Bree Collaborative Meeting

September 18th, 2019 | Puget Sound Regional Council

Agenda

Welcome and IntroductionsChair Report and Meeting Minutes

Action Item: Approve minutes Implementation: 2020 and 2021Presentation for Public Comment: Shared Decision Making

Action Item: Approve for dissemination for public commentPresentation for Public Comment: Palliative Care

Action Item: Approve for dissemination for public commentWorkgroup Update: Risk of Violence to OthersBREAKLearning from Adriane LabsWorkgroup Update: Maternity Bundle Workgroup Update: Opioid Prescribing Next Steps and Close Slide 2

July 24th Meeting Minutes

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Implementation: 2020 and 2021

Ginny Weir, MPHDirector, Bree Collaborative

September 18th, 2019 | Bree Collaborative Meeting

Implementation Funding ESHB 1109

(31) $300,000 of the general fund—state appropriation for fiscal year 2020 and $300,000 of the general fund—state appropriation for fiscal year 2021 are provided solely for the Bree collaborative to support collaborative learning and targeted technical assistance for quality improvement initiatives. The collaborative must use these amounts to hire one full-time staff person to promote the adoption of Bree collaborative recommendations and to hold two conferences focused on the sharing of best implementation practices.

Slide 5

Welcome Amy!

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Targeted technical assistance

Build off 2016 survey

Building AwarenessAssessmentGap Analysis Barriers Facilitators

Facilitating adoption Conjunction with conferenceSharing best practices

Save the DateMarch 25th, 2020

First Implementation Conference SeaTac Conference CenterFocus on:Behavioral Health Integration Bundled Payment Models

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Next Steps

Conference planning committee calls – starting October

Get to know Amy

Prioritize outreach

Slide 8

Presentation for Public Comment: Shared Decision Making

Ginny Weir, MPHDirector, Bree Collaborative

September 18th, 2019 | Bree Collaborative Meeting

Workgroup Members

Chair: Emily Transue, MD, MHA, Associate Medical Director, Washington State Health Care Authority David Buchholz, MD, Medical Director, Premera Sharon Gilmore, RN, Risk Consultant, Coverys Leah Hole-Marshall, JD, General Counsel and Chief Strategist, Washington Health Benefit Exchange Steve Jacobson MD, MHA, CPC, Associate Medical Director, Care Coordination, The Everett Clinic, a DaVita

Medical Group Dan Kent, MD, Medical Director, United Health Care Andrew Kartunen, Program Director, Growth and Strategy, Virginia Mason Medical System Dan Lessler, MD, Physician Executive for Community Engagement and Leadership, Comagine Health Jessica Martinson, MA, Director of Clinical Education and Professional Development, Washington State

Medical Association Karen Merrikin, JD, Consultant, Washington State Health Care Authority Randy Moseley, MD, Medical Director, Quality, Confluence Health Michael Myint, MD, Medical Director, Population Health, Swedish Hospital Martine Pierre Louis, MPH, Director, Interpreter Services, Harborview Medical Center Karen Posner, PhD, Research Professor, Laura Cheney Professor in Anesthesia Patient Safety, Department

of Anesthesiology & Pain Medicine, University of Washington Angie Sparks, MD, Family Physician and Medical Director, Clinical Knowledge Development, Kaiser

Permanente of Washington Anita Sulaiman, Patient Advocate Slide 10

Today’s Goal

Review content of recommendationsVote to disseminate for public comment

Slide 11

Focus Areas

A common understanding and shared definition of shared decision making and the benefit of shared decision making.Ten priority areas as an initial focus for the health care community.Highly reliable implementation using an existing framework customized to an individual organization.Documentation, coding, and reimbursement structure to support broad use.

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Defining Shared Decision Making

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Appropriateness

Slide 14

Adapted from Neumann I, Akl EA, Vandvik PO, Agoritsas T, Alonso-Coello P, Rind DM, et al. Chapter 26: How to Use a Patient Management Recommendation: Clinical Practice Guidelines and Decision Analyses. Graves RS. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. J Med Libr Assoc. 2002;90(4):483.

