Spokane Pain Initiatives
Alliance Consistent Care Program A community program aimed at
addressing prescription drug abuse and overutilization of the
emergency department
Alliance Consistent Care Program of South Eastern Washington
Tri-Cities Pain Management NetworkMay 22, 2014 My name is Becky
Grohs, RN, CM- I have been an RN for 23 years and a Case Manager
for about 18 years. The majority of my career was spent working for
a managed care organization as a CM. I did spend a lot of time
providing CM services to our members, travelled into the community,
visiting patients in the hospital, working with home health
agencies, nursing home, etc.- I specifically focused on providing
care for Special Needs kids, behavioral health and cd issues, end
of life issues and complex cases, those with trauma or co-morbid
chronic diseases. I come from a community of about 253 K people. We
have 3 separate cities- 3 separate city govts, police, emergency
services, city council, etc. but all 3 cities border each other and
you can get across all 3 cities in about 20 minutes. I started
working for Washington State University and the current ED that I
serve back in January. I met Dr. Neven when he interviewed for my
position and I have been running since. Im incredibly busyIm the
program coordinator the CCP. We have essentially built this program
from the ground up since January. Today I want to share with you my
story of how we have built our program, give you some background
about why were doing what were doing and hopefully, youre able to
take back with you some ways in which you may be able to implement
a similar program in your area. Next Slide1Objectives Learn more
about the Alliance Consistent Care Program
Gain a better understanding of the drivers behind inappropriate
ED visits
Understand the risk of prescription drug misuse
Learn about a CDC sponsored clinical trial
Learn the role Medicaid policy has had in driving better
coordinated emergency department care in Washington State.
I hope that by the end of our hour together that you have a
better understanding.of the need for..2What is the Consistent Care
Program?A community program to reduce Inappropriate ED visitsFocus
attention on preventing prescription drug misuse and overdose
deathsIdentifies and coordinates care for patients that over
utilize the ED at four hospitals-KRMC, Trios Health, LMC and PMHOne
coordinated and shared system (EDIE) Primary methods
used:Coordinate care with primary care physicianDevelop ED Care
Guidelines for each patient that is accessible by emergency
physicians Provide individualized patient-centered case
management
2006- Spokane Consistent CareSeptember, 2011- A study to address
prescription drug abuse and overdose deaths (CDC) August, 2012-
Alliance Consistent Care Program of SE WA
3What we knowPatients frequent multiple EDs for many reasons,
including: pain, multiple chronic diseases, mental illness,
substance abuse issuesMany patients have multiple providers Most
have concurrent mental health diagnosesMany report chronic painSome
have a primary care physicianMost have one hospital they prefer to
frequent, many visit several Most are not forthcoming with
informationMost commonly have Medicaid, Medicare, or no
insuranceThere is a lack of systems in place to coordinate care
between EDs and multiple providersLack of education exists
regarding alternatives to the EDThere is a high incidence of
prescription drug abuse and deaths
Discuss some of these individually4Prescription Drug abuseAmount
of opioid medications sold in the US has quadrupled since 1999.In
2007, Washington state opioid overdose rate exceeded the nations
rate at 8.2 per 100,000 to 4.6 per 100,000 2013 showed a 27%
reduction in WA. More deaths related to opioids than cocaine and
heroin combined. Main cause of death in 17 US states. Nearly 1 in
12 high school seniors reported nonmedical use of Vicodin; 1 in 20
reported abuse of Oxycontin.There has been an increase in Heroin
abuse- Half of those being treated for heroin report an opioid
addiction to start.Now Americas fastest growing drug problem!
Opioids are second only to Marijuana.
Centers for Disease Control. (2012). CDC grand rounds:
Prescription drug overdoses-a U.S. epidemic [MMWR 61(10dCenters for
Disease Control. (2009). Overdose deaths involving
prescriptionopioids among Medicaid enrollees- Washington 2004-2007
[Morbidity and Mortality Weekly Report 58(42) 1171-1175].
Birnbaum, H. G., White, A. G., Schiller, M., Waldman, T.,
Cleveland, J. M., & Roland, C. (2011). Societal costs of
prescription opioid abuse, dependence, and misuse in the United
States. Pain Medicine, 12, 657-667.
