Overview

Nurses provide electronic and in-person monitoring of high-risk primary care patients on long-term opioid prescriptions to ensure appropriate use and efficacy of medication.

Organization Name

Boston Medical Center (BMC) General Internal Medicine

Organization Type

• Academic Medical Center
• Community health center
• Safety net hospital

National/Policy Context

• Opioid use disorder (OUD) prevalence in Massachusetts was estimated to be 4.6% among people 11 years or older in 2015.
• This intervention was designed based on the well-established Chronic Care Model, which emphasizes improving patient outcomes by changing ambulatory care through six major system changes: health care organization, clinical information systems, delivery system design, decision support, self-management support, and community resources.

Local/Organizational Context

• BMC reports to be one of the most comprehensive and influential centers for addiction treatment in the country. BMC has created widely replicated care models and training programs for those at the front lines of the opioid crisis sweeping the nation.
• The Grayken Center for Addiction was established in 2017 and is the umbrella for BMC’s work in addiction treatment. TOPCARE is one of BMC’s many research initiatives in this area.

Patient Population Served and Payor Information

• The general internal medicine practice at BMC serves about 40,000 patients, 50% of whom are insured by Medicaid and 30% by Medicare.

Leadership

• The current TOPCARE team at BMC’s GIM department consists of a General Internal Medicine Nurse Manager, a Program Manager, and a Program Nurse.
• During the randomized control trial (RCT) to test TOPCARE’s efficacy, the clinical staff at the main site consisted of two physicians (Dr. Liebschutz and Dr. Lasser) and two nurses.

Research + Planning

• This program initially started as a pilot in 2013 involving 2 primary care providers and 33 patients over a 5-month period. The intervention was well-received by patients and providers.
  • During the pilot, four of the 33 patients were noted to have either incorrect pill counts, cocaine on urine drug screens, or were not taking their medication as prescribed.
  • The pilot also allowed TOPCARE leaders to learn more about prescription patterns, treatment agreement initiation, and overall workflow at each site.
• The program was expanded to an RCT in which primary care providers were randomized to the TOPCARE program versus usual care.
  • 53 primary care providers (NPs and physicians) were randomized such that 25 clinicians with 586 patients total were in the intervention group and 28 clinicians with 399 patients total were in the control group.
  • Inclusion criteria included being aged 18 years or older and receiving long-term opioid treatment, defined as three opioid prescriptions at least 21 days apart in a six month period.
• The TOPCARE intervention included four components:
  • Nurse care management
  • An electronic registry
  • One-on-one academic detailing (healthcare professional outreach education)
  • Electronic decision tools for safe opioid prescribing
• Clinicians in the control group received electronic decision tools only.
• One or more primary care providers served as a clinical champion at each site.
  • Clinical champions helped to communicate with each site’s administration, the study team and clinicians.

Tools or Products Developed

• Electronic registry:
  • The web-based electronic registry is separate from the EHR and contains imported EHR data such as refill dates and urine drug test results.
  • It produces aggregate results, such as patient lists for prescriptions due on a certain day of the week.
  • It contains an algorithm for determining urine drug test intervals based on a patient’s risk profile as entered in by the nurse care manager.
• Electronic decision tools:
  • These are evidence-based tools for assessment of patient opioid misuse risk (e.g., the Opioid Risk Tool) and interactive tools about ordering and interpreting urine drug tests.
  • The tools are at the publicly available website, at http://mytopcare.org/, and contain content for patients, prescribers, and pharmacists.

Training

• Primary care providers in the intervention participated in a single 45 to 60 minute one-on-one academic detailing session with an opioid prescribing expert.
• This session included information about safe opioid prescribing and monitoring practices, registry reports, patient monitoring and risk stratification, and how to handle complex patient cases.
• Primary care providers in both the intervention group and the standard care group were oriented to usage of the electronic decision tools.