Workgroup Goal

State-wide movement toward greater use of shared decision making in clinical practice at a care delivery site and organizational level. All care delivery sites move toward greater adoption using a stages of change framework (i.e., precontemplation, contemplation, preparation, action, maintance). In some locations will be starting in the precontemplations (e.g.,

leadership engagement and buy-in) while others will be ready to start action (e.g., pilots of shared decision making in one health service area such as abnormal uterine bleeding), and others will be maintaining or spreading use.

Slide 15

Drivers of Shared Decision Making Implementation

Skills-based Education/TrainingPatient Decision AidsPatient/Family EngagementSystems-Based

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Selected Health Care Services

Surgical/Procedural: Knee and Hip Osteoarthritis (HCA certified) Spine Surgery (HCA certified) Abnormal Uterine Bleeding Trial of Labor After Cesarean Section (HCA certified)

Advanced Care Planning (HCA certified) Screening:

Prostate Specific Antigen Testing Breast Cancer Screening

Behavioral health: Depression Treatment Attention Deficit Hyperactivity Disorder Treatment Opioid Use Disorder Treatment

Slide 17

Implementation Framework

National Quality Partner’s Playbook: Shared Decision Making in Healthcare = implementation fundamentals with basic, intermediate, advanced steps Leadership and culture Patient education and engagementHealthcare team knowledge and training Action and implementation Tracking, monitoring and reporting Accountability The Agency for Healthcare Research and Policy (AHRQ) developed the SHARE (Seek, Help, Assess, Reach, and Evaluate) approach

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http://www.qualityforum.org/National_Quality_Partners_Shared_Decision_Making_Action_Team_.aspx

Health Care Delivery Organizations and Systems

Slide 19

Stage of Change StepsPrecontemplation • Review your organization’s mission, vision, and values.

• Define how shared decision making can help advance your organizational goals and align with regional, state-wide, and Federal programs, expectations, and contracting.

Contemplation • Define/select a framework with which to implement shared decision making.

• Identify clinical champions who will be willing to help educate their peers, and administrative champion to support necessary operational changes.

• Select an appropriate training for your providers and staff about shared decision making. Preparation • Spread awareness about shared decision making broadly within your organization. Use the

definitions and materials within this report.

• Work with your clinical champion(s) to educate providers about the value of shared decision making and how to have a good conversation that uses the patient decision aid or references the patient decision aid if the aid will be distributed to patients prior to the visit.

• Select one of the 10 clinical areas to pilot (e.g., breast cancer screening).

• Select a patient decision aid or aids to integrate into the care stream. If using a patient decision aid that has not been certified by the HCA, the workgroup recommends using the IPDAS-based criteria adapted by the HCA within Appendix G.

Health Care Delivery Organizations and Systems

Slide 20

Stage of Change StepsPreparation • Define where in the care stream to use the aid (e.g., prior to visit via email).

• Clearly identify roles for care team members. Non-clinical staff can have a shared decision making conversation.

• Providing templates for documentation of use of shared decision-making.

• Conduct clinic- or system-wide training.

Action • Implement your shared decision making pilot.

• Implement performance metrics outlined on page 16.Maintenance • Evaluate use of the shared decision making process including feedback on the specific patient

decision aid.

• Decide whether to change any components within the pilot if not working.

• Spread to other sites or adopt shared decision making within another clinical area.

• Review new evidence on a regular basis to update the shared decision making options based on the most current evidence.

Health Plans and/or Professional Liability Carriers

ReimbursementValue-based care standardsMetrics Availability of patient decision aidsPrior authorization requirement Continuing education Discounts or other incentives Documentation templates

Slide 21

Documentation, Coding, Reimbursement

Documented like any other clinical encounterSome limited existing codes (e.g., G0296 Counseling)Development of additional coding for added shared decision making reimbursement. Prior authorizationIncluded as part of some alternative payment models (e.g., total joint replacement bundles)

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Next Steps

Adopt Shared Decision Making Report and Recommendations for adoption for public comment

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Workgroup Update: Risk of Violence to Others