Centers for Disease Control. (2009). Overdose deaths involving
prescriptionopioids among Medicaid enrollees- Washington 2004-2007
[Morbidity and Mortality Weekly Report 58(42) 1171-1175].
Prescription drug abuse and death is a huge driver of our work
in reducing inappropriate ED use. In fact, deaths attributed to
prescription drug abuse totals deaths by heroin and cocaine
combined.
In 2007we have a significant problem here in WA state..5Commonly
abused prescriptionsOpioids (used to treat pain): Addiction.
Prescription opioids act on the same receptors as heroin and can be
highly addictive. People who abuse them sometimes alter the route
of administration (e.g., snorting or injecting) to intensify the
effect; some even report moving from prescription opioids to
heroin. NSDUH estimates about 1.9 million people in the U.S. meet
abuse or dependence criteria for prescription opioids.Overdose.
Abuse of opioids, alone or with alcohol or other drugs, can depress
respiration and lead to death. Unintentional overdose deaths
involving prescription opioids have quadrupled since 1999 and now
outnumber those from heroin and cocaine combined.Heightened HIV
risk. Injecting opioids increases the risk of HIV and other
infectious diseases through use of unsterile or shared equipment.
Noninjection drug use can also increase these risks through
drug-altered judgment and decisionmaking.CNS Depressants (used to
treat anxiety and sleep problems): Addiction and dangerous
withdrawal symptoms. These drugs are addictive and, in chronic
users or abusers, discontinuing them absent a physician's guidance
can bring about severe withdrawal symptoms, including seizures that
can be life-threatening.Overdose. High doses can cause severe
respiratory depression. This risk increases when CNS depressants
are combined with other medications or alcohol.Stimulants (used to
treat ADHD and narcolepsy): Addiction and other health
consequences. These include psychosis, seizures, and cardiovascular
complications
Lack of Coordinated careMany patients frequent numerous hospital
EDsLack of communication between EDs
Lack of consistent communication between hospital EDs and
assigned Primary Care Providers (PCPs).
Patients are not forthcoming with medical information Leading to
duplication in diagnostic studies- Radiation overexposureMedication
overprescribingBarrier to communication with care providersHospital
EDs have separate Medical record systems, many have providers that
are owned by the individual hospital systems, but as patients move
around, coordination is lost. Our hospitals are only about 7 miles
apart. Forthcomingeither by choice, or they simply dont have the
tools to organize their care.
7Cross-Domain Communication is
DifficultInter-FacilityIntra-Facility
Kennewick General HospitalKadlec Regional Medical CenterLourdes
Medical Center
Cross Channel
HospitalPrimary
Mental illness and emergency room useMajority (estimated at
around 90%) of our clients have underlying MH needsEstimated that
53% of patients with drug use disorders have co-occurring mental
illness Complicates the treatment of pain opioid abuse is as high
as 32% in patients being treated for painPain potentiates
depression, anxiety and other symptoms of mental illnessPresence of
mental illness compromises patients ability to engage in
coordinated care Lack of communication between behavioral health
providers and medical providers
Horsfall, J., Cleary, M., Hunt, G. E., & Walter, G. (2009).
Psychosocial treatments for people with co-occurring severe mental
illness and substance use disorders (dual diagnosis): A review of
empirical evidence. Harvard Review of Psychiatry, 17, 24-34.
Schindler, A., Thomasius, R., & Petersen, K. (2009). Heroin
as an attachment substitute? Differences in attachment
representations between opioid, ecstasy, and cannabis users.
Attachment and Human Development, 11, 307-330.