Team Members Involved

• NPs
• Physicians
• RNs

Workflow Steps

• Two nurses work with primary care providers (PCPs) to help treat chronic non-cancer pain.
• Nurses review the patient list with each PCP to identify patients at risk for opioid misuse or dependence.
• Nurses perform weekly assessments of patients with upcoming visits or need for medication refills. Nurses determine whether guideline adherent-care is being met for each patient, by using electronic tools and the electronic registry. Guideline adherent care includes:
  • Clinical assessments for pain, addiction, and opioid misuse risk
  • Controlled substance agreements
  • Urine toxicology screens
  • Pill counts
  • Scheduled visits with primary care provider visits for pain assessment
• Nurses relay to PCPs whether patients need controlled substance agreements and arrange for urine tests and pill counts.
• Nurses do not have a set number of visits or assessments with patients. During visits with the patient, the nurses educate high-risk patients regarding safe medication storage and symptoms of addiction.
• Nurses also perform prescription monitoring checks and prepare prescriptions for primary care providers.
• If abnormalities arise in the prescription monitoring or urine tests, nurses alert primary care providers so that relevant changes are made to the prescription or monitoring plan.
  • Changes to the plan could include closer monitoring, a referral to Boston Medical Center’s Office-Based Addiction Treatment program (a similar nursing-based program managing patients with addiction), a substance use disorder treatment program, other community resources, and/or tapering medications.
  • The next steps take into account the severity of the patient’s addiction, the risk level, and the patient’s interest.
• Nurses have weekly meetings with the project leaders to discuss challenging cases and incorporate registry data (such as results by provider with percentage of patients having treatment agreements and urine tests). Some examples of challenging cases include:
  • Issues with nurses reaching PCPs
  • PCPs and nurses disagreeing about the care of a high-risk patient
  • PCPs and nurses finding it difficult to come up with an appropriate plan for a particular patient

Where We Are

• The RCT was implemented from January 2014 through March 2016 at four urban primary care practices in Boston: the general internal medicine practice affiliated with Boston Medical Center and three internal medicine and family medicine practices at federally qualified community health centers (FQHCs). One FQHC focused on homeless populations, another served a primarily white working-class population, and the third served a mix of Latino and Vietnamese populations.
• In all, the TOPCARE program has been in existence for five years and has expanded since its initial RCT stage.
• As of 2018, there were 36 providers in the program and approximately 240 patients enrolled with BMC GIM.

Outcomes

• Receiving early refills: There was no difference in odds of receiving early refills between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8).
• Guideline-concordant care: At one year, patients in the TOPCARE program were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2).
• Patient-clinician agreement: At one year, patients in the TOPCARE program were more likely to have a patient-clinician agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2).
• Urine drug testing: At one year, patients in the TOPCARE program more likely to undergo at least 1 urine drug test (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0).
• Dose reduction/discontinuation: Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001).
  • In adjusted analyses, intervention patients had a mean (SE) morphine-equivalent daily dose 6.8 (1.6) mg lower than controls (P < .001).

Benefits

• This program aims to decrease misuse of and addiction to prescription opioids.
• Using the interventions in the TOPCARE program resulted in a significant increase in adherence to guideline-based care.
• This program has strengthened the partnership between nurses and primary care providers.

Unique Challenges

• The clinical team also does not have access to prescription and visit data at other hospitals, which can make it difficult to keep track of pertinent patient issues such as substance use and mental health diagnoses and early refill data.
• There was no institutionally-sponsored registry to assist with workflows after the RCT was concluded.
• Not all PCPs in the practice were accustomed to co-management, but PCPs gradually adjusted to the new workflow over time.
• Many providers are interested in this care model and are trying to get patients into the program; however, there are a limited number of nurses (due to funding) for the program to meet the demand.
• RCT limitations:
  • The clinical team relied heavily on EHR information for measuring outcomes, and the study was unable to capture the patient experience such as pain control and function.
    • It was difficult to determine whether opioid dose changes and discontinuation were due to judicious or fearful prescribing. Fearful
  • EHR data is also limited in the accuracy of substance use and mental health diagnoses. It is unclear if patient-provider relationships were affected by dosage changes.

Sources

• Joanna D’Afflitti (BMC GIM Physician)
• Donna Beers (STATE OBAT Associate Director and former BMC Nurse Care Manager on TOPCARE)
• Sherry Brink (BMC GIM Nurse Manager)
• Liebschutz JM, Xuan Z, Shanahan CW, et al. Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial. JAMA Intern Med. 2017;177(9):1265-1272. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710574/
• Lasser KE, Shanahan C, Parker V, et al. A Multicomponent Intervention to Improve Primary Care Provider Adherence to Chronic Opioid Therapy Guidelines and Reduce Opioid Misuse: A Cluster Randomized Controlled Trial Protocol. J Subst Abuse Treat. 2015;60:101-9. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679615/
• TOPCARE site (http://mytopcare.org/)