Kim Moore, MDAssociate Chief Medical Officer, CHI Franciscan

September 18th, 2019 | Puget Sound Regional Council

Workgroup Members

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Chair: Kim Moore, MD, Associate Chief Medical Officer, CHI Franciscan G. Andrew Benjamin, JD, PhD, ABPP, Clinical Psychologist, Affiliate Professor of Law, University of Washington Kate Comtois, PhD, MPH, Professor, Department of Psychiatry and Behavioral Sciences, Harborview Medical Center Jaclyn Greenberg, JD, LLM, Policy Director, Legal Affairs, Washington State Hospital Association Laura Groshong, LICSW, Clinical Social Work, Private Practice Ian Harrel, MSW, Chief Operating Officer, Behavioral Health Resources Neetha Mony, State Suicide Prevention Plan Program Manager, Injury & Violence Prevention, Prevention and Community Health, Washington State Department of Health Kelli Nomura, MBA, Behavioral Health Administrator, King County Mary Ellen O'Keefe, ARNP, MN, MBA, Clinical Nurse Specialist - Adult Psychiatric/Mental Health Nursing; President Elect, Association of Advanced Psychiatric Nurse Practitioners Jennifer Piel, MD, JD, Psychiatrist, Department of Psychiatry, University of Washington Julie Rickard, PhD, Program Director, American Behavioral Health Systems – Parkside Samantha Slaughter, PsyD, Member, WA State Psychological Association Jeffery Sung, MD, Member, Washington State Psychiatric Association Amanda Ibaraki Stine, MFT, Member, Washington Association for Marriage and Family Therapists Marianne Marlow, MA, LMHC, Member, Washington Mental Health Counseling Association Adrianne Tillery, Harborview Mental Health and Addiction Services (Certified Counselor)

Background Volk v. DeMeerleer187 Wn.2d 241, 386 P.3d 254

This 2016 Washington State Supreme Court decision alters the scope of the ‘duty to warn or protect’.

now clearly applies to clinicians in voluntary inpatient and outpatient settings

persons to ‘warn or protect’ now includes those who are ‘foreseeable’ victims, not ‘reasonably identifiable’ victims subject to an actual threat

Source: www.phyins.com/uploads/file/Volk%20recs-FINAL.PDF

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http://www.phyins.com/uploads/file/Volk%20recs-FINAL.PDF

Background: Presentation and Literature Review

Slide 27

Dr. Piel Presentation: “Duty to Protect: Historical Review and Current Considerations”

Keywords: homicide, homicidal ideation, violence. Excluding intimate partner violence interventions directed at the recipient

59 articles reviewed, variably applicable

Included review of WA Involuntary Treatment Act (ITA) statute

Key Points

Clinicians cannot predict impending violent acts with certainty Patients’ right to both confidentiality and also to care in the least

restrictive environmentDuty to protect the community Violence cannot be treated, violence is not a disorder, underlying

diagnoses, thought patterns, and/or behaviors can be managed Substance use disorder more strongly associated with risk of violence,

especially when present with mental illness diagnos(es)How to discharge duty to warn or protect

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Focus Areas

Initial identification of increased risk for violence

Further assessment of violence risk

Violence risk management

Community protection

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Initial identification of increased risk for violence

Screen all patients over 18 years for the following behavioral health conditions:Depression Suicidality Alcohol misuse and drug use For youth ages 14-18, use developmentally appropriate screening

tools

Other observations that may increase risk for violence (e.g., acute agitation)Screen for thoughts of doing physical harm to othersPast history of violent actsDocument identification in the record including low risk of violence to others

Slide 30

Assessment of Violence Risk

Historical risk and/or triggering factors (e.g., history of criminal acts)Clinical risk factors (if not already identified previously) Protective factors that may mitigate risk (e.g., community and family ties)Other relevant psychiatric symptoms or warning signs at clinician’s discretion (e.g., texting, stalking) If appropriate, arrange for a second opinion risk assessment If appropriate for further assessment, use a validated instrument (e.g., Historical Clinical Risk Management-20) TrainingDevelopmentally appropriate

Document results in the health recordSlide 31

Violence Risk Management

Match level of risk for violence with management plan. If patient in acute crisis or acutely agitated, first ensure personal safety Evidence-based treatment plan, if present, including medication, if

indicated. Consultation Additional management strategies:

