescribe Less Have Same Patient Experience Opioid Prescribing Rate vs. Press Ganey Mean Score by Physician % 5% 10% 15% 20% 25% 30% 35% 40% Opioid Prescribing Rate To Ease Fears, Removed Patient Satisfaction for Pain Despite Lack of Correlation Setting Expectations for Our Patients 4

5 Rx/Day Total Rx 7/6/2018 ED Opioid Prescriptions Opioid Prescribing in the ED , , , Blinded Data Began Un-blinded Data 4,500 4,000 3, , Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ,500 Rx/Day Total Rx ED Compliance To Guidelines 90% % 70% % % 40% % 20% 10% Blinded Data Began Un-blinded Data Formally Published Guidelines % Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2016 Guideline % Average of MEQ/RX

6 OB Expanding to Other Specialties Quantity Standardization (14 Tablets) % of Patients Receiving Opioids (Vaginal vs. C-section Delivery) Rheumatology Quantity Standardization New Patients Receiving Opioids Opioid Risk Tool Transplant 70% 65% 60% 55% 50% 45% 40% 50.3% OB Compliance with Guidelines 52.4% 51.0% 49.8% 48.4% Un-blinded Data 55.1% 55.7% 61.6% 61.9% 65.8% 65.8% 67.1% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Guideline % 2017 Epic Default Quantities Average of MEQ Using our EHR to Help 6

7 Opioid Risk Tool (ORT) Assesses patient s risk of abusing opioids Series of yes/no questions Answers can be pulled in from other areas of chart (PMH, problem list, etc.) Access tool Opioid Management activity Banners 2018 Epic Systems Corporation. Used with permission. Opioid Health Maintenance Plan Four Opioid Health Maintenance Plans based on patient s risk level Unknown or Low Risk Pain contract Opioid Risk Tool (ORT) Moderate Above plus Urine drug screen every year High Above plus UDS every 6 months Prescribe naloxone 2018 Epic Systems Corporation. Used with permission. 7

8 Morphine Equivalent Daily Dose (MEDD) MEDD calculated for opioid outpatient prescriptions Normalizes various opioid potencies and doses Appears in workflows where providers prescribe medications 2018 Epic Systems Corporation. Used with permission. Louisiana Prescription Monitoring Program (PMP) one click 2018 Epic Systems Corporation. Used with permission. 8

9 Opioid Management Activity - Links 2018 Epic Systems Corporation. Used with permission. Opioid Management Activity 2018 Epic Systems Corporation. Used with permission. 9

10 Pain Contract Provider prescribing opioids should initiate with chronic opioid users Patient and provider sign contract Contract includes various requirements for the patient Main requirement Can only have opioids prescribed by contract provider Banner to alert other providers patient is on pain contract 2018 Epic Systems Corporation. Used with permission. Preventing Patient Overdoses Identify High-Risk Patients Epic Alert to Help Identify Patients at High Risk for Overdose: Patient Takes an MEQ >90/day or Patient is Currently Prescribed Both an Opioid and a Benzodiazepine or Patient has a Diagnosis of Substance Abuse or Opioid Dependence. If MD Enters Opioid Rx and Patient Meets Criteria, Epic Alerts Provider to Consider Writing Naloxone Order Increase Naloxone Availability Established Naloxone Standing Orders in All Ochsner Pharmacies At the Time, Only 4 LA Pharmacies Had Naloxone Standing Orders 10

11 Doing Our Part: Drug Diversion Response Team Use Data Analytics to Audit Internal Controlled Substance Utilization Investigate Any Reports of Drug Diversion or Loss of Controlled Substances Monthly Interdepartmental Meeting Representation from Pharmacy, Nursing, Compliance, Legal, and Pain Management In Pilot Phase- Plan to Expand to All Ochsner Sites in 2018 Innovative Approaches to Pain Treatment Healthy Back Program 10 Week Program- Two Times Per Week Patients Reported a 62.5% Decrease in Pain After 10 Weeks of Treatment Medicaid Grants to Provide Services Not Usually Covered: PT Paravertebral Facet Joint Blocks Virtual Reality to Reduce Initial Exposure to Opioids 11

