team-based intakes, inductions, and visits: key …...team-based intakes, inductions, and visits:...

TEAM-BASED INTAKES, INDUCTIONS, AND VISITS: KEY ROLES ANDCONSIDERATIONS FOR NON-PRESCRIBERSDescribe models of triaging patients by telephone or in-person interview

ROLE OF CLINIC RN CARE COORDINATOR

Danielle Jones, RN-BSN Care Coordinator Fairview Mesaba Clinic 3605 Mayfair Ave Hibbing, MN 55746 218-362-6922 #3 djones18@range.fairview.org

8 years at Mesaba Clinic, 3 years in current role Chronic pain role Addiction role

ERIN FOSS, RN

Opioid Program Development and Outreach Coordinator

CHI Saint Gabriel’s Health Little Falls, MN

I spent the bulk of my nursing career as an OR nurse, and then moved into management before joining the Little Falls team. I feel that becoming an addiction nurse has taught me patience and empathy which have made me a better person, nurse, wife, and mom.

ErinFoss@catholichealth.net

LAUREN ANDERSON, PHARMD, BCACP

Clinical Pharmacist Minnesota Community Care

Saint Paul, MN651-389-2414

llapinta@mncare.org

I work with the Renewal Services Team as well as in primary care and the out patient dispensing pharmacy. I have been with MCC for over 6 years and

have been working in addiction medicine for about 1.5 years

ROLE OF CLINIC RN CARE COORDINATOR

ROLE OF CLINIC RN CARE COORDINATOR

ROLE OF CLINIC RN CARE COORDINATOR

Telephone screenings: try to make short and sweet Could occur through provider referral, “word of mouth

referral”, or through ED follow up phone call Don’t judge, educate Empathetic and understanding Educate that addiction is a chronic disease

Gather patient data – PMH, demographics, PCP etc. Current substance of choice and additional

substances Treatment history – previous MAT? Insurance/Transportation Recent legal issues/probation

ROLE OF CLINIC RN CARE COORDINATOR

Suboxone Screening Criteria 1: Where do you live? County: 2. What is the drug/substance that you are currently using? 3. Have you been on Suboxone in the past or currently? A: If current, dose? B: Why are you changing Suboxone providers? 4. Who is your doctor now? If no one, who in the past? 5. Have you had any previous treatment? Rule 25 completed? Y / N A: Inpatient Days spent in jail in the past 3 yrs. B: Outpatient Pending legal charges? C: Current Insurance? 6: Are you currently in counseling? A: NA or AA? 7. What medications are you currently taking? Please list all meds

including herbals, supplements, OTC and prescriptions.

ROLE OF CLINIC RN CARE COORDINATOR

Chart review Discuss with waivered provider Educate patient on program requirements and

what to expect Honesty #1 Moderate withdrawal No benzodiazepines/ETOH Risk of precipitated withdrawal Schedule induction Place appropriate referrals

ROLE OF CLINIC RN CARE COORDINATOR

In Person Interview – able to “see” where the patient is at ED visit for OD or withdrawal or office visit with

provider requesting help Current substance use/past substance use COWS scale Lab tests ROIs, consents, consent for treatment and treatment

agreement Role of care team Honesty #1 Words matter

ROLE OF CLINIC RN CARE COORDINATOR

Caring, compassionate, nonjudgmental

Positive reinforcement Active listener The “go to” person Educator Manage referrals Respectful

Develop patient-centered goals

Keep patient on track Support provider/care

team Holistic approach Prep charts Prior authorizations

HOW TO MANAGE INDUCTIONSBY PROTOCOL

MEETING BASIC NEEDS

Offer blankets Ensure comfort Offer water Relaxed body language Speak softly Ask if its ok with the patients for friends/family

members to stay Show kindness and empathy- establish

rapport and trust

THE “MUST HAVES”

UDASCOWS (hr/pupils/10)

CARE PLAN/ind packetCharting Templates

LETS TALK ABOUT BENZOS

AtivanXanaxValiumKlonopin

Educate- RRAdd to allergy list-

“Contraindicated when taking Suboxone”

SUBOXONE DOSING

Provider orders Suboxone Family/friend/nurse picks up med (last resort

patient) Patient is instructed to take med (self

administer/SL dissolve/bioavailability) Start with small doses of Suboxone (2-4mg) Reassess every 30 min

TROUBLESHOOTINGPatient arrives with COWS below 10

(reassess every 15 min)Precipitated withdrawal (clinic

inductions)No $$$ to pay for meds

TROUBLESHOOTING CONT…Prior AuthsPatient education for refillsClear expectations Non punitive approach

WHAT DO PATIENT’S NEED TO GETINTO OUR PROGRAM?

NOTHING!

Rule 25 is not needed for patient to be seen Insurance can be set up at first appDo you have a foundation?

INDUCTION FOLLOW UP

Next day clinic visit or phone callFrequent clinic visits at first Relationship building

THE ROLE OF PHARMACISTS ANDNURSES

ROLE OF A NURSE OR PHARMACIST

Inductions

Follow-up visits and phone check-ins

Coordinating Medication Access

Acute Pain and Surgery Management

Management of other comorbid disease states or primary care

“Provider extender”

FOLLOW-UP VISITS

Induction follow-up visits Visits between provider visits for patients who are

high risk Weekly visits for patients who have relapsed or missed

appointments Weekly visits for patients needing more mental health

support Phone follow-up visits for patients with

transportation concerns Accommodate walk in visits Benefits

Flexibility of scheduling and more patient appointments Collaborative Practice Agreements allow lab monitoring

and prescribing Ability to work with patients when they are struggling and

have a hard time coming in for scheduled appointments

COORDINATING MEDICATION ACCESS

Prior Authorizations Insurance Changes Formulary Changes Pharmacy Questions Medication Availability

Assist patients in selecting formulations and flavors of medication that make the medication experience more positive for the patient

Buprenorphine Menu

ACUTE PAIN AND SURGERY MANAGEMENT

Prepare and maintain an acute pain and surgery management protocol

Coordinate with surgeons and other providers to assess what pain management is anticipated for specific scheduled procedures

Educate outside providers on pain management for patients using buprenorphine

Coordinate insurance coverage for patients receiving opioids + buprenorphine

Create a plan for buprenorphine dosing for planned procedures and discuss with patients

Assist with transition from opioids back to buprenorphine when needed

MANAGEMENT OF COMORBIDITIES ANDPRIMARY CARE

HIV pre exposure prophylaxis (PrEP) HIV post exposure prophylaxis (PEP) Hepatitis C treatment Ensure vaccines are up to date Prescription of supportive cares for withdrawal Primary Care management Comprehensive Medication Review

Pharmacist specific visits Improves access to primary care

“PROVIDER-EXTENDER” Allow for overbooks on provider’s schedules

Check vitals, order labs, room and prep patients for a provider visit

Joint visits Providers can see more patients in less time Ability to monitor more patients Ability to monitor high risk patients more

frequently

CASE

BN is a 65 y/o M who is seen in clinic. He has a diagnosis of OUD. Currently using heroin IN, previously using pills along with buprenorphine-naloxone. He is uninsured. July 2019: Appointment with provider - diagnosed with

OUD July 2019: Induction with pharmacist (same day) July 2019: Induction follow-up appointment with

pharmacist August 2019: Provider follow-up appointment x 2 August 2019: Pharmacist follow-up appointment - relapse September 2019: Provider + pharmacist visit September 2019: Pharmacist visit September 2019: Provider + pharmacist visit -continued

alternating