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Opioid Management using Medication-Assisted Treatment Waivers @ Providence Portland Medical Center

Keywords: Opioid, MAT

Overview

A multidisciplinary effort to increase buprenorphine waiver rates

Innovator

Brinton Clark MD

Editor

Ashley Shaw BA

Location

Providence Medical Group, Providence Portland Medical Center, Portland, Oregon

Organizational Context

  • Providence Portland Medical Center is a community-based academic medical healthcare system that serves the entirety of the large multi-state Portland Service Area and sees patients with various payor sources.
  •  Providence Medical Group primary care clinics are patient-centered medical homes and incorporate behaviorists, pharmacists, and care managers into their practice. 
  •  Oregon ranks second in the nation for non-medical use of prescription pain medication, at 5.7% of the state’s population.
  •  The author Dr. Clark and her colleague Dr. Mari Kai brought this proposal to the Providence Portland Medical Center’s Clinical Transformation Council who were issuing grants of up to $150,000 to providers within the system.

Population Served

  • Providence Medical Group is a large primary care network within a large multi-state integrated healthcare system which sees about ~25% of patients on Oregon Health Plan, the state’s Medicaid plan.

Project Leadership

  • This project was initiated by the author and her colleague Dr. Mari Kai who are teaching attending physicians within the Providence Medical Group. 
  • The leadership team included the two physician champions (the author and Dr. Kai), a clinical pharmacist, a behavioral specialist, and a project manager.

Funding

  • The authors successfully submitted a grant proposal to the Providence Portland Medical Center Clinical Transformation to cover the cost of hiring a part-time project manager for one year and other costs (an extra continuing medical education day, video production, and time for training staff).

Project Research and Planning

  • Baseline Provider Survey
    • The authors conducted a baseline provider survey that was sent to all PCPs (n=300) within the Providence Medical Group to identify attitudes and barriers of medication-assisted treatment of opioid use disorder. 
    • They found that while 77% of responding providers surveyed (n=102) believed that MAT should be provided in primary care, only 24% were somewhat likely to prescribe buprenorphine.
  • Outreach to Medical Directors
    • The authors presented the findings of their baseline provider survey and their video to the Portland Medical Group’s East Side and West Side Medical Directors’ meetings and offered to attend provider meetings at clinic sites.
  • Invitation to Clinic Provider Meetings
    • The authors were then extended invitations to 27 Portland Medical Group clinics to present at clinic provider meetings for on average 20 minute slots.

Project Tools & Components

  • Educational Video
    • The authors collaborated with the organization’s media department to produce a 12-minute educational video highlighting the physician champions’ own experiences with prescribing buprenorphine in the primary care setting.
  • Provider Toolkit
    • The authors formulated a “Provider Toolkit” PDF document easily accessible via the system’s intranet system containing pragmatic instructions for new providers within the system who were interested in obtaining their DATA waiver and answered questions such as:
      •  How do you get training on MAT?
      •  How do you get your buprenorphine prescribing waiver?
      • Suggested clinic protocols and workflows
      • Epic provider note templates for MAT visits
      • MAT Billing FAQ
      • Keeping a DEA patient log
  • Monthly Conference Call
    • The authors set up a monthly conference call using the system’s audio conferencing system into which providers adopting MAT could speak with the authors to troubleshoot any difficulties.
  • Monthly Newsletter
    • The authors produced a monthly newsletter sent out via the system’s e-mail list to any provider who had previously indicated interest in becoming a prescriber, often containing a patient story, scholarly articles, news about recent legislation, and practical tips for integrating a new practice.

Training

  • Over the span of one year, the authors visited 27 area clinics within 45 minutes of their home clinic and spoke on average for 20-minute slots at each clinic’s regular provider meeting. 
  • The authors presented their baseline provider survey, presented their educational video, the Provider toolkit, and introduced themselves as a resource for providers looking to gain this new practice.

Daily Workflow

  • After training, clinicians interested in integrating MAT for opioid use disorder into their practices and/or obtaining their MAT waivers had access to the variety of reference resources listed above.

Budget

$155,000

  •    $150,000 for a part-time project manager (who had already been employed by the health system) for one year to manage:
    • Administration of a provider cohort study in collaboration with the Providence Medical Group’s research group to observe any change in patient costs and healthcare utilization (PCP visits, ER visits) for patients of providers who had adopted MAT practice
    • Project management of video distribution, scheduling clinic meetings, scheduling monthly conference calls, sending out monthly newsletters
  • $5000 for the production of the 12-minute educational video
     

Status

  • The project has concluded but the resources are still available for providers.

Key Outcome

  • Providers with buprenorphine waivers and patients on buprenorphine therapy

Outcome Analysis

  • As of January 2018:
    • Increase in # of Providence Medical Group clinicians with buprenorphine waivers from 5 physicians to 44 physicians
    • Increase in # of patients inducted into buprenorphine therapy from 5 patients to 237 patients
    • Reports of providers new to this practice adopting treatment with 2-3 patients at a time

Benefits

  • The main benefit of this intervention was increased provider awareness and activation surrounding their role combating opioid use disorder in the Portland Service Area.
  • Providers given a post-intervention survey by the authors felt this intervention “gave them a sense of purpose” in combatting a seemingly limitless societal problem and gave them specific pathways to follow after a positive screening for opioid use disorder.
  • The intervention also raised the issue within the larger healthcare system and sparked increased dialogue over improved screening methods and safe transition of patients with opioid use disorder from the hospital back to the community.
  • The intervention sparked ongoing conversations about increased integration of services across the spectrum, including producing clear referral pathways from inpatient treatment of opioid use disorder to intensive behavioral health treatment over time.
  • This intervention increased engagement from the Providence Portland Medical Center’s hospitalist group on inpatient induction of buprenorphine therapy and warm hand-off procedures to community resources.
  • This intervention engaged leadership at all levels, particularly behavioral health leadership and infectious diseases leadership.

Unique Challenges

  • Even with the suite of new support resources created by this intervention, the majority of providers surveyed on the follow-up survey still felt it would be difficult for them to integrate MAT into their practice.
  • Primary care providers relied heavily on the buy-in of behavioral therapists in their clinic as an indicator of whether they could practically support these patients.
  • Younger primary care providers were more open to adopting this practice.

Personnel Challenges

  • This intervention was time-consuming for the leadership team who met for an hour in person every 2 weeks over this period.
  • The next phase of this intervention, which would be to develop referral pathways, would require another full-time project manager.

Relevant Quality Metrics

2018 MIPS Quality Payment Program (QPP) Measures:
Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Relevant metrics include:

  • Documentation of Signed Opioid Agreement
    • All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record
  • Evaluation or Interview for Risk of Opioid Misuse
    • All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record
  • Opioid Therapy Follow-Up Evaluation
    • All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

More details about measures included in the QPP set can be found here.
 

Patient-Centered Medical Home Metrics:
Establishing a team-based opioid prescribing program may help practices meet a number of NCQA Patient Centered Medical Home 2017 Standards. Potential opportunities include standards such as:

  • KM04: Conducts behavioral health screenings and/or assessments using a standardized tool (such as for a substance use disorder)

More information can be found here.

HEDIS Measures:
A number of HEDIS measures added in 2018 relate to opioid prescribing, and may indicate how other programs will measure quality of care related to opioid prescribing in the future. Related HEDIS measures include:

  • Use of Opioids at High Dosage
  • Use of Opioids from Multiple Providers 

More information can be found here.

 

Direct Billing:
Depending on how the program is structured, practices may be able to bill Medicare or other insurers for screening, brief intervention and referral to treatment services. More information about billing Medicare for these services can be found here.

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