More frequent visits. Medication compliance/changes Lethal means safety. Involving others Referral Hospitalization

Addressing non-adherence Addressing termination of therapeutic relationship At each clinical decision point, document actions taken in the health record. Slide 32

Community Protection

If in an acute crisis, attempt to keep patient in an observed, safe, and appropriate environment Contact Designated Crisis Responder (DCR) for assessment for

involuntary commitment. If the provider decides that issuing a warning is needed, current

law permits the clinicians to notify law enforcement before notifying potential victim(s). The clinician may follow RCW 70.02.230 as needed. If needed and feasible, contact potential victim or victims including

relatives, or parent or guardian if the potential victim is a minor, is a vulnerable adult, or has been adjudicated incompetent, employers, or household members of the patient, if reasonably identified. At each decision point, document actions taken in the health

record.

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Presentation for Public Comment: Palliative Care

John Robinson, MD, SMChief Medical Officer, First Choice Health

September 18th, 2019 | Puget Sound Regional Council

Workgroup Members

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Chair: John Robinson, MD, SM, Chief Medical Officer, First Choice Health Lydia Bartholomew, MD, Senior Medical Director, Pacific Northwest, Aetna George Birchfield, MD, Inpatient Hospice, EvergreenHealth Raleigh Bowden, MD, Director, Okanogan Palliative Care Team Mary Catlin, MPH, Senior Director, Honoring Choices, Washington State Hospital Association Randy Curtis, MD, MPH, Director, Cambia Palliative Care Center of Excellence, University of Washington Medicine Leslie Emerick, Legislative Consultant, Home Care Association of Washington Ross Hayes, MD, Palliative Care Program, Bioethics, Rehabilitation, Pediatrician, Seattle Childrens Greg Malone, MA, MDiv, BCC, Palliative Care Services Manager, Swedish Medical Group Kerry Schaefer, MS, Strategic Planner for Employee Health, King County Bruce Smith, MD, Medical Director of Providence Hospice of Seattle, Providence Health and Services Richard Stuart, DSW, Psychologist, Swedish Medical Center - Edmonds Campus Stephen Thielke, MD, Geriatric Psychiatry, University of Washington Cynthia Tomik, LICSW, Manager, Palliative Care, Evergreen Health Gregg Vandekieft, MD, MA, Medical Director for Palliative Care, Providence St. Peter Hospital Hope Wechkin, MD, Medical Director, Hospice and Palliative Care, EvergreenHealth

Today’s Goal

Review content of recommendationsVote to disseminate for public comment

Slide 36

Focus Areas

Defining palliative care using the standard definition developed by the National Consensus Project including appropriateness of primary and specialty palliative care. Spreading awareness of palliative care.Clinical best practice provision of palliative that is:

Responsive to local cultural needs Includes advance care planning Incorporates goals of care conversations into the medical record and

plan of care

Availability of palliative care through revision of benefit structure such as a per member per month (PMPM) benefit. Slide 37

Definitions

Serious illness is a condition that “negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments, or caregiver stress… [and] carries a high risk of mortality.” “Palliative care focuses on expert assessment and management of

[symptoms including] pain…assessment and support of caregiver needs, and coordination of care [attending] to the physical, functional, psychological, practical, andspiritual consequences of a serious illness. It is a person-and family-centered approach to care, providing people living with serious illness relief from the symptoms and stress of an illness.”

Source: Kelley AS. Defining "serious illness". J Palliat Med. 2014 Sep;17(9):985.Source: National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative

Care, 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018. www.nationalcoalitionhpc.org/ncp.