Majority of our patients that have been identified have
underlying behavioral health issues9Core Principles of Consistent
CareDo what is best for the patient- not punitiveIdentify the
driving force behind ED use Coordinate care among providers and
hospitalsKeep the primary care provider in controlAssist in
resource identification and application Provide skills and tools
for patients to treat themselvesPrevent prescription
overmedication, abuse and deathAddress community gaps leading to
higher ED utilization
Resource identification- beh health care, drug assessment and
treatment, housing, in-home custodial support, equipment10Tools for
consistent careCommunity CollaborationHospitals working together
Care Guidelines Committee Organizational points of contact, go to
peoplePrescription Monitoring ProgramPatient specific
controlled-substance tracking Habitual access and use by ED
providers and CM staffEmergency Department Information Exchange
(EDIE)Communication among treating hospital EDs and PCPsDatabase
for Case Management trackingPatient Centered Care Plan
developmentCase ManagementProactive and available outside the
emergency departmentSkilled in addressing BH/CD
issuesPatient-CenteredOne Team across all hospitals
There are four main components or tools that are used by the
CCP. They are..11Community collaborationHospitals working
togetherHeld meetings with key leadership in Case Management,
Health Information Technology, Compliance/Privacy and Emergency
DepartmentCommunity effort
Care Guidelines CommitteeIdentified experts and organizations in
the community vested in decreasing inappropriate ED use Create an
opportunity to collaborate
Target and communicate with key go to people in clinics,
hospitals, urgent cares, and community organizations
Went out and met with each hospitals CEO to discuss opportunity
to implement to the program, lead to meeting with key leadership
for buy-in12Care Guidelines Committee Mental Health & Chemical
DependencyCrisis Response, Detox, Lourdes Counseling Center (jail),
community providers, CWCMHHospital Case Management & Emergency
PhysiciansDSHSCPSPublic HealthSafe Moms Safe Babies (BFHD)Community
ResourcesAging and Long Term Care (ALTC)
Pastoral CareFire Departments-Pre Hospital Care
PlansPharmacistConsistent Care Program StaffMedical Director- Dr.
Darin NevenPrimary Care
Just added the Jail Services Supervisor- She is a DMHP that
coordinates the MH and CD services for incarcerated individuals.
Many of whom are the same patients that are in and out of the ED.
Working closer together to coordinate care for individuals as they
leave jail and return to the community. We work with her to obtain
CD assessment and treatment, identify the need for and re-establish
BH care while our patients are incarcerated.13Prescription
monitoring Program (PMP)Controls prescription misuse by providing
practitioners prescription historiesChanges the clinical management
in 41% of the casesAccess to PMP for ED providers and ED Case
Management staffPromote the use of PMP for other providers; dental,
pain management specialists, PCPAbility to use PMP to assess
provider prescribing behavior and identify areas of
improvement/education
Executive Office of the President of the United States. (2011).
Epidemic: Responding to Americas prescription drug abuse crisis
[Policy Report]. DOH program14Emergency department information
exchange (EDIE) Internet delivered tool that facilitates
communication across hospitals and care providers2.5M ED visits
going through EDIE (98%)Ability to identify high users across all
service areasCreates a mechanism to re-insert the PCP as the center
of care through automated notificationsAllows the automated
delivery of individualized care guidelines to the treating ED 24/7
Notifications automatically trigger the delivery of Case Management
services at the time of the ED visitHIPAA Compliant
How EDIE Notifications Work
NotificationsEDIE
HospitalPrimary Care ProviderClinic
Mental Health Provider
2.1.3.4.16Case managementPatient-Centered Establish PCM for
every client
Face to Face or follow-up phone call following day
Care Guideline development Care Plan reflects a individualized
plan for the patient
Promote clinical coordinationCommunicate with PCP, specialists,
pain management, Health Homes, community resources
Proactive Case Management Chemical Dependency refer to substance
abuse screening and treatmentBehavioral Health promote access to
BHSCommunity resource needs- housing, transportation,
medicationsAlternative plans and education to the use of the ED
Key to the effectiveness of this program is the case management.
We are providing a proactive form of case management, were not
waiting for the patient to show up in the er and deliver crisis
mgt, we are contacting them in an effort to divert their care back
to their PCP. Taking the time to learn their story, discover the
gaps, provide the education.
Promote clinical coordination- facilitate the communication
between providers, help identify the sole prescriber and notify the
other providers, be the glue that links the care team together.
Face to Face interaction- provide that consistent message,
consistent face that educates them about approp use of the ER,
together we walk through decision making that lead to their
decision to come to the ED, redirection, gap
identification17Development of the care guidelines
Referral is called in 24 hour referral line
compiled and researched.