12 Functional Restoration Program Outpatient, Multidisciplinary, Three-Week Program Includes: Pain Medicine, Pain Psychiatry Specialists, Physical & Occupational Therapists, Social Workers & Nutrition Coaches Focus on Reclaiming Function & Patient- Centered Goals Program Currently Completing 6 th Cohort, 30-days After Program, Patients Report: 51% Decrease in Disability Due to Pain 32% Improvement in Sleep 63% Improvement in Mood Opioid Free Cases Opiate Free Protocol Cases > 2 Hours Pre-operative IV Acetaminophen and IV Ibuprofen Started with Colorectal & Urology Procedures Other Procedures to Limit Opioid Use: Knee & Hip Replacements 12

13 Engaging With Our Community Drug Take-Back Bins Supply Naloxone to Police Departments Education to Middle School & High School Students Future Partnership with LSU Vet School Act #76 (Senate Bill 55) Requires Accessing a Patient s PMP Every 90 Days for Patients on Opioids >90 days. Auto Enroll Prescribers into the PMP Who Get a New License and at Renewal (Every 3 years) Require 3 Hours of Continuing Education Prior to License Renewal Worked to Successfully Pass Louisiana Legislation Act #82 (House Bill 192) Limit Opioid Prescriptions to Seven Days for a Patient s First Prescription Act #88 (House Bill 490) Create an Advisory Council on Heroin and Opioid Prevention and Education 13

14 Expanding Opioid Use Disorder Treatment Options Our New Psychiatric Hospital- River Place Behavioral Health- Will Open a Dual Diagnosis Unit in Early 2018 Offering Detoxification and Induction with Buprenorphine for Opioid Dependent Patients with Acute Psychiatric Issues Psychiatry's Suboxone Program (OchMAT) is Underway Adding Additional Support to Capture a Greater Range of Disease Severity. Intensive Outpatient Program for Substance Use (Addictive Behavior Unit) is Streamlining its Services for Opioid Dependent patients Providing Easier Access to Outpatient Suboxone Treatment. Partnerships with Behavioral Health LGEs Zip Code City Parish LGE Metairie Jefferson JPHSA Metairie Jefferson JPHSA Metairie Jefferson JPHSA Metairie Jefferson JPHSA Metairie Jefferson JPHSA Metairie Jefferson JPHSA Metairie Jefferson JPHSA Metairie Jefferson JPHSA Metairie Jefferson JPHSA Des Allemands Saint Charles SCLHSA Ama Saint Charles SCLHSA Arabi Saint Bernard MHSD Metairie Jefferson JPHSA Barataria Jefferson JPHSA Belle Chasse Plaquemines MHSD Boothville Plaquemines MHSD Boutte Saint Charles SCLHSA Braithwaite Plaquemines MHSD Buras Plaquemines MHSD Chalmette Saint Bernard MHSD Chalmette Saint Bernard MHSD Destrehan Saint Charles SCLHSA Edgard St John The Baptist SCLHSA Empire Plaquemines MHSD Garyville St John The Baptist SCLHSA Gramercy Saint James SCLHSA Gretna Jefferson JPHSA Gretna Jefferson JPHSA Metairie Jefferson JPHSA Gretna Jefferson JPHSA Hahnville Saint Charles SCLHSA 14

15 Hard Decisions: Seek Care Elsewhere 2017 Strategy Review Education Patient Education (1-pager and Packet) Patient Video Nurse Education Conference Finalize Policy System Communication Data Transparency Prescribing Reports (Hospital and Clinic) could they be done off of PMP Dashboard in Tableau Opioid Risk/Benefit Dashboard (Epic) Improving Practice Opioid Risk Tool Registry Urine Drug Screen Patient Contract PMP/Epic Integration High Risk Flags Patients with Multiple prescribers Quantity and Potency Standards* Patient Resources Grants Safe Pain Management Program BCBS Partnership need integration of governmental, payer, and providers Addiction Treatment and Recovery 15

16 2018 Goals Education Opioid Conference Monroe Hall Educational Series PSO Protection Expand CVS Education into Schools Opioid Stewardship Website Improving Practice 100% Adoption of the PMP Inpatient MEQ Calculator Pre-Op Opioid Screening Opioid Smart Set Project ECHO Data Transparency Sharing prescribing data throughout Primary Care Establish Routine metrics for Prescribing Multiple Prescribing Letter Develop System Metrics Patient Resources Grants Safe Pain Management Program Addiction Treatment and Recovery More integrated (Investigate Referral Center) More non- pharmacological Chronic Pain Options Pediatric Sickle Cell Initiative If Not Us, Not Us, Then Who? Then Who? 16