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http://www.nationalcoalitionhpc.org/ncp

The power of metaphor

Weir Slide 39

Primary V Specialty Palliative Care

Primary palliative careDelivered within primary and relevant sub-specialty careMeets physical, functional, psychological, practical, and spiritual

consequences of a serious illness Refer patients to specialty palliative care when needs cannot be met

Specialty palliative care Interdisciplinary team Includes or has access to a care coordination function and is able to

meet medical, psychological, and spiritual care needs Access (e.g., telemedicine) to 24/7 specialty expertise highly

recommended

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Interdisciplinary Team

The National Consensus Project defines the interdisciplinary team as a “team of physicians, advanced practice registered nurses, physician assistants, nurses, social workers, chaplains, and others based on need” and breaks out professions by the following roles:

Slide 41

Physicians and/or advanced practice providers

Nurses

Social workers

Chaplains

Clinical pharmacists

Illness trajectory, prognosis, and medical treatments

Assessment, direct patient care, serving as patient advocate, care coordinator, and

educator

Family dynamics, assess and support coping mechanisms and social determinants of health, identify and facilitate access to resources, and mediate

conflicts

Spiritual care specialists, assess and address spiritual issues and help to facilitate continuity with the patient’s faith community as requested

Medication management, adjustment and deprescribing

Initial Assessment and Ongoing Assessment and Management

Goals of care conversations including around hospitalization Advance care planning Cognitive impairmentFunctional needsSymptom management and medical carePharmacy managementCaregiver needsBehavioral health and psychosocial (i.e., depression, anxiety, suicidality, others)Spiritual care needs+ Care Coordination + Urgent Issues Slide 42

Benefit Structure

A per member per month (PMPM) palliative care benefit for seriously ill patientsOpen to all agesFollows a patient across settings (e.g., if hospitalized)Does not require the patient to be homebound or to stop curative or active therapy Setting of provision of specialty palliative care services (e.g., hospital) as accountable entity

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Benefit Structure

Identification: Develop an agreed-upon strategy to identify seriously ill patients (e.g., such as with the PACSSI Eligibility and Tiering Criteria outlined in Appendix D). Interdisciplinary: Require an interdisciplinary approach to care that

does not require a physician to lead the interdisciplinary team. Payment structure: Offer a larger payment for the initial intake visit, a

PMPM payment, and a smaller per-in-person visit payment. Services: Use recommendations on the following pages to define the

included specialty palliative care services and which services are excluded (e.g., hospitalizations). Measure: Measure success using at least one metric related to (1)

potentially avoidable complications and (2) patient-specific quality of life. See page 18 for options under each of these categories. Metrics may be tied to gainsharing.

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Stakeholder Groups

Washington State Health Care Authority and Department of HealthHealth PlansHealth Care Purchasers (employers and union trusts)Patients and Family MembersSpecialty Palliative Care TeamsPrimary Care Providers and Sub-specialty ProvidersHealth Systems

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Next Steps

Adopt Palliative Care Report and Recommendations for adoption for public comment

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BREAK

47

Implementing TeamBirth to Promote Effective Communication,

Safety, & Dignity in Childbirth

@neel_shah

Healthy People 2000: 15% CD Rate

United States Cesarean Delivery Rate (%)

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Baby’s safety

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Simplicity

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Labor and Delivery Planning Board

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FEASIBILITY EFFECTIVENESS EFFICACY

ACCEPTABILITY

FIDELITY

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DIGNITY

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RURALITY

FEASIBILITY

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FIDELITY0% 20% 40% 60% 80% 100%

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Definitely Probably Maybe

Probably not Definitely not

81%

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Clinicians recommend the project

FEASIBILITY

ACCEPTABILITY

FIDELITY 0% 20% 40% 60% 80% 100%

Improves TeamCommunication

Improves Care

Clarifies Non-UrgentCesareans

Yes, definitely Yes, somewhat

Don't know / no opinion No

80%

92%

95%

Clinicians report benefits for decision-making and communication

0% 20% 40% 60% 80% 100%

Believed preferencesinfluenced care

Had preferredrole in care

Understoodconversations

Yes, definitely Yes, somewhat

Don't know / no opinion No

FEASIBILITY

ACCEPTABILITY

FIDELITY

99%

98%

90%

People in labor report being involved in their care

FEASIBILITY

ACCEPTABILITY

FIDELITY 0%

20%

40%

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At Least One Huddle Multiple Huddles

People in labor report increasing frequency of huddles

FEASIBILITY

ACCEPTABILITY

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s Trial

Workgroup Update: Maternity Bundled Payment Model

Carl Olden, MDFamily Physician, Pacific Crest Family Medicine

September 18th, 2019 | Puget Sound Regional Council

Workgroup Members

Slide 80

Chair: Carl Olden, MD, Family Physician, Pacific Crest Family Medicine Anaya Balter, RN, CNM, MSN, MBA, Clinical Director for Women's Health, Washington State Health Care Authority David Buchholz, MD, Medical Director, Collaborative Health Care Solutions, Premera Andrew Castrodale, MD, Family Physician, Coulee Medical Center Francie Chalmers, MD, Pediatrician, Member , Washington Chapter of the American Academy of Pediatrics Angela Chien, MD, Obstetrics and Gynecology, EvergreenHealth Neva Gerke, LM, President, Midwives Association of Washington Molly Firth, MPH, Patient Advocate Lisa Humes-Schulz, MPA/Lisa Pepperdine, MD, Director of Strategic Initiatives/ Director of Clinical Services, Planned Parenthood of the Great Northwest and Hawaiian Islands Rita Hsu, MD, FACOG, Obstetrics and Gynecology, Confluence Health Caroline Kline, MD, Obstetrics and Gynecology, Overlake Medical Center Dale Reisner, MD, Obstetrics and Gynecology, Swedish Medical Center Janine Reisinger, MPH, Director, Maternal-Infant Health Initiatives, Washington State Hospital Association Mark Schemmel, MD, Obstetrics and Gynecology, Spokane Obstetrics and Gynecology, Providence Health and Services Vivienne Souter, MD, Research Director, Obstetrics Clinical Outcomes Assessment Program

Overview

Slide 81

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post-delivery

Single Payment Ideal is to move to 365 days post delivery including pediatric care

Structure

Fee-for-service with retrospective reconciliation initially The workgroup recommends moving toward a prospective payment model

Risk adjustment based on patient-specific factors Including prenatal care, labor and delivery, postpartum services for both facility and professional servicesObstetric care provider or group is the accountable entity Exclusion criteria:

Age: younger than 16, older than 40 Cost below first percentile or higher than ninety-ninth percentile Diagnoses within the episode window or 90 prior to or after episode window

as determined by the payer or purchaser based on high-cost claims. See Appendix D for Exclusion criteria examples. The workgroup does not recommend basing exclusion criteria on behavioral health diagnoses including substance use disorder or drug use and/or body mass index (BMI). Death within episode window Slide 82

Care PathwayPrenatal Care

Intake visit as soon as possible after a patient contacts the provider or group with a positive pregnancy test. At a minimum, the intake visit should happen in the first trimester. (e.g., insurance, nutrition, dating ultrasound, behavioral health screenings)At a minimum, monthly visits up to 28 weeks gestation at minimumAt a minimum, biweekly visits up to 36 weeks gestation at minimum.Content:

Cardiovascular disease Behavioral Health Screening Infectious Disease Screening Gestational Diabetes Screening Vaccination Third trimester education (e.g., breastfeeding, birth spacing, shared decision

making as appropriate) Social Determinants of Health

Slide 83

Care PathwayLabor Management and Delivery

Emphasizing a physiologic birth when safe (e.g., spontaneous onset and progression of labor, vaginal birth of the infant and placenta)Shared decision making, where appropriate Endorse standards within the Washington State Hospital Association Labor Management Bundle 2012 Bree Collaborative Obstetric guidelines Comprehensive, client-centered contraceptive counseling (including LARC)

Slide 84

Care PathwayPostpartum Care

At least two visits with additional visits as needed (e.g., if higher-risk) Three weeks postpartum visit Additional comprehensive visit prior to 12 weeks postpartum including

Assessment of mood and emotional well-being including screening with a validated tool for depression (e.g., PHQ-9, Edinburgh Postnatal Depression Scale), anxiety (e.g., GAD), suicidality, and tobacco, alcohol, marijuana, and other drug use. Sexuality including contraception Infant care and feeding including breastfeeding Sleep and fatiguePatient supportPostpartum discharge summaryConnection to primary care

Slide 85

Other stakeholder groups

Health Care Purchasers (Employers and Union Trusts) Investigate moving to value-based reimbursement in partnership with other

purchasers such as the Washington State Health Care Authority.

