Overview

A program to improve opioid prescribing and management via practice guidelines, EMR modules, and a team-based management approach.

Organization Name

Tufts Medical Center Adult Primary Care

Organization Type

• Academic Hospital
• Academic Medical Center
• Community outpatient clinic
• Integrated healthcare system/network

National/Policy Context

• Tufts Medical Center Adult Primary Care Service consists of 40 Physicians (~28 FTE), 6 NPs (~4.5 clinical FTE), 2 PAs, 3 social workers, 72 residents, 8 FTE RNs, and 60 support staff
• It sees 38,000 patients via 6,500 office visits a month. The practice gets 14,000 incoming phone calls a month
• From 2008 to 2011, the number of Tufts primary care patients with opioids on their medication list grew from 1000 to almost 2000 patients.
• There was limited PCP training in pain management and poor communication with specialists about prescribing medications. Patients and providers were frustrated and documentation was unclear.

Patient Population Served and Payor Information

• Tufts serves a diverse patient population, with ~10% of its population African American, 10% Asian, and 9% Hispanic. 25% of its patients are on Medicaid, and 32% are on Medicare

Leadership

• Three MDs were central to setting up the program.
• Two physician assistants help to manage the program, and three social workers assist with behavioral health management.
• Tufts Primary Care’s IT specialist set up the EMR components supporting the program.

Tools or Products Developed

The following components were developed for the intervention:

• An electronic health record component was developed that:
  • Helps providers keep track of active medications and automatically calculates refill due dates.
  • Helps providers document monitoring activities and provides quick links to resources.
  • Prompts risk assessments, keeps a running record of prior red flags, and has a space for provider to provider comments to facilitate communication
• Newly developed practice guidelines for initiating and managing chronic opioid prescribing, which stipulate that:
  • Minimum monitoring for all patients includes: 1) patients’ problem list including “chronic pain – opioid requiring,” 2) a controlled substances agreement signed and filled yearly, 3) quarterly office visits with a PCP, NP, or PA, 4) two urine tox screens per year, 5) a prescription monitoring program (PMP) checked at every refill, 6) a 28 day refill schedule.
  • Higher risk patients receive increased monitoring.
• A team-based algorithm for caring for high-risk patients.
  •  Two PAs dedicated half their time to managing the chronic opioid program, including coordinating refills and managing gaps in monitoring
  • Three social workers assist with behavioral health management, including identifying community resources, contracting with detox centers, and emergency counseling.
• Standardized risk assessment tools were either developed (Opioid Risk Tool) or acquired (Current Opioid Misuse Measure).

Tech Involved

• eClinicalWorks
• EMR-based registry

Team Members Involved

• PAs
• Physicians
• Social Worker

Workflow Steps

• The program uses the Opioid Risk Tool (ORT) to assess all patients new to the practice or prior to starting chronic opiates.
  •  A score of 0-7 is considered low to moderate risk. A score of 8 or higher is considered high risk.
  • If patients received a score of 0 to 7 on the ORT, they received no additional intervention beyond standard care.
  • Patients with a score of 8 or higher on the ORT or with a personal history of substance abuse or provider discretion are considered moderate to high risk.
• These patients are scheduled for a social work consult, at which time social workers will complete the Current Opioid Misuse Measure (COMM) and conduct a psychosocial assessment.
  • If the patient has a COMM score less than 9, the COMM will be administered again in 6 months.
  • If the patient has a score greater than or equal to 9, the patient will be recommended for further review and individualized planning, which can include pain management consultations, 3 months of alternative therapy, and increased monitoring in conjunction with opioid prescribing.
• PCPs receive monthly reports about all of their patients on chronic opioids, including who has overdue contracts, tox screens, PMPs, refills
• PAs help PCPs coordinate refills and gaps in monitoring
• Social workers address social needs arising from population health management or at visits
• PCPs interact with the EMR-based opioid prescribing module for every relevant patient, facilitating medication refills, monitoring activities, and awareness of red flags.

Budget

• $100K to $500K

Budget Details

• The budget covers half the salaries of two PAs; notably PA revenues from the other half of their time paid for these salaries

Where We Are

• The intervention is currently ongoing

Outcomes

• The percentage of  patients with urine drug screening increased from 63% to 92%.
• Patients checked using the MA Prescription Monitoring Program in the past year rose from 21% to 98%.
• The percentage of patients on chronic opiates with a signed contract in the past year rose from 52% (n = 551) to 70% (n = 469).
• IM residents felt more comfortable managing chronic opiates with the program in place, with average comfort increasing from 2.77 (n = 44) to 3.06 (n = 32) on a 5-point Likert scale

Benefits

• The program successfully increased provider comfort with managing chronic opioids and standardized processes.
• A comprehensive population health approach contributed to patient safety by more accurately assessing risk, increasing compliance with monitoring parameters, and improving counseling of patients.

Unique Challenges

• Need for enhanced prescription of intranasal naloxone.
• Need for increased social work capacity.
• Need for more support for dual diagnosis patients with limited access to psychiatry/addiction services

Metrics

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.