Bree Collaborative Meeting

July 17th, 2018 | Puget Sound Regional Council

Housekeeping

Web Access: listed throughout room

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Agenda

Chair Report and May 23rd Meeting MinutesAction Item: Approve minutes

Reviewing New Topic Proposals and Selecting New TopicsAction Item: Select 3 topics for 2019

Final Adoption: AMDG Opioid Prescribing Guidelines ImplementationAction Item: Adopt Supplemental Guidance on Prescribing Opioids for

Postoperative Pain Disseminate for Public Comment: LGBTQ Health Care

Action Item: Approve for dissemination for public commentDisseminate for Public Comment: Suicide Care

Action Item: Approve for dissemination for public commentTopic Update: Lumbar Fusion Re-ReviewTopic Update: Collaborative Care for Chronic Pain Next Steps and Close Slide 3

May 23rd Meeting Minutes

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Reviewing New Topic Proposals and Selecting New Topics

Hugh Straley, MDChair, Bree Collaborative

July 17th, 2018 | Puget Sound Regional Council

Our Purpose

“…to provide a mechanism through which public and private health care stakeholders can work together to improve quality, health outcomes, and cost effectiveness of care in Washington State.”

“…identify health care services for which there are substantial variation in practice patterns or high utilization trends in Washington state, without producing better care outcomes for patients, that are indicators of poor quality and potential waste in the health care system. On an annual basis, the collaborative shall identify up to three health care services it will address.”

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From May 23rd Meeting

Endorsed:AMDG Opioid Prescribing Workgroup – new focus area: best practices

for managing patients on chronic opioid therapy including best practices for tapering patients off opioids.Responding to the Legislative request to define standards for clinical

care where patients may be exhibiting homicidal or suicidal ideation

Today’s Action Item to select three from the list below: Shared decision makingMaternity bundle (including long-acting reversible contraceptive) Adapting the total joint replacement bundle to outpatient careRetinal imaging Expanding end-of-life care recommendations/palliative care Slide 3

1. Shared Decision MakingBackground

“a process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.” –Washington State Health Care Authority HCA began accepting patient decision aids for certification in April 2016. More information: www.hca.wa.gov/about-hca/healthier-washington/certified-aids

Maternity and labor/deliveryJoint replacement and spine care

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1. Shared Decision MakingPatient Advocate Testimony

“As a patient and the long-time caretaker of my disabled elderly father, I am so glad that the Bree Collaborative is considering Shared Decision Making (SDM) as one of its three topics for 2019. By definition, SDM is a process that allows patients and their healthcare providers to work together to determine the most appropriate treatment choices based on evidence-based information and patients’ goals. For patients, SDM is more than a process; it is the core of patient-centered care that respects patients’ perspectives and rights, provides patients with enough information that they can consider all different treatment options, and enables patients to make informed healthcare decisions. As a caretaker who witnessed how the lack of shared-decision contributed to my father’s death, I believe SMD is the only way to provide compassionate care and to make “Nothing about me, without me” into a reality. To improve the quality of care, I hope the Bree Collaborative will seriously consider the call by the National Quality Forum and make Shared Decision Making a standard of care in Washington State for all patients, across all settings and conditions.”-Yanling Yu

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1. Shared Decision MakingExpert Speakers

Matt Handley, MDSenior Medical Director for Quality and SafetyKaiser Permanente of Washington

Karen Merrikin, JDContracted Program DirectorWashington State Health Care Authority

Emily Transue, MD, MHAAssociate Medical DirectorWashington State Health Care Authority

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Shared Decision Making

Emily Transue, MD, MHA, FACPAssociate Medical Director

Why is SDM important?• Systematic use of shared decision making can:

– Improve patient experience– Improve health outcomes– Reduce variation and health disparities– Improve appropriateness of utilization and spending– Support value based care and population health strategies

• But: uptake remains limited; need a path toward broader use

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Why Bree Collaborative?• Central to Bree Collaborative purpose

– Address variation, appropriateness, spending, etc.

• Aligns with HCA priorities, leverages Healthier Washington advances

• Enables/supports previous and future Bree recommendations, many of which specifically reference SDM

• Public/private stakeholder engagement and leadership are critical to success

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Shared Decision Making in Washington

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• State and HCA role:– Foundational legislation to support SDM– Certification of patient decision aids (PDAs): Process

developed, 3 cycles complete– Promotion of SDM and PDA use in HCA’s role as purchaser

(1.8M Medicaid lives, 200K PEB)

• Implementations by Group Health/Kaiser for 10+ yrs• Many engaged stakeholders:

– Providers, plans, malpractice carriers, PDA developers, etc

SDM “Thought Leader Group”• Stakeholders convened by HCA spring 2018• Preliminary development of vision and principles• Establishment of criteria to guide selection of priority

topic area(s)• Endorsement of NQF playbook as general approach• Foundation to inform potential Bree workgroup

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Potential Roles of Bree WorkgroupTBD - “Nothing about you without you”• Develop a Washington specific SDM roadmap/toolkit

– Build upon the work of the Thought Leader Group– Leverage/adapt the newly issued NQF SDM Playbook– Address barriers/recommend enablers for practice

transformation

• Provide guidance/support for cross-sector implementation activities

• Potential funding availability

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Questions?More Information:www.hca.wa.gov/about-hca/healthier-Washington/shared-decision-making

Emily Transue, MD, MHA, FACPAssociate Medical Directoremily.transue@hca.wa.gov

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Draft topic prioritization rubric • Base Criteria: (Beneficial to people we serve)

– Is SDM the best approach? (More than one clinically appropriate treatment option, with significantly different clinical and/or personal implications for patients.)

– Are quality PDAs available (OPTIONAL or under development?)– Is the condition highly prevalent, AND/or is there high use/high variation IN WA?– Would an SDM intervention advance health equity?

• Selection criteria: (provider, hospital, health plan, purchaser benefits)– Is this a current or future state health care priority area? Eg Bree– Would the SDM intervention have significant financial or other value to providers?– Would the SDM intervention have significant financial or other value to payors and/or purchasers?– Are there clinical and policy champions throughout the affected health care entity? At the

agency/policy level? Are we likely to get “engagement rather than mere compliance” among affected staff?

– Are there lower “barriers to entry” to affected providers?– Is there real potential for the SDM intervention to spread beyond the affected clinical area or staff?– Are there certified PDAs available for the affected condition? (If no, could this be done in a timely

manner?)

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2. Maternity BundleBackground

USA has highest maternal death rate of developed countriesMore than 50,000 mothers have life-threatening complications every yearBlack mothers 3x-4x more likely to die in childbirth than white mothersBlack infants born to college educated parents 2x more likely to die as white infants born to college educated parentsHigh variation in reimbursement

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Bogdansks K. Severe Complications for Women Drub Childbirth are Skyrocketing and Could Be Prevented. Propublica. https://www.propublica.org/article/severe-complications-for-women-during-childbirth-are-skyrocketing-and-could-often-be-preventedCenters for Disease Control and Prevention. Pregnancy-Related Deaths. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htmRobeznieks A. US has highest maternal death rate among developed countries. May 2015. http://www.modernhealthcare.com/article/20150506/NEWS/150509941

2. Maternity BundleBundled Payment Model Examples

Bundled payments can address quality issues and cost issuesHumana – January 2018

Targets for uncomplicated C-section rate, preterm birth rate, C-section rate for women giving birth for the first time Bundle triggered on members’ admission to hospital and include all prenatal

visits 200 days prior and 45 days post-discharge

Cigna – January 2018 Targets for C-sections, infections, postpartum depression

Blue Cross Blue Shield New Jersey – 2013 Delivery, prenatal, and postpartum care. Results: 32% reduction in unnecessary C-sections

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Butcher L. Bundled Payment for Bundles of Joy. January 2018. https://www.managedcaremag.com/archives/2018/2/bundled-payment-bundles-joyButcher L. Why Horizon BCBSNY Likes Episode of Care Payments. http://www.hfma.org/Content.aspx?id=54164HCP-LAN Maternity Multi-Stakeholder Action Collaborative. Issue Brief: The Business Case for Maternity Care Episode-Based Payment. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&ved=0ahUKEwjc1ZKvnLPbAhUPB3wKHZWMCbQQFghfMAg&url=http%3A%2F%2Fhcp-lan.org%2Fworkproducts%2FMAC-maternity-care-VBP-business-case-03-20-2017.docx&usg=AOvVaw1qxa2iOXAOQ4Y5vK762-C2Castellucci M. Humana Launches Bundled-Payment Model for Maternity Care. April 2018. http://www.modernhealthcare.com/article/20180418/TRANSFORMATION04/180419927

2. Maternity BundleBundled Payment Model Examples

Arkansas Health Care Payment Improvement Initiative –January 2013 Prenatal care bundle (excludes neonatal care) Provider responsible for bundleQuality metrics tied to payment and those tied just to reporting

Geisinger Perinatal ProvenCare – 2007 Prenatal, labor and delivery, postpartum care (excludes neonatal care) 103 evidence-based best practice measures by trimester (e.g.,

smoking cessation) Results: Improvements in nearly all 103 measures, NICU admissions

reduced 25%, no early induction or elective C-section before 41 weeks unless medically indicated since 2011

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HCP-LAN Maternity Multi-Stakeholder Action Collaborative. Issue Brief: The Business Case for Maternity Care Episode-Based Payment. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&ved=0ahUKEwjc1ZKvnLPbAhUPB3wKHZWMCbQQFghfMAg&url=http%3A%2F%2Fhcp-lan.org%2Fworkproducts%2FMAC-maternity-care-VBP-business-case-03-20-2017.docx&usg=AOvVaw1qxa2iOXAOQ4Y5vK762-C2Lally S. Transforming Maternity Care: A Bundled Payment Approach. Integrated Healthcare Association. September 2013. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&ved=0ahUKEwiYqfGgkbPbAhVIsVQKHZzkDikQFghJMAU&url=https%3A%2F%2Fwww.iha.org%2Fsites%2Fdefault%2Ffiles%2Fresources%2F

issue-brief-maternity-bundled-payment-2013.pdf&usg=AOvVaw2SKJv_LBUSxFMH0QEMai6Y

2. Maternity BundleExpert Speakers

Carl Olden, MDFamily PhysicianPacific Crest Family Medicine, YakimaMember, Bree CollaborativeMember, Obstetrics Care workgroup

Janine Reisinger, MPHDirector, Maternal-Infant Health Initiatives, Patient SafetyWashington State Hospital Association

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Safe Deliveries RoadmapMaternity Bundle Recommendations

BREE Collaborative

July 17, 2018

Safe Deliveries Roadmap, July 17, 2018

Question

Is it useful for the Bree to develop recommendations on a maternity bundle payment model in Washington state?

83,000 deliveries per year (HCA, 2016)

59 Birthing Hospitals (WSHA, 2017)

814 Ob Mds (UW, 2014) &

112 midwives (MAWS, 2018)

How a Bundle Can be Beneficial?

• Identify opportunities to measure quality, improve outcomes and

patient experience

• Reduce waste and unnecessary variation

• Improve safety and quality of care

• Work in teams across settings

How are babies being born?

C/s slide here from Neel Shah

Severe Maternal Morbidity is Increasing

Maternal Mortality in Washington

Maternal Mortality Disparities

Example indicators for each domain

Recommendations

• Utilize current MQI measures• Severe Maternal Morbidity: Sepsis Protocol • Severe Maternal Morbidity: OB Hemorrhage Cart and Medication Kit• Severe Maternal Morbidity: Blood Transfusions in Delivering Women• Early Elective Delivery (PC-01)

• Reduce maternal morbidity by aligning with national recommendations • Hemorrhage (QBL, carts, medications, blood transfusion)• Hypertension (Timely treatment, blue band initiative)• Sepsis (Protocol and response)

• Create guidelines for minimizing opioid use • postpartum for vaginal delivery recommendations• limiting discharge prescriptions for post-surgical patients

Recommendations

• Incentivizing increased family planning access, including LARC. • Developing local protocols for hospital stocking and immediate postpartum

placement.

• Reduce unnecessary cesarean section• Including balance measures or risk adjustment (severity of illness, unexpected

newborn complications)

• Address maternal disparities• Align with DOH Maternal Mortality review panel recommendations

Questions?

3. Adapting Total Joint Replacement Bundle to Outpatient CareExpert Speakers

Bob Mecklenburg, MDMedical Director, Center for Health Care SolutionsVirginia Mason Medical CenterMember, Bree Collaborative Co-Chair, Accountable Payment Models workgroups

Jordan MitchelProgram Manager Providence St. Joseph Health

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3. Adapting Total Joint Replacement Bundle to Outpatient CareArthroplasty of the knee is big business. It is the most common

inpatient surgery and has the second highest growth rate for an inpatient surgical procedure. Orthopedic surgeons are the top generators of revenue for hospitals. Inpatient surgeries have “facility” overhead and are several fold more

costly for purchasers than outpatient surgeries. Ambulatory surgery centers now compete with hospitals for health

care dollars. Health plans can also compete for health care dollars by reducing

payment to providers for “site of service” or shift a greater proportion of cost to patients based on interpretation of their subcontracted standards for “outpatient surgery”. The observational evidence base supports the conclusion that for

selected patients, experienced surgeons and major medical centers, ambulatory surgery can be safe. Data informing explicit standards for ambulatory surgery is not definitive.

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Sources: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb186-Operating-Room-Procedures-United-States-2012.jsphttps://www.beckershospitalreview.com/finance/which-physicians-generate-the-most-revenue-for-hospitals.htmlhttps://www.cdc.gov/nchs/data/databriefs/db210.htm; https://archive.ahrq.gov/data/hcup/factbk9/factbk9b.htmhttp://www.modernhealthcare.com/article/20160604/MAGAZINE/306049986; ttps://www.arthroplastyjournal.org/article/S0883-5403(17)31032-X/fulltexthttps://www.orthopedic.theclinics.com/article/S0030-5898(17)30147-5/fulltext; https://www.orthopedic.theclinics.com/article/S0030-5898(16)30068-2/fulltext?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Orthopedic_Clinics_TrendMD_0&code=ocl-site

3. Adapting Total Joint Replacement Bundle to Outpatient CareDiscussion Points

For elective joint replacement surgery Bree has set voluntary standards for appropriateness, fitness for surgery, safe surgery and return to function that include standards for transitions of care. The Bree bundle is silent on site of service.Facility standards, either inpatient or outpatient, are regulated by the State.

One perspective: Bree’s bundle for total joint replacement has established voluntary clinical standards for providers based on patient safety without regard to site of service or length of stay. Bree has no standing or authority related to reimbursement based on a patient’s clinical status, site of service or length of stay in a medical facility.

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4. Retinal Imaging

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Source: Washington Health Alliance. First Do No Harm: Calculating Health Care Waste in Washington State. www.wacommunitycheckup.org/media/47156/2018f d h df

Measure based on Choosing Wisely recommendations from American Academy of Ophthalmology and American Association of Pediatric Ophthalmology and Strabismus. Clinical imaging tests generally not needed without symptoms or signs of

significant disease

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4. Retinal Imaging Five Things Physicians and Patients Should Question

American Academy of OphthalmologyReleased February 2013 Imaging Tests Don’t routinely order imaging tests when there are no symptoms or signs of

significant eye disease.

American Association for Pediatric Ophthalmology and Strabismus Released October 8, 2013 Don’t order retinal imaging tests for children without symptoms or signs of

eye disease Retinal imaging, such as taking a photograph or obtaining an Ocular

Coherence Tomography (OCT) image of the back of a child’s eye, can be useful for documenting or following known retinal or optic nerve pathology. These imaging studies should not be obtained routinely for documentation of normal ocular anatomy in asymptomatic children.

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4. Retinal Imaging Expert Speakers

Philip C Paros, ODPhysician in Chief: Eye CareKaiser Permanente

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5. Expanding End-of-life Care Recommendations/Palliative care

“Palliative care is specialized care for people living with serious illness. Care is focused on relief from the symptoms and stress of the illness and treatment—whatever the diagnosis. The goal is to improve and sustain quality of life for the patient, loved ones and other care companions. It is appropriate at any age and at any stage in a serious illness and can be provided along with active treatment. Palliative care facilitates patient autonomy, access to information, and choice. The palliative care team helps patients and families understand the nature of their illness, and make timely, informed decisions about care.”

- Washington State Department of Health Rural Palliative Care Initiative- Goal to “help Washington rural communities develop skills and services to

serve people with serious illnesses and their loved ones, in the community at any stage of illness.”

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5. Expanding End-of-life Care Recommendations/Palliative care

“I would like to strongly encourage the Bree to take on this topic. Based on the work [we at the Northwest Rural Health Network] have done in the palliative care pilot so far, I believe these services will be particularly important for rural health systems and the communities they serve. The proportion of older adults is already higher in rural communities than in urban centers and that proportion is growing over time. Being able to receive palliative care services within their home communities will help rural residents stay home longer and improve quality of life for both patients and their families. Providing palliative care services in the community will also help rural health systems better manage the health of the populations they serve and reduce the overall cost of care, which will be critical for sustainability as they move into value-based contracts.”

-Jac Davies, MS, MPHExecutive DirectorNorthwest Rural Health Network

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5. Expanding End-of-life Care Recommendations/Palliative careExpert Speakers

Richard Stuart, DSWClinical Professor Emeritus, PsychiatryUniversity of WashingtonMember, Bree Collaborative End-of-Life Care workgroup

Cynthia Tomik, LICSWManager – Palliative Care & Hospice EHMC Liaisons, Spiritual Care, Bereavement, Volunteer Services and Honoring ChoicesEvergreenHealth

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Select Three

1. Shared decision making2. Maternity bundle (including long-acting reversible

contraceptive) 3. Adapting the total joint replacement bundle to

outpatient care4. Retinal imaging 5. Expanding end-of-life care

recommendations/palliative care

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Break

FinalAdoption:AMDGOpioidPrescribingGuidelinesImplementation-Peri-operativesupplementto2015AMDGGuideline

GaryFranklin,MD,MPHMedicalDirector,WashingtonStateDepartmentofLaborandIndustries

July17th,2018|BreeCollaborativeMeeting

WorkgroupMembers�  Co-Chair:GaryFranklin,MD,MPH,MedicalDirector,WashingtonStateDepartmentofLaborandIndustries

�  ChrisBaumgartner,DirectorPrescriptionMonitoringProgram,WashingtonStateDepartmentofHealth

�  CharissaFontinos,MD,DeputyChiefMedicalOfficer,WashingtonStateHealthCareAuthority� DebGordonRN,DNP,FAAN,TeachingAssociate,AnesthesiologyandPainMedicine,UniversityofWashington

�  FrancesGough,MD,ChiefMedicalOfficer,Molina� DanKent,MD,ChiefMedicalOfficer,UnitedHealthcare�  KathyLofy,MD,ChiefScienceOfficer,WashingtonStateDepartmentofHealth�  JaymieMai,PharmD,PharmacyManager,WashingtonStateDepartmentofLaborandIndustries� MarkMurphy,MD,AddictionMedicine,MulticareHealth�  YusufRashid,PharmD,VicePresident,CommunityHealthPlanofWashington�  ShirleyReitz,PharmD,Pharmacist,OmedaRx,CambiaHealth� GregRudolf,MD,PainServices,Swedish� MarkStephens,Principal,CareSyncConsulting,LLC� DavidTauben,MD,ChiefofPainMedicine,UniversityofWashingtonMedicalCenter� GregoryTerman,MD,PhD,Professor,DepartmentofAnesthesiologyandPainMedicineandtheGraduatePrograminNeurobiologyandBehavior

� MichaelVonKorff,ScD,SeniorInvestigator,KaiserPermanenteWashingtonResearchInstitute� GaryWalco,MD,Professor,DepartmentofAnesthesiology;AdjunctProfessor,DepartmentofPediatrics,SeattleChildren’sHospital,UWSchoolofMedicine

� MiaWise,DO,MedicalDirector,CollaborativeHealthcareSolutions,PremeraBlueCross

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FocusAreas

� Opioidprescribingmetrics–adopted,July2017� Educatingprovidersandpatients–Alliancepartnership,publishedJanuary2017� Reducinginappropriateacuteprescribing

� Dentalprescribingguideline-adopted,September2017� DentalconferencesinSpokaneandSeattle,WA

� Peri-operativeopioidprescribing-withfocusondischargeRxguidance� SupportingGovernorInslee’sExecutiveOrder� Reportingoverdoses Slide3

Background

� BreeCollaborativeworkgroupandWashingtonAgencyMedicalDirectors’Groupincollaborationwithanadvisorygroupofthestate’sacademicleaders,painexpertsandsurgeonsingeneralcareandspecialtyareasinresponsetothegrowingopioidcrisis.� SupplementalignspostoperativedischargeopioidprescribingwithbestpracticefromtheAMDGInteragencyGuidelineonPrescribingOpioidsforPainandthebestpracticesfromtheAMDG/BreeDentalGuidelineonPrescribingOpioidsforAcutePainManagement� Evidencerepresentsrapidlyevolvingliteratureonappropriatepostoperativeopioidprescribing-over100studiesinpast3years.� Recommendationsbasedonthecurrentbestavailableclinicalandscientificevidencefromtheliteratureandaconsensusofexpertopinionandareintendedforuseinadditionto,ratherthanareplacementof,theguidelinesforopioidprescribingforpostoperativepaininthe2015AMDGguidelines.

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AtTimeofDischarge

� Patientsoftenreceivemoreopioidsforhomeusethanarenecessaryforpainrelatedtomanyprocedures.

� Mayresultindangerousandillegaldiversionofopioids

� Increaseddurationofinitialopioidprescriptionassociatedwithincreasedincidenceofchronicopioiduseandriskofopioidmisuseandoverdose.� Nooptimalnumberofpillsforagivenprocedure,butrecommendationsintendedtoserveasageneralframeworkformanagingpostoperativepain,whileminimizingleftoverpills,persistentopioiduse,andsubsequentabuse,dependenceandoverdose.� Prescribingopioidsforpostoperativepainshould,inmostcases,followtheguidanceinTable1.� Rationaleforanyexceptionsshouldbewelldocumentedintherecord.� Evenintheseexceptionsinitialprescriptionshouldnotexceedtwoweeks.

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Table1:Evidence-BasedDurationofOpioidPrescriptionsonDischargeFollowingSurgery

TypeI–ExpectedrapidrecoveryDentalproceduressuchasextractionsorsimpleoralsurgery(e.g.,graft,implant).

•  Prescribeanonsteroidalanti-inflammatorydrug(NSAID)orcombinationofNSAIDandacetaminophenformildtomoderatepainasfirst-linetherapy.

•  Ifopioidsarenecessary,prescribe≤3days(e.g.,8to12pills)ofshort-actingopioidsincombinationwithanNSAIDoracetaminophenforseverepain.Prescribethelowesteffectivedosestrength.

•  Formorespecificguidance,seetheBreeCollaborativeDentalGuidelineonPrescribingOpioidsforAcutePainManagement.

Proceduressuchaslaparoscopicappendectomy,inguinalherniarepair,carpaltunnelrelease,thyroidectomy,laparoscopiccholecystectomy,breastbiopsy/lumpectomy,meniscectomy,lymphnodebiopsy,vaginalhysterectomy.

•  Prescribenon-opioidanalgesics(e.g.,NSAIDsand/oracetaminophen)andnon-pharmacologictherapiesasfirst-linetherapy.

•  Ifopioidsarenecessary,prescribe≤3days(e.g.,8to12pills)ofshort-actingopioidsincombinationwithanNSAIDoracetaminophenforseverepain.Prescribethelowesteffectivedosestrength.

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Table1:Evidence-BasedDurationofOpioidPrescriptionsonDischargeFollowingSurgery

TypeII–ExpectedmediumtermrecoveryProceduressuchasanteriorcruciateligament(ACL)repair,rotatorcuffrepair,discectomy,laminectomy,openorlaparoscopiccolectomy,openincisionalherniarepair,opensmallbowelresectionorenterolysis,widelocalexcision,laparoscopichysterectomy,simplemastectomy,cesareansection.

•  Prescribenon-opioidanalgesics(e.g.,NSAIDsand/oracetaminophen)andnon-pharmacologictherapiesasfirst-linetherapy.

•  Prescribe≤7days(e.g.,upto42pills)ofshort-actingopioidsforseverepain.Prescribethelowesteffectivedosestrength.

•  Forthoseexceptionalcasesthatwarrantmorethan7daysofopioidtreatment,thesurgeonshouldre-evaluatethepatientbeforeathirdprescriptionandtaperoffopioidswithin6weeksaftersurgery.

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Table1:Evidence-BasedDurationofOpioidPrescriptionsonDischargeFollowingSurgery

TypeIII–ExpectedlongertermrecoveryProceduressuchaslumbarfusion,kneereplacement,hipreplacement,abdominalhysterectomy,axillarylymphnoderesection,modifiedradicalmastectomy,ileostomy/colostomycreationorclosure,thoracotomy.

•  Prescribenon-opioidanalgesics(e.g.,NSAIDsand/oracetaminophen)andnon-pharmacologictherapiesasfirst-linetherapy.

•  Prescribe≤14daysofshort-actingopioidsforseverepain.Prescribethelowesteffectivedosestrength.

•  Forthoseexceptionalcasesthatwarrantmorethan14daysofopioidtreatment,thesurgeonshouldre-evaluatethepatientbeforerefillingopioidsandtaperoffopioidswithin6weeksaftersurgery.

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Table1:Evidence-BasedDurationofOpioidPrescriptionsonDischargeFollowingSurgery

PatientsonChronicOpioidAnalgesicTherapyElectivesurgeryinpatientsonchronicopioidtherapy

•  Prescribenon-opioidanalgesics(e.g.,NSAIDsand/oracetaminophen)andnon-pharmacologictherapiesasfirst-linetherapy.

•  Resumechronicopioidregimenifpatientsareexpectedtocontinuepostoperatively.

•  Followtherecommendationaboveforprescribingthedurationofshortactingopioidsfollowingaparticularsurgery(e.g.,3,7,or14days).Anincreasednumberofpillsperdaymaybeexpectedcomparedtoanopioidnaïvepatient.Patientsonchronicopioidtherapyshouldhaveasimilartaperingperiodasopioidnaïvepatientspostoperatively.Prescribethelowesteffectivedosestrength.

•  Forthoseexceptionalcasesthatwarrantmorethan14daysofopioidtreatmentafterhospitaldischarge,thesurgeonshouldre-evaluatethepatientbeforerefillingopioidsandtaperoffopioidswithin6weeksaftersurgerytonohighertotaldailydosethanwaspresentpre-operatively. Slide9

Clarifyinglanguage

� Althoughaprescriptionmaybewrittenforfrequentdosingintervalssuchas“prneveryfourtosixhours,”avoidroutinedispensingofthenumberofpillsthatequalsthetotalallowablemaximumdosing.

� EX:patientsusingtwopillsprneveryfourhoursonhospitaldischargepost-operativelywouldbecalculatedtoneedasmuchas84pillsinthenextweek.Apatientshouldbeexpectedtoneedlessfrequentdosing,however,aspainresolvesandthuswilllikelyneedasignificantlylowernumberofpills(aslittleashalf)foraspecificspecifiedtimeline(e.g.,three,seven,or14days).Intheabovescenario,thepatientcouldbedispensed42pillswithinstructionsthattheprescriptionshouldbetakenasneededforseverepainandwillprobablylastaweekashealingcontinues.

� Considerdiscussingpartialrefillswithyourpatient,linktomoreinformationhere.

� Whilepainmaypersistformanyweeksfollowingsomesurgeries,patientswhoareunabletotaperopioidusetocoincidewithexpectedhealingorwhoreportpainsevereenoughtowarrantongoingopioiduseaftertheprocedure-specificusualnumberofdaysrequirere-evaluationinanefforttounderstandthefactorsdelayinganormalcourseofrecovery.

� Forpatientswhoarestillonopioidsaftersixweeks,followtherecommendationsintheSubacuteorChronicPhaseoftheAMDGInteragencyGuidelineonPrescribingOpioidsforPain. Slide10

Clarifyinglanguage

� Ifopioidsarecontinued,bestpracticeforahealthcareprovideristoassessanddocumentthefollowingtodeterminesuccessoftreatment:� (a)Changeinpainlevel;� (b)Changeinphysicalfunction;� (c)Changeinpsychosocialfunction;� (d)Changeinmedicalcondition;and� (e)Diagnosticevaluationstoinvestigatecausesofcontinuedacuteperioperativepain(e.g.,infection,ischemia,lackofhealing).

� Acutepainlastsnolongerthansixweeksandopioidprescribingforpainmorethansixweeksaftersurgeryshouldbetreatedassubacuteorchronicpain(AMDGInteragencyGuidelineonPrescribingOpioidsforPain).

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PublicCommentsMay29th–June22nd

Slide12

38Individualsorgroupsrespondedtosurvey3letters

OverviewofPublicComments

� Stronglypositive� Somesuggestionsforadditionallanguagearoundpaincontrolthatwasoutofscope-eg,naloxonedetail� Requestforinclusionofpodiatricprocedures� FeedbackonopioidprescribingforC-section/hysterectomy� Requesttoamplifyimportanceofpreoperativeeducation(outlinedin2015AMDGGuideline)� SpecifytheCOMBOofacetaminophen/NSAIDSforfirstlinetreatment� ConcernaboutadverseimpactofNSAIDSonhealingbonesandtendons

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OverviewofChanges

� Clarifiedsurgicalroletoalsoprovidepre-opeducationondischargeopioidplans,includingtapering,andlinkto2015AMDGGuidelinelanguage

� “Inadditiontoprescribingtheappropriateamountofopioidsforagivenprocedure,itisimportantthatthesurgeonprovideeducationforthepatientandcaregiversaboutrealisticexpectationsforpostoperativepainmanagement,functionalrecoveryactivities,andtimelyreductioninopioiduseaswellasprovidinginstructionforsafestorageanddisposalofopioidsasspecifiedinthe2015AMDGGuidelinehere.Thesurgeonshouldalsofollowthepreoperativeriskassessmentandeducationasoutlinedinthe2015AMDGGuidelines.”

� ClarifiedcombinationofNSAIDSandacetaminophen,eg,byaddingNSAIDsand/oracetaminophen

Slide14

OverviewofChanges

� Clarified“Prescribethelowesteffectivedosestrength.”� Addedevidencesectiononpodiatry

�  “EvidencehassuggestedacombinationofNSAID/acetaminophenwasequivalenttoacetaminophen/codeineinthefirstfourpostoperativedaysfollowingfootsurgery,andacetaminophen/codeinewasinferiorregardingdropoutsforsideeffects(31).InarandomizedtrialofaCOXinhibitorcomparedtotramadolsustained-releasefollowingelectivehalluxvalgussurgery,COXinhibitorsweremoreeffectiveandhadfewersideeffects(32).Inasystematicreviewofrandomizedtrialsofpainmanagementforelectivefootandanklesurgery,theauthorsconcludedthatoptimalpainmanagementincludelocoregionalanalgesictechniquesplusAcetaminophen/NSAIDS.Opioidsareonlyrecommendedas"rescue"medication(33).Merrilletal.reportedinaretrospectivecaseseriesthatthemeannumberofopioidtabstakenafterfootandanklesurgerywas27,withthemajorityofpatientshavingleftovermedication(34).InamorerecentprospectivecomparativestudyacrossmultipleproceduresbyGuptaetal.(35),patientsconsumedameanof22.5pills,witha95%confidenceintervalof18-27pills.Acrossmultipleproceduretypes,themeanreportedpainscoresonpostoperativedaythreewasfouronatenpointscale.ThisdatasuggeststhatmostfootprocedureswouldfitintotypeIinTable1,withasmallernumberofpatientsfittingintotypeII.”

Slide15

OverviewofChanges

� AddednewevidencesectiononimpactofNSAIDSonbone(eg,fracture)ortendonhealing:

� ArecentsystematicreviewofallhumanstudiesrelatedtouseofNSAIDSandboneorfracturehealingwasreportedbyMarquez-Laraetal(36).Thisreviewhighlightsgreatvariabilityintheliteratureonthisissue.Theauthorsconcludethat"withholdingthesemedications(NSAIDs)doesnothaveanyprovenscientificbenefittopatientsandmayevencauseharmbyincreasingnarcoticrequirementsincasesinwhichtheycouldbebeneficialforpainmanagement."Arecentprospectiveobservationalregistrystudyfoundthatamongover7,000patientsundergoinganteriorcruciateligamentreconstruction,thosereceivingNSAIDspostoperativelyhadnoworseoutcomesrelatedtograftsurvival,riskofrevision,orqualityoflife.TheauthorsconcludethatusingsomecautionwhenadministeringNSAIDspostoperativelyincludeskeepingthedurationanddosageofNSAIDsasshortandlowaspossibletoensuresufficientpainreliefwhilelimitingexposuretoanyknownandunknownadverseeffects(37,38).

Slide16

Evidence�  RawalN.(2001)Treatingpostoperativepainimprovesoutcome.MinervaAnestesiol.67:200-5.�  BuvanendranA,FialaJ,PatelKA,GoldenAD,MoricM,KroinJS.(2015)TheIncidenceandSeverityofPostoperativePainfollowingInpatientSurgery.PainMed.16:2277-83.�  NationalPainStrategyAComprehensivePopulationHealth-LevelStrategyforPain.NationalInstitutesofHealthInteragencyPainResearchCoordinatingCommittee.2017.MackeySC,PortorL,ed.Accessed:April2018.Available:

https://iprcc.nih.gov/sites/default/files/HHSNational_Pain_Strategy_508C.pdf�  HillMV,McMahonML,StuckeRS,BarthRJJr.(2017)WideVariationandExcessiveDosageofOpioidPrescriptionsforCommonGeneralSurgicalProcedures.AnnSurg.265:709-714.�  ThielsCA,AndersonSS,UblDS,HansonKT,BergquistWJ,GrayRJ,GazelkaHM,CimaRR,HabermannEB.(2017)WideVariationandOver-prescriptionofOpioidsAfterElectiveSurgery.AnnSurg.266:564-573.�  OsmundsonSS,SchornackLA,GraschJL,ZuckerwiseLC,YoungJL,RichardsonMG.(2017)Post-dischargeOpioidUseAfterCesareanDelivery.ObstetGynecol.130(1):36-41.�  KimN,MatzonJL,AbboudiJ,JonesC,KirkpatrickW,LeinberryCF,etal.(2016)

AProspectiveEvaluationofOpioidUtilizationAfterUpper-ExtremitySurgicalProcedures:IdentifyingConsumptionPatternsandDeterminingPrescribingGuidelines.JBoneJointSurgAm.98:e89.�  GuptaA,KumarK,RobertsMM,SandersAE,JonesMT,LevineDS,O'MalleyMJ,DrakosMC,ElliottAJ,DelandJT,EllisSJ.(2018)PainManagementAfterOutpatientFootandAnkleSurgery.FootAnkleInt.39:149-154.�  BartelsK,MayesLM,DingmannC,BullardKJ,HopferCJ,BinswangerIA.(2016)OpioidUseandStoragePatternsbyPatientsafterHospitalDischargefollowingSurgery.PLoSOne.11:e0147972.�  KumarK,GulottaLV,DinesJS,AllenAA,ChengJ,FieldsKG,YaDeauJT,WuCL.(2017)UnusedOpioidPillsAfterOutpatientShoulderSurgeriesGivenCurrentPerioperativePrescribingHabits.AmJSportsMed.45:636-641�  BaruchAD,MorganDM,DaltonVK,SwensonC.(2018)OpioidPrescribingPatternsbyObstetricsandGynecologyResidentsintheUnitedStates.SubstUseMisuse.53:70-76.�  AttumB,Rodriguez-BuitragoA,N,EvansA,ObremskeyW,SethiMK,JahangirAA.(2018)OpioidPrescribingPracticesbyOrthopaedicTraumaSurgeonsAfterIsolatedFemurFractures.JOrthopTrauma.32:e106-e111.�  VanCleveWC,GriggEB.(2017)VariabilityinopioidprescribingforchildrenundergoingambulatorysurgeryintheUnitedStates.JClinAnesth.41:16-20.�  RuderJ,WallyMK,OliverioM,SeymourRB,HsuJR(2017).PatternsofOpioidPrescribingforanOrthopaedicTraumaPopulation.JOrthopTrauma.31:e179-e185.�  BatemanBT,ColeNM,MaedaA,BurnsSM,HouleTT,HuybrechtsKF,etal.(2017)PatternsofOpioidPrescriptionandUseAfterCesareanDelivery.ObstetGynecol.130:29-35.�  MylonasKS,ReinhornM,OttLR,WestfalML,MasiakosPT.(2017)Patient-reportedopioidanalgesicrequirementsafterelectiveinguinalherniarepair:Acallforprocedure-specificopioid-administrationstrategies.

Surgery.162:1095-1100.�  HanB,ComptonWM,BlancoC,CraneE,LeeJ,JonesCM.(2017)PrescriptionOpioidUse,Misuse,andUseDisordersinU.S.Adults:2015NationalSurveyonDrugUseandHealth.AnnInternMed.167:293-301.�  BrummettCM,WaljeeJF,GoeslingJ,MoserS,LinP,EnglesbeMJ,etal.(2017)NewPersistentOpioidUseAfterMinorandMajorSurgicalProceduresinUSAdults.JAMASurg.152:e170504.�  HarbaughCM,LeeJS,HuHM,McCabeSE,Voepel-LewisT,etal.(2018)PersistentOpioidUseAmongPediatricPatientsAfterSurgery.Pediatrics.141:e20172439.�  ShahA,HayesCJ,MartinBC.(2017)CharacteristicsofInitialPrescriptionEpisodesandLikelihoodofLong-TermOpioidUse-UnitedStates,2006-2015.MMWRMorbMortalWklyRep.66:265-269.�  HootenWM,BrummettCM,SullivanMD,GoeslingJ,TilburtJC,MerlinJS,etal.(2017)AConceptualFrameworkforUnderstandingUnintendedProlongedOpioidUse.MayoClinProc.92:1822-1830.�  BratGA,AgnielD,BeamA,YorkgitisB,BicketM,HomerM,etal.(2018)PostsurgicalPrescriptionsforOpioidNaivePatientsandAssociationwithOverdoseandMisuse:RetrospectiveCohortStudy.BMJ.360:j5790.�  HillMV,StuckeRS,McMahonML,BeemanJL,BarthRJJr.(2018)AnEducationalInterventionDecreasesOpioidPrescribingAfterGeneralSurgicalOperations.AnnSurg.267(3):468-472.�  HowardR,WaljeeJ,BrummettC,EnglesbeM,LeeJ.(2018)ReductioninOpioidPrescribingThroughEvidence-BasedPrescribingGuidelines.JAMASurg.153:285-287.�  ScullyRE,SchoenfeldAJ,JiangW,LipsitzS,ChaudharyMA,LearnPA,etal.(2018)Definingoptimallengthofopioidpainmedicationprescriptionaftercommonsurgicalprocedures.JAMASurg.153:37-43.�  DowellD,HaegerichTM,ChouR.(2016)CDCGuidelineforPrescribingOpioidsforChronicPain-UnitedStates,2016.MMWRRecommRep.65:1-49.�  WashingtonStateAgencyMedicalDirectorsGroup.InteragencyGuidelineonPrescribingOpioidsforPain.3rdedition,June2015.Available:http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf�  MichiganSurgicalQualityCollaborative.OpioidPrescribingRecommendationsforOpioidNaivePatients.March12,2018.Available:

https://static1.squarespace.com/static/598c503737c58117428e7cc9/t/5aa6e145c830250430d7f46a/1520886087058/Opioid_Prescribing_Recommendations_for_Opioids_Web_20180312.pdf�  PrabhuM,McQuaid-HansonE,HoppS,BurnsSM,LeffertLR,LandauR,etal.(2017)ASharedDecision-MakingInterventiontoGuideOpioidPrescribingAfterCesareanDelivery.ObstetGynecol.130:42-46.�  HillMV,StuckeRS,BillmeierSE,KellyJL,BarthRJJr.(2017)GuidelineforDischargeOpioidPrescriptionsafterInpatientGeneralSurgicalProcedures.JAmCollSurg.pii:S1072-7515(17)32055-0.�  OttingerML,KinneyKW,BlackJR,WittenbergM.(1990)ComparisonofFlurbiprofenandAcetaminophenwithCodeineinPostoperativeFootPain.JAmPodiatrMedAssoc.180(5):266-70.�  BratwallM,TuranI,JakobssonJ.(2010)PainManagementAfterElectiveHalluxValgusSurgery:AProspectiveRandomizedDouble-BlindStudyComparingEtoricoxibandTramadol.AnesthAnalg.111(2):544-9.�  WangJ,LiuGT,MayoHG,JoshiGP.(2015)PainManagementforElectiveFootandAnkleSurgery:ASystematicReviewofRandomizedTrials.JFootAnkleSurg.54(4):625-35.�  MerrillHM,DeanDM,MottlaJL,NeufeldSK,CutticaDJ,BuchananMM.(2018)OpioidConsumptionFollowingFootandAnkleSurgery.FootAnkleInt.2018Jun;39(6):649-656.�  GuptaA,KumarK,RobertsMM,SandersAE,JonesMT,LevineDS,etal.(2018)PainManagementAfterOutpatientFootandAnkleSurgery.FootAnkleInt.39(2):149-54.�  Marquez-LaraA,HutchinsonID,NunezFJr,SmithTL,MillerAN.(2016)NonsteroidalAnti-inflammatoryDrugsandBone-healing:ASystematicReviewofrResearchQuality.JBJSRev.15;4(3).pii:01874474-201603000-00005.�  SoreideE,GrananLP,HjorthaugGA,EspehaugB,DimmenS,NordslettenL.(2016)TheEffectofLimitedPerioperativeNonsteroidalAnti-inflammatoryDrugsonPatientsUndergoingAnteriorCruciateLigamentReconstruction.AmJ

SportsMed.44(12):3111-3118.�  ChouR,GordonDB,deLeon-CasasolaOA,RosenbergJM,BicklerS,BrennanT,etal.(2016)ManagementofPostoperativePain:AClinicalPracticeGuidelineFromtheAmericanPainSociety,theAmericanSocietyofRegional

AnesthesiaandPainMedicine,andtheAmericanSocietyofAnesthesiologists'CommitteeonRegionalAnesthesia,ExecutiveCommittee,andAdministrativeCouncil.JPain.17(2):131-57.�  Voepel-LewisT,WagnerD,TaitAR.(2015)LeftoverPrescriptionOpioidsAfterMinorProcedures:AnUnwittingSourceforAccidentalOverdoseinChildren.JAMAPediatr.169:497-498.�  MonittoCL,HsuA,GaoS,VozzoPT,ParkPS,RoterD,etal.(2017)OpioidPrescribingforTheTreatmentofAcutePaininChildrenonHospitalDischarge.AnesthAnalg.125:2113-2122.�  PoonaiN,DatooN,AliS,CashinM,DrendelAL,ZhuR,etal.(2017)OralMorphineVersusIbuprofenAdministeredatHomeforPostoperativeOrthopedicPaininChildren:ARandomizedControlledTrial.CMAJ.189(40):E1252-E1258�  AvansinoJR,PetersLM,StockfishSL,WalcoGA.(2013)AParadigmShifttoBalanceSafetyandQualityinPediatricPainManagement.Pediatrics.131(3):e921-7.�  FitzgeraldM,WalkerSM.(2009)InfantPainManagement:ADevelopmentalNeurobiologicalApproach.NatClinPractNeurol.5:35-50.�  WalcoGA,KopeckyEA,WeismanSJ,StinsonJ,StevensB,DesjardinsPJ,eral.(2018)ClinicalTrialDesignsandModelsforAnalgesicMedicationsforAcutePaininNeonates,Infants,Toddlers,Children,andAdolescents:ACTTION

Recommendations.Pain.159:193-205.

Slide17

ActionItem

AdoptSupplementalGuidanceonPrescribingOpioidsforPostoperativePain

Slide18

Disseminate for Public Comment:LGBTQ Health Care

Dan Lessler, MD, MHAChief Medical Officer, Washington State Health Care Authority

July 17th, 2018 | Bree Collaborative Meeting

Workgroup Members

Chair: Dan Lessler, MD, MHA, Chief Medical Officer, Washington State Health Care Authority Olivia Arakawa, MSN, CNM, ARNP, RN, Parent Advocate Scott Bertani , Director of Policy, Lifelong AIDS Alliance Kathy Brown, MD, HIV and PrEP Medical Director, Kaiser Permanente LuAnn Chen, MD, MHA, FAAFP, Medical Director, Community Health Plan of

WashingtonMichael Garrett, MS, CCM, CVE, NCP, Principal, Mercer Chris Gaynor, MD, MA, FAAFP, Family Practice Clinician, Capitol Hill MedicalMatthew Golden, MD, Professor of Medicine/Director, HIV/STD Program,

University of Washington/Public Health – Seattle & King County Kevin Hatfield, MD, Family Practice Clinician, The Polyclinic Corinne Heinen, MD, Physician Lead, UW Transgender Clinical Pathway,

Department of Internal Medicine, Allergy & Infectious Disease, University of Washington Tamara Jones, End AIDS Washington Policy and Systems Coordinator,

Department of Health Slide 2

Recommendations

Whole-person care frameworkTaking into consideration a person’s multiple individual factors that make up health, wellness, and experience (e.g., behavioral health, past trauma, race/ethnicity) Not identity or diagnosis-limiting.That all health care encounters occur using non-judgmental, non-stigmatizing language, body language, and tone.Oriented mainly to primary careAlso includes language for other stakeholders

Slide 3

Three Focus Areas

I. Communication, Language, and Inclusive Environments

II. Screening and Taking a Social and Sexual HistoryIII. Areas Requiring LGBTQ-Specific Standards and

Systems of Care

Slide 4

Communication, Language, and Inclusive Environments

Use of appropriate pronouns, the patient’s chosen name, and gender identity. Use of appropriate and respectful terms for chosen family, HIV status, transgender people, and other areas.Support from electronic health record and health plan data. Onsite access to gender-neutral restrooms. Staff use of preferred pronouns on badges. Use of diverse images (e.g., images of same-sex families on hallway posters, website, or other marketing materials). Non-discrimination reflected in forms and protocols (e.g., mission statement, employee materials).

Slide 5

Screening and Taking a Social and Sexual History

Screening for the following: Behavioral health concerns including depression, suicidality, anxiety, alcohol

misuse, and drug use (by specific type as relevant to STI risk). Intimate partner violence. Tobacco use.

Social history using recommended minimum information with flexibility around language depending on patient population: Sexual partners in last 12 months (e.g., men, women, both men and women,

other/non-binary, none). Type of sex (e.g., oral, vaginal, insertive or receptive anal sex).

History of sexually transmitted infections, by specific relevant type.

Slide 6

Areas Requiring LGBTQ-specific Standards and Systems of Care*Appropriate referrals and follow-up based on needs defined through screening and clinical evaluation (e.g., depression, other health concern).HIV, Hepatitis C, or other STI screening. Immunizations.HIV pre-exposure prophylaxis based on risk assessment.HIV treatment and engagement with care.Appropriate cervical cancer screening and breast cancer screening for patients with cervical and breast tissue for whom screening would be appropriate.Hormonal therapy, surgical care, and other services for gender minority depending on patient preference. Information on appropriate community resources.* Providers and health care systems should establish referral networks to provide these services when they cannot be provided within an individual practice.

Slide 7

Ex: Primary Care ProvidersAreas Requiring LGBTQ-Specific Standards and Systems of Care: HIV and STI screening

Follow the Washington State STD screening guidelines for men who have sex with men and transgender persons. For sexually active men who have sex with men outside of long-term,

mutually monogamous relationships, these guidelines recommend STI testing (HIV, syphilis, gonorrhea and chlamydial infection) every three to 12 months based on defined risks. Providers should test men who have sex with men and transgender persons who have sex with men for gonorrhea and chlamydial infection at all exposed anatomical sites of potential infection (i.e., pharynx, rectum, urethra/vagina). Hepatitis C screening for those using injection drugs or off-market

hormonal therapy. Providers should also consider HCV screening in HIV-infected MSM and transgender persons who have sex with men. Follow other age-appropriate screenings (e.g., Hepatitis C screening for

those born between 1945 and 1965). Inform patients who test positive for HIV or other STIs that are reportable

that their infections will be reported to public health and that they may be contacted by the Health Department.

Slide 8

Table 2: Recommendations for LGBTQ-Competent Health Care

Slide 9

Action Item

Approve LGBTQ Health Care Report and Recommendations for dissemination for public comment

Slide 10

Disseminate for Public Comment: Suicide Care

Hugh Straley, MDChair, Bree CollaborativeChair, Suicide Prevention Workgroup

July 17th, 2018 | Bree Collaborative Meeting

Workgroup Members

Chair: Hugh Straley, MD, Chair, Bree Collaborative Kate Comtois, PhD, MSW, Psychologist, Harborview Medical CenterKaren Hye, PsyD, Clinical Psychologist, CHI Franciscan HealthMatthew Layton, MD, PhD, FACP, DFAPA, Clinical Professor,

Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University Neetha Mony, MSW, Statewide Suicide Prevention Plan Program

Manager, Washington State Department of Health Julie Richards, MPH, Research Associate, Kaiser Permanente

Washington Health Research Institute Julie Rickard, PhD, Program Director of Integrated Behavioral Services,

Confluence Health Jennifer Stuber, PhD, Associate Professor, University of Washington

School of Social Work Jeffrey Sung, MD, Member, Washington State Psychiatric Association Slide 2

New Data from CDCSuicide rates rising across US

Slide 3

Framework and Background

Suicide is a preventable outcome and a public health issue. The effect of a suicide on family members, friends, and clinical providers is long-lasting and profound.Suicide rate in Washington State higher than national average Over 75% of all violent deaths in Washington State are suicides. Firearms account for almost half of all deaths by suicide with suffocation at 24% and poisoning at 19% followed by falls and jumps, cutting and piercing, drowning, and other all under 5%.

American Association of Suicidology. USA Suicide 2016; Final Data File. Accessed: February 2018. Available: www.suicidology.org/Portals/14/docs/Resources/FactSheets/2016/2016datapgsv1b.pdf?ver=2018-01-15-211057-387 Slide 4

Six Focus Areas

I. Identification of Suicide Risk II. Assessment of Suicide RiskIII. Suicide Risk ManagementIV. Suicide Risk Treatment V. Follow-up and Support After a Suicide AttemptVI. Follow-up and Support After a Suicide Death

Slide 5

Identification of Suicide Risk

Screen all patients over 13 annually for behavioral health conditions (i.e., mental health, substance use), associated with increased suicide risk using a validated instrument(s), including:Depression Suicidality (i.e., suicidal ideation, current plans, past attempts) Alcohol misuseAnxietyDrug use

Slide 6

Assessment of Suicide Risk

Based on results from identification above, further assess risk of suicide with a validated instrument such as the full C-SSRS and assess additional risk factors including: Mental illness diagnosis Substance use disorder(s) Stressful life event

Other relevant psychiatric symptoms or warning signs (at clinician’s discretion)

Slide 7

Suicidal Risk Management

Ensure individuals at risk of suicide have pathway to timely and adequate care (e.g. follow-up contact same day or later as indicated by suicide risk assessment).Keep patients in an acute suicidal crisis in an observed, safe environment.Address lethal means restriction. Engage patients in collaborative safety planning. If possible, involve family members or other key support people in suicide risk management.

Slide 8

Collaborative Safety Planning

Key components should include: Recognition of warning signs of a suicidal crisisAddressing lethal means restriction (e.g. safe firearm and medication storage) Internal coping strategies Socialization strategies for distraction and supportContact numbers for friends and family members to ask for helpProfessionals/agencies to contact during crisis, including Suicide Prevention Lifeline 1-800-273-TALK (8255) and local emergency numbers

Slide 9

Source: Stanley B, Brown GK. Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice. 2012 May;19(2):256-264.

Suicide Risk Treatment

Use effective evidence-based treatments provided onsite that directly target suicidal thoughts and behaviors rather than focusing on specific mental health diagnoses through integrated behavioral health or off-site with a supported referral. The interventions with the most robust evidence include: Following-up with a patient by initiating a non-demand caring contact Dialectical behavior therapy Suicide-specific cognitive behavioral therapy Collaborative assessment and management of suicidality

Document patient information related to suicide care and referrals.

Slide 10

Sources: Luxton DD, June JD, Comtois KA. Can postdischarge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence. Crisis. 2013 Jan 1;34(1):32-41. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006 Jul;63(7):757-66. Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005 Aug 3;294(5):563-70. Stanley B, Brown G, Brent D, et al. Cognitive Behavior Therapy for Suicide Prevention (CBT-SP): Treatment Model, Feasibility and Acceptability. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48(10):1005-1013. Comtois KA, Jobes DA, S O'Connor S, Atkins DC, Janis K, E Chessen C, et al. Collaborative assessment and management of suicidality (CAMS): feasibility trial for next-day appointment services. Depress Anxiety. 2011 Nov;28(11):963-72. CAMS.care. What is the “Collaborative Assessment and Management of Suicidality” (CAMS)? Accessed: June 2018. Available: https://cams-care.com/about-cams/.

Follow-up and Support After a Suicide Attempt

Provide contact and support during transition from inpatient to outpatient sites.Ensure supported pathway to adequate and timely care, as outlined above (e.g., collaborative safety planning, onsite or referral to offsite behavioral health)

Slide 11

Follow-up and Support After a Suicide Death

Follow-up and support for family members, friends, and for providers involved in care including screening for depression, suicidality, anxiety, alcohol misuse, and drug use.

Slide 12

Ex: Primary Care Providers and Behavioral Health Care ProvidersSuicide Risk Management and Treatment Keep patients in an acute suicidal crisis in an observed, safe environment. Ensure individuals at risk of suicide have pathway to timely and adequate

care (e.g. follow-up contact same day or later as indicated by suicide risk assessment). Engage patients in collaborative safety planning, including:

Addressing lethal means safety (e.g. safe firearm and medication storage). Warning signs of suicidal crisis. Internal coping strategies (i.e., activities that can be done alone). Contact numbers for friends and family members to ask for help. Providing professionals or agencies to contact during crisis, including Suicide

Prevention Lifeline 1-800-273-TALK (8255) and local emergency numbers. Refer to onsite behavioral health or conduct a supported warm handoff to

offsite behavioral health for effective evidence-based treatments that directly target suicidal thoughts and behaviors rather than focusing on specific diagnoses (e.g., depression, anxiety). The interventions with the most robust evidence include: Following-up with a patient by initiating a non-demand caring contact Dialectical behavior therapy Suicide-specific cognitive behavioral therapy Collaborative assessment and management of suicide risk (CAMS)

Slide 13

Action Item

Approve Suicide Care Report and Recommendations for dissemination for public comment

Slide 14

TopicUpdate:LumbarFusionReview.KerrySchaefer,MSStrategicPlannerforEmployeeHealth,KingCountyBobMecklenburg,MDMedicalDirector,CenterforHealthCareSolutions,VirginiaMasonMedicalCenter

July17th,2018|BreeCollaborativeMeeting

ActionItem:TotalKneeandTotalHipReplacementQualityMetrics� The2017versionoftheBreebundlefortotaljointreplacementspecifiesashortenedandvalidatedformatforthepreviouslyrequiredtheKneeOsteOarthritisScore(KOOS)andtheHipOsteOarthritisOutcomeScore(HOOS).� Thenewformatisknownas“KOOSJr”and“HOOSJr.”Thenewformatwouldrequireproviderstoreportonlyonenumberforeachindicatorinsteadofthesevenpreviouslyspecified.� However,thesectionofthebundledocumentrelatingtospecificreportsofqualitywasnotchangedtoalignwiththenewer,simplifiedstandard.� Thisisanerrorandresultsininconsistencywithinthebundledocument.

Slide2

ActionItem:TotalKneeandTotalHipReplacementQualityMetrics–Pages11-12

Slide3

ActionItem:TotalKneeandTotalHipReplacementQualityMetrics-Page18

Slide4

� ActionItem:Changeitem1donpage11ofthebundledocumenttoread:“Report:ResultsofscoresforKOOSJr.andHOOSJr.andquestionsregardingeverydayphysicalactivities(Question7)andpain(Question10)onthePROMIS-10survey”andtomakecorrespondingchangestothetableintheAppendixonpage18.”

Slide5

Members

� Consumer� LindaRadach,PatientAdvocate

� ProvidersandSurgeons� Co-Chair:RobertMecklenburg,MD,VirginiaMasonMedicalCenter� FarrokhFarrokhi,MD,Neurosurgeon,VirginiaMasonMedicalCenter� AndrewFriedman,MD,Physiatrist,VirginiaMasonMedicalCenter� MichaelHatzakis,MD,Physiatrist,OverlakeMedicalCenter�  JasonThompson,MD,SpineSurgeon,ProlianceSurgeons

� Administrators� SaraGroves-Rupp,AsstAdministrator,PerformanceImprovement,UniversityofWashingtonMedicine

�  Purchasers� Co-Chair:KerrySchaefer,KingCounty� GaryFranklinMD,MPH,MedicalDirector,WashingtonStateDepartmentofLaborandIndustries

� MarciaPeterson,ManagerofBenefitsStrategyandDesign,WashingtonStateHealthCareAuthority

�  HealthPlans� LydiaBartholomew,MD,Aetna

6

Scope

� 2014:Limitedtosingle-levelfusion� “Althoughthisbundleislimitedtosinglelevelspinalfusionitcouldbeusedasaminimumstandardformulti-levelspinalfusionsurgery.“

� 2018:Appliestolumbarfusioningeneral

Slide7

InclusionsandExclusions

� InclusionCriteria� Patientswithmorethan12weeksofbackorlowerextremitypainofconfirmedspinaloriginwithneurologicsymptomsorsigns.

� ExclusionCriteria� Backpainassociatedwithdegenerativejointdiseaseintheabsenceofstructuralinstability.� Patientsunder18yearsofage.� Useoflumbarfusioninthecareofpatientswithspinaltrauma,osteoporoticfracture,tumor,infection,inflammatoryconditions,andscoliosis.

Slide8

CycleI:DisabilityDespiteNon-SurgicalTherapyA.  Specificationofthepatient’sdegreeoffunctionalimpairment

1.  Clinically:a.  Duetobackorradicularpainand/orb.  Neurologicsymptomsorsigns

2.  Withatleastoneofthefollowingpatientreportedoutcomemeasures:a.  PROMIS10PFandPROMIS10PI,thepreferredmeasuresb.  OswestryDisabilityIndexc.  Roland-MorrisDisabilityScaled.  EuroQual-5Dimensions(EQ-5D)e.  ShortForm36(SF-36)f.  Asimilarlypeer-reviewedandvalidatedpatient-reportedoutcomeg.  TherapeuticAssociatesOutcomeScore

B.  Documentimagingfindingsoflumbarinstabilityonastandardscalethatcorrelateswithsymptomsandsigns

C.  Documentatleastthreemonthsofstructurednon-surgicaltherapydeliveredbyacollaborativeteam

D.  Documentationofseveredisabilityunresponsivetonon-surgicaltherapyE.  ShareddecisionmakingwithWA-approvedpatientdecisionaid,when

available. Slide9

Cycle1:Documentationofseveredisabilityunresponsivetonon-surgicaltherapy

� 1.Formalconsultationwithcollaborativeteamledbyboardcertifiedphysiatristtoconfirmappropriateness,adequacy,completeness,andactiveparticipationinnon-surgicaltherapyandneedforlumbarfusion.Needforlumbarfusionshouldbebasedonpersistentdisabilityandabsenceofpsychosocialbarriers.Adecisionforlumbarfusionrequiresameetingofallmembersoftheteamandadocumentedrecommendationforfusionbythephysiatrist.

Slide10

CycleII:FitnessforSurgery

A.   Documentrequirementsrelatedtopatientsafety1.  Patientshouldmeetthefollowingminimumrequirementspriortosurgeryand

assistpatientsinmeetingtheserequirements.Exceptionstotheserequirementsshouldbediscussedinthemultidisciplinaryconference:a.  BodyMassIndexlessthan40.b.  HemoglobinA1clessthan8%inpatientswithdiabetes.c.  Adequatenutritionalstatustoensurehealing.d.  Sufficientliverfunctiontoensurehealingparticularlyforhighriskpatients.e.  Pre-operativeplanformanagementofopioiddependency,ifpatienthastakenopioids

formorethanthreeprecedingmonthsasperBreeCollaborativeSupplementtoAMDGGuidelines.

f.  Avoidanceofnicotinewithconfirmationofatleastonenegativeurinescreenforaminimumoffourweekspre-operatively.

g.  Screenforalcoholabuse;manageifscreenispositive.h.  Absenceofseveredisabilityfromanunrelatedconditionthatwouldseverelylimitthe

benefitsofsurgery.i.  Absenceofdementiathatwouldinterferewithrecovery–performingsurgeryfora

patientwithsuchdementiarequiresinformedconsentofapersonwithDurablePowerofAttorneyforHealthCare,andacontractwiththepatient’scarepartner

j.  Screenforuntreateddepression,psychiatricdisorder,orcognitivedysfunction;manageifscreenispositive.

k.  Completeapre-operativeplanforpost-operativereturntofunction.Slide11

CycleII:FitnessforSurgery

B.  Documentpatientengagement1.  Patientmustdesignateapersonalcarepartner.:2.  Patientmustparticipateinendoflifeplanning,

includingcompletionofanadvancedirectiveanddesignationofdurablepowerofattorneyforhealthcare.

3.  PatientagreestoparticipateinaregistrysuchasSpineCOAPandunderstandthattheymaybecontactedattwoyearsforfollow-updatacollection.

C.  Documentoptimalpreparationforsurgery1.  Performpre-operativehistory,physical,andscreening

labtestsbasedonreviewofsystems2.  Obtainrelevantconsultations

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TopicUpdate:CollaborativeCareforChronicPainLeahHole-Marshall,JD

July17th,2018|BreeCollaborativeMeeting

WorkgroupMembers

�  Chair:LeahHole-Marshall,JD�  RossBethel,MD,FamilyPhysician,SelahFamilyMedicine� MaryEngrav,MD,MedicalDirector,SouthwestWA,MolinaHealthCare�  StuFreed,MD,ChiefMedicalOfficer,ConfluenceHealth�  AndrewFriedman,MD,Physiatrist,VirginiaMasonMedicalCenter�  LynnDeBar,PhD,MPH,SeniorInvestigator,KaiserPermanenteWashingtonHealthResearchInstitute� MarkMurphy,MD/GregRudolf,MD,President,WashingtonSocietyofAddictionMedicine� MaryKayO’Neill,MD,MBA,Partner,Mercer�  JimRivard,PT,DPT,MOMT,OCS,FAAOMPT,President,MTIPhysicalTherapy�  KariA.Stephens,PhD,AssistantProfessor-Psychiatry&BehavioralSciences,UniversityofWashingtonMedicine

� MarkSullivan,MD,PhD,Professor,psychiatry;Adjunctprofessor,anesthesiologyandpainmedicine,UniversityofWashingtonMedicine

�  DavidTauben,MD,ChiefofPainMedicine,UniversityofWashingtonMedicine�  NancyTietje,PatientAdvocate�  EmilyTransue,MD,MHA,AssociateMedicalDirector,WashingtonStateHealthCareAuthority� MichaelVonKorff,ScD,SeniorInvestigator,KaiserPermanenteWashingtonHealthResearchInstitute�  ArthurWatanabe,MD,President,WashingtonSocietyofInterventionalPainPhysicians

Slide2

FrameworkandBackground� Chronicpain,painlastingthreemonthsorlonger,isexperiencedbyanapproximate11.2%ofAmericans� Somesurveyshaveestimatedthistobecloserto30%� Moreprevalentforwomenthanmen,tendstoincreasewithage,ismainlyattributedtolowbackfollowedbyosteoarthritispain,andisreportedassevereforaboutathirdofrespondents� Treatmentofchronicpainisalsowidelyvariablewithhighfinancialandhumancost� Needflexiblebutdefinedmodelforcollaborativecarespecifictochronicpain

NationalCenterforComplementaryandIntegrativeHealth.PainintheU.S.,August,2015.Available:https://nccih.nih.gov/news/press/08112015.

JohannesCB,LeTK,ZhouX,JohnstonJA,DworkinRH.TheprevalenceofchronicpaininUnitedStatesadults:resultsofanInternet-basedsurvey.JPain.2010Nov;11(11):1230-9.doi:10.1016/j.jpain.2010.07.002.

Slide3

PatientattheHeartofCare

Slide4

MinimumStandards

� PatientIdentificationandPopulationManagement� CareTeam� CareManagement� Evidence-BasedCare� SupportedSelf-Management

Slide5

PatientIdentificationandPopulationManagement

� Identifyingpatientswithpersistentpaincoupledwithpsychosocialbarriers� Preventingthetransitionfromacutetochronicpainthroughscreeningwithabrief,validatedinstrumentforpsychosocialbarrierstorecovery(e.g.,STarTBackToolforlowbackpain)� Trackingpatientsinaregistryandaggregationofdataforprogramimprovement� Useofadashboardforpatientprogress� Patient-reportedoutcomemeasuresatinitialvisitandfollow-up

Slide6

CareTeam

� Definedrolesforcareteammembers,careteamcoordination,andcommunicationexpectations� Accesstospecialtypainorbehavioralhealthconsultation,ifneeded� Patientpointofcontactforcareteam� Standardworkflowwithplannedinteractions� Systemsupports(e.g.technology,training)

Slide7

CareManagement

� Coordinationofthecollaborativecareprocessincludingfacilitationofcareteamaccess� Facilitationofreferrals,ifneeded� Managementofmedication� Proactiveoutreach

Slide8

Evidence-BasedCare� Trauma-informedcare� Developingandimprovingpainmanagementskills(e.g.relaxation)� Conventionalmedicaltreatmentoptions(e.g.,NSAIDsasfirstlinetreatmentratherthanopioids,topical,heatandice)� Addressingpainamplifiers(e.g.,sleepproblems)� Integrativehealthpractices(e.g.,massage,acupuncture)� Movementandbodyawarenessstrategies Slide9

SupportedSelf-Management

� Patientgoal-settingandaddressingbarrierstogoalachievement� Paineducationincludingunderstandingofthecycleofpain� Addressinganxietyandanger� Removingbarrierstophysicalactivity� Shiftingthoughtsfromreactivetocreative

Slide10

Example:PrimaryCareProvidersPatientIdentificationandPopulationManagement

� Conductathoroughhistoryandphysicalexaminationtoruleoutconditions(e.g.,cordcompression)needingspecialtyreferral,imaging,orotherintervention.

� Forpatientspresentingwithchronicorpersistentpainasdefinedbypainonmostdaysinthepastthreemonths,andmaladaptivebehaviors,identifyasgoodcandidatesforcollaborativecareforchronicpainintheelectronicmedicalrecord.

� Forpatientspresentingwithacutepain,useavalidatedinstrumentsuchastheSTarTBacktoolorFunctionalRecoveryQuestionnaire(FRQ)forlowbackpainortheSTarTBack-Gtoidentifypatientsthatarenotlikelytorespondtoroutinecare.Patientswhoareunlikelytorespondtoroutinecaremaybegoodcandidatesforcollaborativecare.

� Screenforbehavioralhealthdiagnosesusingavalidatedtoolincludingfor:�  Depression(e.g.,PatientHealthQuestionnaire(PHQ)twoorthreequestion)�  Suicidality(e.g.,ninthquestionofthePHQ-9,thefirsttwoquestionsoftheColumbiaSuicideSeverityScale)

�  Anxiety(e.g.,GeneralizedAnxietyDisorderseven-item)�  Alcoholuse(e.g.,AlcoholUseDisorderIdentificationTest)�  Druguse(e.g.,DrugAbuseScreeningTest)

� Atthefirstvisitandatfollow-upvisits,useavalidatedpatient-reportedoutcomemeasuretoassessresponsetotreatment.

� Maintainadashboardtomeasurepatientprogress.� Aggregateprogramdataforcollaborativecareperformanceimprovement. Slide11

Next Meeting:

Wednesday, September 26th, 2018 12:30 – 4:30

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