Emergency Department and Urgent Care Cardiovascular Disease. Assess all women of childbearing age for recent

pregnancy and last menstrual period. Women may be at higher risk for cardiovascular disease up to five months postpartum and may present with shortness of breath, chest pain, unresolved cough or swelling.

Department of Health Link the gestational parent’s member ID and newborn ID. Resources around social determinants of health

Washington State Health Care Authority Extend Washington State Medicaid eligibility to 12 months (365 days)

postpartum at the same income level as for pregnancy.

Slide 86

Quality Metrics

Will finalize in OctoberTie to important facets of care pathway (e.g., prenatal, postpartum care)Reflect priorities (e.g., behavioral health)Need to be retrievable

Slide 87

Workgroup Update: Opioid Prescribing: Supporting Patients on Chronic Opioid Therapy

Gary Franklin, MD, MPHMedical Director, Washington State Department of Labor and Industries

September 18th, 2019 | Bree Collaborative Meeting

Workgroup Members

Co-Chair: Gary Franklin, MD, MPH, Medical Director, Washington State Department of Labor and Industries

Co-Chair: Charissa Fotinos, MD, Deputy Chief Medical Officer, Washington State Health Care Authority

Co-Chair: Andrew Saxon, MD, Director, Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System

Rose Bigham and Cyndi Hoenhous, Co-chairs, Patient Advocates Washington Patients in Intractable Pain

Katharine Bradley, MD, MPH, Senior Investigator, Kaiser Permanente Washington Research Institute Malcolm Butler, MD Chief Medical Officer Columbia Valley Community Health Pamela Stitzlein Davies, MS, ARNP, FAANP Nurse Practitioner Departments of Neurology & Nursing,

University of Washington Andrew Friedman, MD Physical Medicine and Rehabilitation Virginia Mason Medical Center Kelly Golob, DC Chiropractor Tumwater Chiropractic Center Dan Kent, MD Chief Medical Officer UnitedHealthcare Kathy Lofy, MD Chief Science Officer Washington State Department of Health Jaymie Mai, PharmD Pharmacy Manager Washington State Department of Labor and Industries Joseph Merrill, MD, MPH Associate Professor of Medicine University of Washington Anne Blake-Nickels Patient Advocate Gregory Rudolph, MD Addiction Medicine Swedish Pain Services Jennifer Davies-Sandler Patient Advocate Mark Stephens President Change Management Consulting Mark Sullivan, MD, PhD Psychiatrist University of Washington David Tauben, MD Chief of Pain Medicine University of Washington Medical Center Gregory Terman MD, PhD Professor Department of Anesthesiology and Pain Medicine and the

Graduate Program in Neurobiology and Behavior, University of Washington John Vassall, MD, FACP Physician Executive for Quality and Safety Comagine Health Michael Von Korff, ScD Senior Investigator Kaiser Permanente Washington Research Institute Mia Wise, DO Medical Director, Collaborative Healthcare Solutions Premera Blue Cross Slide 89

Recap: Patient-Centered Approach to Chronic Opioid ManagementVancouver, WA Conference August 9th

Slide 90

250-300 attendees

GuidelinesBackground

Help primary care and other providers support patients in managing chronic pain Follow National Pain Strategy:

Patient-centered, accounting for individual preferences, risks, and social contexts Comprehensive, meeting biopsychosocial needs Multimodal and integrated, using evidence-based treatments

Focus on goals of clinically meaningful improvement in function, as well as improved quality of life, and greater patient functional independence rather than on pain relief Priority = safety and avoidance of serious adverse outcomes

Slide 91

https://iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf

Slide 92

GuidelinesFocus Areas

Patient Engagement and SupportAssessmentDevelop a Treatment Plan Treatment PathwaysMaintain and MonitorReduce DosageTransition to medication-assisted therapy