Reviewed for appropriateness
Case Manager does case prep
Case Manager calls patient and team
PCPRecommendationsED Care Guidelines Committee
ED Care GuidelinesED PhysicianCare guidelinesED Visit Summary: A
table of all ED visits made by the patient in the metropolitan area
for the past two years.Primary Care Provider: A statement
identifying the patients primary care provider/clinic name
including the phone number. Opioid Recommendation: A recommendation
from the Care Guidelines Committee regarding administering or
prescribing opioids in the ED when objective findings to
substantiate complaints of pain are absentChronic Pain Medication:
A statement identifying if the patient has entered into an opioid
agreement with their provider or is receiving a scheduled supply of
controlled substancesOpioid- No controlled substances should be
administered in the ED or prescribed from the ED for subjective
pain.19Care guidelinesPast Medical History: A compilation of
diagnoses listed on medical records, summary of other pertinent
psychosocial history factors obtained from hospital medical records
including overdose historySecurity Summary: Statements regarding
the security risk of the patient to ED staff and describing
patterns of dangerous behavior demonstrated on prior
visitsReferrals: A statement regarding the referrals recommended by
the Care Guidelines Committee such as chemical dependency
evaluation, psychiatric evaluation, or physical therapy evaluation
CT Scan Statement: A statement summarizing number of CT scans the
patient has received in the last year
What Does edie Look Like?Patient / Visit Summary SectionCare
Guideline SectionInvestigation Section
Registration Reveals Patient on Consistent Care
Patients Care Guidelines placed on chart
EDIEAuto-NotificationAuto-NotificationED HUC is called ED case
manager called/faxed/emailED Care Guidelines Faxed to ED Medical
Director sent text messagePrimary Care Provider faxed
Physician reviews ED care guidelines
Patient Discharged
medical screening exam by ED physician
No controlled substances
ED case manager talks to patient prior to dischargeED Visit
Process
Usual TriageThe next time the patient registers two things
happen- the ED is faxed a copy of the care guidelines and the Auto-
Notifications are sent.22Results
n=540 patients (enrolled from 2006-2011)Ed care coordination
study (CDC)Began in September, 2011- February, 2014No informed
consent requiredFocus on prescription drug abuse and preventing
overdose deaths
165 Participants randomized into the TAU (control) and CCare
(treatment) groupsScreened for those patients with > 50% visits
related to pain complaints
All payer sources- Medicaid, Medicare, Commercial and
uninsured
Collecting data Prescribing behavior- PMP and hospital data 80%
less likely to receive a prescription for controlled substanceED
visit utilization- EDIE>60% reduction in ED visitsFinancial
indicators- hospital data
Replication of the program that has been in existence since 2006
in Spokane, metropolitan area- community with multiple hospital
systems, across several communities.165 patients, TAU defined as
what was a standard of care when study began, numerous changes
across the board and CCare is the CCP program, measure
effectiveness through a number of data sources24What weve
learnedJust communicating with each other and having access to EDIE
information has made huge impactMental health care is key-improving
patient access and adherence We need to learn how better to
communicate with the vulnerable- better skills in the ED around
patient engagement and motivation for changeBeginning to access
training for staffWe need around the clock or late hours access to
Urgent CareBetter screening for Substance Abuse- SBIRT trainingWe
need timely access to primary care appointments- Patients have
PCPs, they just cant get into themEstablish relationships to open
up slots for patients within our programIdentify complex patients
that need regularly scheduled appointments
Mental health care- so many patients have ceased obtaining MH
care, much of what we do is working to re-establish MH
servicesBetter communication- this might also mean, less
communication in the ED. Were learning from MH experts that
promoting the victim role in the ED with some of our borderline
patients is encouraging repeat ED use- instead we are educating ED
providers how best to communicate, limit empathytreat quickly and
release and were directed them back to their therapist where they
can address these issues more appropriately. 25Final thoughtsIts
important to slow the flow of controlled substances our family,
neighbors, and children are dying!
Communication and collaboration with community stakeholders is
critical- get to know your neighbors!
Over-utilization of the emergency room is a symptom of
underlying disease, whether that is poor primary care access or
prescription drug abuse, use your assessment skills and create a
treatment plan. It cant be fixed overnight but you can go a long
way in a short amount of time!
Questions?Becky Grohs, RN, BSN, CCM(509)
[email protected] Case examples27