A multidisciplinary committee for improving controlled substances prescribing
Primary Care at UCSF Mt. Zion
- Academic Hospital
- Academic Medical Center
- Community outpatient clinic
- Integrated healthcare system/network
- The Mount Zion Clinic is an academic primary care subsidiary of UCSF Primary Care
- As of 2016, 700 of the practice’s 24,000 patients are on chronic (greater than 6 month prescription) opioids for non-cancer pain. This does not take into account patients with prescriptions less than 6 months, or those with cancer-related pain treated with opioids.
- In 2014, Dr. Scott Steiger of UCSF’s Division of General Internal Medicine decided a process was needed to review patient cases related to chronic opioids that involved complex management decisions or which doctors found difficult.
- He thus established the Controlled Substance Review Committee.
- Dr. Kryzhanovskaya now chairs the Committee.
Patient Population Served and Payor Information
- About 30% of the Mount Zion Primary Care Clinic’s patients have Medicaid insurance, while a similar percentage are on Medicare or have private payor insurance.
- Dr. Scott Steiger established the program in 2014.
- Dr. Irina Krzyhanovskaya has taken over leadership of the program as of 2017.
- Funded internally by the Division of General Internal Medicine.
Tools or Products Developed
- Epic is the EMR used by Mt. Zion and UCSF
- Zoom videoconferencing is used to link in staff members who cannot join the meeting in person.
- Zoom’s screen share function is used to present the chart biopsy that the primary care provider has formulated with those who are joining remotely
- Recommendations are sent to participants via secure email and a copy of the recommendations are added to the patient’s chart in the EMR
- A secure Box folder is used to store confidential patient information involved in Committee meetings
- Box folder
- Electronic medical record
- Video conferencing
Team Members Involved
- Administrative Assistant
- Panel Manager
- Social Worker
- See Figure 1 for a brief overview,
- PCPs send difficult cases to Dr. Kryzhanovskaya or another committee member,
- If a request is urgent, a 1:1 session between a pain management doctor and the PCP can be scheduled.
- Otherwise the case is scheduled to be reviewed at the upcoming month’s Controlled Substance Review Committee meeting or the meeting after that.
- Prior to the meeting, the PCP requesting the case review performs a chart biopsy.
- This includes the main issue they want to present to the group, the patient’s psych history, their medical history, their prescription drug monitoring records, urine toxicology results, any trauma history, any history of violent or aggressive behavior, and their home life/social supports. To help identify the available and covered resources for the patient, the patient’s insurance is added at the end.
- Meetings all take place the 4th Wednesday of the month at 1 PM. A light lunch is provided (this helps incentivize attendance).
- Meetings begin by the patient’s PCP presenting the chart biopsy they have prepared. This takes 5-10 minutes.
- After the formal review, committee members will ask clarifying questions.
- Recommendations are derived through a multidisciplinary discussion lasting about an hour
- Two sample recommendations include:
- “We recommend mid-prescription nurse visits or coordination with Nephrology during HD [hemodialysis] for pill counts or repeat urine toxicology”
- “For a safer option to treat his pain, consider switching to Buprenorphine and/or adding Lidocaine gel/patches as adjuncts”
- See Figure 2 for a more complete list of sample recommendations
- Two sample recommendations include:
- Recommendations are noted during the meeting and subsequently emailed out to the PCP and relevant care team members. Recommendations are also documented in the EMR
- On an annual basis, the Committee chair will review overall outcomes of patients and if recommendations were followed
- $5K to $10K
- 10% of Dr. Kryzhanovskaya’s time is dedicated to chairing the committee
- A member of the administrative staff is responsible for gathering food, coordinating invitations, managing security of the recommendations. This is one of about 20 responsibilities this person has.
Where We Are
The intervention is currently ongoing.
- 14 patients were reviewed during the 2017-2018 academic year. These included 8 attending patients and 6 resident patients.
- Of these patients:
- 8 were prescribed a lower dose of opioid after the meeting
- 8 received a new prescription for naloxone
- 6 are no longer receiving opioid prescriptions from their PCP
- 4 were referred for treatment of an opioid use disorder
- 9 were referred to mental health resources
- The meeting provides a multidisciplinary setting in which providers can work through their most challenging cases.
- It allows providers to gain support around safe prescribing along with diagnosing and treating substance use disorders if they feel uncomfortable with the topics that they are out of scope.
- Multidisciplinary review of cases allows for provision of up to date recommendations based on best practices.
- Monthly case review highlights areas for general improvement in controlled substance prescribing and treatment of opioid use disorder in the Division of General Internal Medicine.
- Monthly meetings facilitate dissemination of up to date recommendations within the clinic as committee members incorporate what they learned into their practice and share it with trainees.
- The Committee has gained significant positive attention within UCSF on the background of a health system-wide focus on the opioid epidemic.
- It took time to gain financial support for both a Chair for the committee and an administrative support person. Overall, making the Committee a priority for Primary Care at UCSF Mt. Zion took a few attempts and the charisma of a strong Chairperson.
- Meetings are currently held monthly, but it would be useful to have them held more often.
- Greater involvement of nurses, pharmacists, and residents in the committee would be beneficial, but schedules often limit this.
- In the future, it would be ideal to have a way to submit an electronic referral to the committee via the EMR.
Figure 1. Overview of the Controlled Substance
Review Committee Workflow
Figure 2. Sample Committee Recommendations
Key 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.
PCMH: Establishing a team-based opioid prescribing program may help practices meet a number of NCQA Patient Centered Medical Home (PCMH) 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.
Other Opportunities: Practices looking to evaluate and demonstrate the quality of their MAT programs might look to a “Cascade of Care” model similar to that for HIV, according to a 2017 Health Affairs Blog post by Arthur Robin Williams, Edward Nunes and Mark Olfson. The authors propose a high-level five-part framework for assessing quality of care for opioid use disorder: diagnosis of affected patients, linkage to care, initiation of medications, retention in care, and continued abstinence. Practices could consider how they would track these numbers using their own administrative, electronic medical record and patient self-report data in order to demonstrate improvement over time as well as overall program quality.
- Irina (Era) Kryzhanovskaya, MD
- Scott Steiger, MD
- Lisa Rotenstein, MD MBA
San Francisco, CATalk to the Innovators