Health Systems

Slide 93

GuidelinesPatient EngagementDiscuss goals of care and preferencesSet expectationsAssess knowledge about pain and medication(s), educate on knowledge gapsAssess concernsRespectInvolve othersConsistencySource: Wyse JJ, Ganzini L, Dobscha SK, Krebs EE, Morasco BJ. Setting Expectations, Following Orders, Safety, and Standardization: Clinicians' Strategies to Guide Difficult Conversations About Opioid Prescribing. J Gen Intern Med. 2019 Jul;34(7):1200-1206.Kennedy LC, Binswanger IA, Mueller SR, Levy C, Matlock DD, Calcaterra SL, Koester S, Frank JW. "Those Conversations in My Experience Don't Go Well": A Qualitative Study of Primary Care Provider Experiences Tapering Long-term Opioid Medications. Pain Med. 2018 Nov 1;19(11):2201-2211.Sullivan MD, Turner JA, DiLodovico C, D'Appollonio A, Stephens K, Chan YF. Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial. J Pain. 2017 Mar;18(3):308-318.

Slide 94

Next Meeting:

Wednesday, November 20th, 201912:30 – 4:30

Puget Sound Regional Council5th Floor Board Room1011 Western Avenue, Seattle WA

Bree Collaborative MeetingAgendaJuly 24th Meeting MinutesImplementation: �2020 and 2021��Ginny Weir, MPH�Director, Bree CollaborativeImplementation Funding �ESHB 1109Welcome Amy!Save the Date�March 25th, 2020Next StepsPresentation for Public Comment: �Shared Decision Making��Ginny Weir, MPH�Director, Bree CollaborativeWorkgroup MembersToday’s GoalFocus AreasDefining Shared Decision MakingAppropriateness Workgroup Goal Drivers of Shared Decision Making ImplementationSelected Health Care ServicesImplementation FrameworkHealth Care Delivery Organizations and SystemsHealth Care Delivery Organizations and SystemsHealth Plans and/or Professional Liability CarriersDocumentation, Coding, ReimbursementNext StepsWorkgroup Update: �Risk of Violence to Others ��Kim Moore, MD�Associate Chief Medical Officer, �CHI FranciscanWorkgroup MembersBackground �Volk v. DeMeerleer�187 Wn.2d 241, 386 P.3d 254Background: �Presentation and Literature ReviewKey PointsFocus AreasInitial identification of increased risk for violenceAssessment of Violence Risk Violence Risk Management Community Protection Presentation for Public Comment: �Palliative Care��John Robinson, MD, SM�Chief Medical Officer, First Choice HealthWorkgroup MembersToday’s GoalFocus AreasDefinitionsThe power of metaphorPrimary V Specialty Palliative CareInterdisciplinary TeamInitial Assessment and Ongoing �Assessment and Management Benefit Structure Benefit Structure Stakeholder GroupsNext StepsBREAKSlide Number 48Slide Number 49Slide Number 50Slide Number 51Slide Number 52Slide Number 53Slide Number 54Slide Number 55Slide Number 56Slide Number 57Slide Number 61Slide Number 62Slide Number 63Slide Number 64Slide Number 65Slide Number 66Slide Number 67Slide Number 68Slide Number 69Slide Number 70Slide Number 71Slide Number 72Slide Number 73Slide Number 78Workgroup Update: Maternity Bundled Payment Model��Carl Olden, MD�Family Physician, �Pacific Crest Family MedicineWorkgroup MembersOverviewStructureCare Pathway�Prenatal Care Care Pathway�Labor Management and DeliveryCare Pathway�Postpartum CareOther stakeholder groupsQuality MetricsWorkgroup Update: �Opioid Prescribing: Supporting Patients on Chronic Opioid Therapy ��Gary Franklin, MD, MPH�Medical Director, Washington State Department of Labor and IndustriesWorkgroup MembersRecap: Patient-Centered Approach to Chronic Opioid Management�Vancouver, WA Conference August 9thGuidelines�BackgroundSlide Number 92Guidelines�Focus AreasGuidelines�Patient EngagementNext Meeting:��Wednesday, November 20th, 2019�12:30 – 4:30 ��Puget Sound Regional Council�5th Floor Board Room�1011 Western Avenue, Seattle WA