Overview

This project utilized virtual care to reduce inappropriate patient opioid use and increase patient safety around opioid use within a network of rural Veterans Affairs adult primary care clinics.

Organization Name

San Francisco Veterans Affairs Medical Center

Organization Type

• Academic Medical Center
• Government organization

National/Policy Context

• Rural communities often lack access to primary care physicians and resources to help those struggling with opioid addiction.
• Telehealth or virtual healthcare visits are being used more frequently to fill gaps in care access.

Local/Organizational Context

• Rural clinics, especially those in socioeconomically disadvantaged populations, often have staff shortages.
• The Veterans Health Administration wanted to assess the potential impact of providing more consistent care to patients in rural clinics via telehealth primary care providers (telePCP) on opioid utilization and opioid-use-related safety measures.

Patient Population Served and Payor Information

• The rural VA clinic involved in this intervention had 2600 patients.

Tech Involved

• Desktop computer
• Video conferencing

Team Members Involved

• NPs
• Physicians

Workflow Steps

• Patients were divided into five patient panels:
  • A nurse practitioner (NP) continuously staffed one panel
  • Three TelePCPs shared two panels
  • The last two panels were staffed by seven locum providers and nine gap coverage providers

Budget Details

• Cost of integrating TelePCPs into multidisciplinary teams
• Labor costs associated with of MDs’ time spent as gap coverage providers

Outcomes

• Patients with >90 Morphine Equivalent Daily Dose (MEDD): Measured the percentage of patients who had >90 MEDD score in October 2018, stratified by the type of team provider.  They also measured percent of patients with >90 MEDD based on clinic location. The CDC states that opioid dosages at or above 50 MEDD increase risks for overdose by at least 2 times the risk of <20 MEDD. 
  • By type of team provider:
    • Locums/temporary (n=973) had 58% of high MEDD prescription patients
    • Medical director (n=450 + unassigned) had 21% of high MEDD prescription patients
    • PCPs’ patients (n=925) had 21% of high MEDD prescription patients
  • By clinic:
    • San Francisco VA: 1.2 % of patients
    • National VA: 0.86% of patients
    • Locums/Temp (rural clinic): 1.75% of patients
    • TelePCP (rural clinic): 0.65% of patients
    • Based on this measure, the Tele-PCPs had the lowest percentage of MEDD prescription patients, which is a positive outcome.
    • PCP/NP (rural clinic): 0.61% of patients
• Opiates per patient: Assessed the total mg/patient opiates given by each type of team provider (n=3592)
  • PCP/NP – Team C: 1.56 mg/patient
  • TelePCP – Team A: 1.94 mg/patient
  • PCP – Team D: 2.24 mg/patient
  • Locums – Team E: 2.68 mg/patient
  • Locums – Team B: 1.40 mg/patient

Benefits

• Using telePCPs can be a favorable option for understaffed rural clinics to provide consistent, safe care to patients, especially safe opioid prescriptions.
• Implementing telePCPs can improve continuity of care for patients who are unable to easily access physicians or who have barriers to following up on appointments.

Glossary

MEDD: morphine equivalent daily dose

Sources

• Crevensten, H., & Abramson, A. (2019 March). VA Virtual Primary Care Providers Reduce Opioid Use and Increase Opioid Safety in Rural VA Clinic. Poster session at the Society of General Internal Medicine Annual Meeting. Washington D.C., United States.
• CDC – National Center for Health Statistics – Calculating Total Daily Dose of Opioids for Safer Dosage. https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf