team-based intakes, inductions, and visits: key …...team-based intakes, inductions, and visits:...
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TEAM-BASED INTAKES, INDUCTIONS, AND VISITS: KEY ROLES ANDCONSIDERATIONS FOR NON-PRESCRIBERSDescribe models of triaging patients by telephone or in-person interview
ROLE OF CLINIC RN CARE COORDINATOR
Danielle Jones, RN-BSN Care Coordinator Fairview Mesaba Clinic 3605 Mayfair Ave Hibbing, MN 55746 218-362-6922 #3 [email protected]
8 years at Mesaba Clinic, 3 years in current role Chronic pain role Addiction role
ERIN FOSS, RN
Opioid Program Development and Outreach Coordinator
CHI Saint Gabriel’s Health Little Falls, MN
I spent the bulk of my nursing career as an OR nurse, and then moved into management before joining the Little Falls team. I feel that becoming an addiction nurse has taught me patience and empathy which have made me a better person, nurse, wife, and mom.
LAUREN ANDERSON, PHARMD, BCACP
Clinical Pharmacist Minnesota Community Care
Saint Paul, MN651-389-2414
I work with the Renewal Services Team as well as in primary care and the out patient dispensing pharmacy. I have been with MCC for over 6 years and
have been working in addiction medicine for about 1.5 years
ROLE OF CLINIC RN CARE COORDINATOR
ROLE OF CLINIC RN CARE COORDINATOR
ROLE OF CLINIC RN CARE COORDINATOR
Telephone screenings: try to make short and sweet Could occur through provider referral, “word of mouth
referral”, or through ED follow up phone call Don’t judge, educate Empathetic and understanding Educate that addiction is a chronic disease
Gather patient data – PMH, demographics, PCP etc. Current substance of choice and additional
substances Treatment history – previous MAT? Insurance/Transportation Recent legal issues/probation
ROLE OF CLINIC RN CARE COORDINATOR
Suboxone Screening Criteria 1: Where do you live? County: 2. What is the drug/substance that you are currently using? 3. Have you been on Suboxone in the past or currently? A: If current, dose? B: Why are you changing Suboxone providers? 4. Who is your doctor now? If no one, who in the past? 5. Have you had any previous treatment? Rule 25 completed? Y / N A: Inpatient Days spent in jail in the past 3 yrs. B: Outpatient Pending legal charges? C: Current Insurance? 6: Are you currently in counseling? A: NA or AA? 7. What medications are you currently taking? Please list all meds
including herbals, supplements, OTC and prescriptions.
ROLE OF CLINIC RN CARE COORDINATOR
Chart review Discuss with waivered provider Educate patient on program requirements and
what to expect Honesty #1 Moderate withdrawal No benzodiazepines/ETOH Risk of precipitated withdrawal Schedule induction Place appropriate referrals
ROLE OF CLINIC RN CARE COORDINATOR
In Person Interview – able to “see” where the patient is at ED visit for OD or withdrawal or office visit with
provider requesting help Current substance use/past substance use COWS scale Lab tests ROIs, consents, consent for treatment and treatment
agreement Role of care team Honesty #1 Words matter
ROLE OF CLINIC RN CARE COORDINATOR
Caring, compassionate, nonjudgmental
Positive reinforcement Active listener The “go to” person Educator Manage referrals Respectful
Develop patient-centered goals
Keep patient on track Support provider/care
team Holistic approach Prep charts Prior authorizations
HOW TO MANAGE INDUCTIONSBY PROTOCOL
MEETING BASIC NEEDS
Offer blankets Ensure comfort Offer water Relaxed body language Speak softly Ask if its ok with the patients for friends/family
members to stay Show kindness and empathy- establish
rapport and trust
THE “MUST HAVES”
UDASCOWS (hr/pupils/10)
CARE PLAN/ind packetCharting Templates
LETS TALK ABOUT BENZOS
AtivanXanaxValiumKlonopin
Educate- RRAdd to allergy list-
“Contraindicated when taking Suboxone”
SUBOXONE DOSING
Provider orders Suboxone Family/friend/nurse picks up med (last resort
patient) Patient is instructed to take med (self
administer/SL dissolve/bioavailability) Start with small doses of Suboxone (2-4mg) Reassess every 30 min
TROUBLESHOOTINGPatient arrives with COWS below 10
(reassess every 15 min)Precipitated withdrawal (clinic
inductions)No $$$ to pay for meds
TROUBLESHOOTING CONT…Prior AuthsPatient education for refillsClear expectations Non punitive approach
WHAT DO PATIENT’S NEED TO GETINTO OUR PROGRAM?
NOTHING!
Rule 25 is not needed for patient to be seen Insurance can be set up at first appDo you have a foundation?
INDUCTION FOLLOW UP
Next day clinic visit or phone callFrequent clinic visits at first Relationship building
THE ROLE OF PHARMACISTS ANDNURSES
ROLE OF A NURSE OR PHARMACIST
Inductions
Follow-up visits and phone check-ins
Coordinating Medication Access
Acute Pain and Surgery Management
Management of other comorbid disease states or primary care
“Provider extender”
FOLLOW-UP VISITS
Induction follow-up visits Visits between provider visits for patients who are
high risk Weekly visits for patients who have relapsed or missed
appointments Weekly visits for patients needing more mental health
support Phone follow-up visits for patients with
transportation concerns Accommodate walk in visits Benefits
Flexibility of scheduling and more patient appointments Collaborative Practice Agreements allow lab monitoring
and prescribing Ability to work with patients when they are struggling and
have a hard time coming in for scheduled appointments
COORDINATING MEDICATION ACCESS
Prior Authorizations Insurance Changes Formulary Changes Pharmacy Questions Medication Availability
Assist patients in selecting formulations and flavors of medication that make the medication experience more positive for the patient
Buprenorphine Menu
ACUTE PAIN AND SURGERY MANAGEMENT
Prepare and maintain an acute pain and surgery management protocol
Coordinate with surgeons and other providers to assess what pain management is anticipated for specific scheduled procedures
Educate outside providers on pain management for patients using buprenorphine
Coordinate insurance coverage for patients receiving opioids + buprenorphine
Create a plan for buprenorphine dosing for planned procedures and discuss with patients
Assist with transition from opioids back to buprenorphine when needed
MANAGEMENT OF COMORBIDITIES ANDPRIMARY CARE
HIV pre exposure prophylaxis (PrEP) HIV post exposure prophylaxis (PEP) Hepatitis C treatment Ensure vaccines are up to date Prescription of supportive cares for withdrawal Primary Care management Comprehensive Medication Review
Pharmacist specific visits Improves access to primary care
“PROVIDER-EXTENDER” Allow for overbooks on provider’s schedules
Check vitals, order labs, room and prep patients for a provider visit
Joint visits Providers can see more patients in less time Ability to monitor more patients Ability to monitor high risk patients more
frequently
CASE
BN is a 65 y/o M who is seen in clinic. He has a diagnosis of OUD. Currently using heroin IN, previously using pills along with buprenorphine-naloxone. He is uninsured. July 2019: Appointment with provider - diagnosed with
OUD July 2019: Induction with pharmacist (same day) July 2019: Induction follow-up appointment with
pharmacist August 2019: Provider follow-up appointment x 2 August 2019: Pharmacist follow-up appointment - relapse September 2019: Provider + pharmacist visit September 2019: Pharmacist visit September 2019: Provider + pharmacist visit -continued
alternating