Quality Improvement and Care Coordination: Implementing CDC’s Opioid Prescribing Guideline CDC National Center for Injury Prevention and Control | 2018 Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain Centers for Disease Control and Prevention National Center for Injury Prevention and Control 1 Quality Improvement and Care Coordination CDC National Center for Injury Prevention and Control | 2018 Acknowledgements The project team from Abt Associates Inc. served as a contractor to the Centers for Disease Control and Prevention (CDC). Project team members Sarah J. Shoemaker, Project Director, Health Services Researcher, PhD, PharmD; Douglas McDonald, Principal Associate, PhD; Leigh Mathias, Project Manager, MPH; Holly Swan, Associate, PhD; Nicole Keane, MS; and Jahin Fayyaz, BS, led the Quality Improvement and Care Coordination effort and provided important input in the development of this document. Work was funded under Contract Numbers 200-2011-42071 and 200-2016-F-92356. Team members from CDC’s Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, provided oversight as well as technical engagement, support, and guidance on this project. MedStar Health Research Institute and its parent organization, MedStar Health, collaborated with Abt to test the feasibility of implementing clinical practices. The MedStar team members were Christopher Kearney, MD, Medical Director of MedStar Health Palliative Care; Kathryn A. Walker, PharmD, BCPS, CPE, Senior Clinical and Scientific Director of Palliative Care, MedStar Health; and Stephanie C. Blease, Informatics Analyst/Coordinator. The following served as consultants to Abt Associates Inc.: Michael Von Korff, Sc.D, Senior Investigator, Kaiser Laura Heesacker, MSW, Jackson Care Connect, Oregon Pain Permanente Washington Health Research Institute, Seattle, WA Guidance Group, OR David Tauben, MD, University of Washington, School of Mark Stephens, BS, Change Management Consultants, WA Medicine, Seattle, WA Michael Parchman, MD, MPH, Senior Investigator, Kaiser Permanente Washington Health Research Institute; Director, MacColl Center for Health Care Innovation, Seattle, WA We also thank the following individuals for sharing their approaches and valuable experience to managing and monitoring chronic opioid therapy and quality improvement efforts: Daren Anderson, MD, Director & VP/Chief Quality Officer, David Labby, MD, PhD, Health Strategy Advisor, Health Weitzman Institute, Community Health Center, CT Share of Oregon Dianna Chamblin, MD, The Everett Clinic Occupational Ben Nordstrom, MD, PhD, SCP Chief Clinical Officer, Phoenix Health Center, Everett, WA House Foundation, AZ Andrea Furlan, MD, PhD, Toronto Rehabilitation Clinic, Ilene Robeck, MD, Bay Pines VA Healthcare System, Bay Pines, FL University of Toronto, Toronto, CA CAPT Stephen “Miles” Rudd, MD, FAAFP, Chair of the Indian Lucinda Grande, MD, Pioneer Family Practice, Lacey, WA Health Service National Committee on Heroin, Opioids, and Pain Efforts (HOPE) and Chief Medical Officer/Deputy Director Carol Havens, MD, Director of Physician Education & of the IHS Portand Area, OR Development, Kaiser Permanente, CA Rachael Stappler, PA-C, MHSc, North Bend Medical Center, Thomas Isaac, MD, MPH, MBA, Director of Medical Quality, Coos Bay, OR Atrius Health. MA Joanna Starrels, MD, MS, Montefiore Medical Center, Bronx, NY Erin Krebs, MD, MPH, Women’s Health Medical Director, Minneapolis VA Healthcare System Nancy Wiedemer, MSN, Philadelphia VA Medical Center, Philadelphia, PA Disclosures The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. Recommended citation Centers for Disease Control and Prevention. Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain. 2018. National Center for Injury Prevention and Control, Division of Unintentinal Injury Prevention, Atlanta, GA. I Quality Improvement and Care Coordination CDC National Center for Injury Prevention and Control | 2018 Table of Contents OVERVIEW………………..................................................................................................................... 1 CHAPTER ONE: EVIDENCED-BASED OPIOID PRESCRIBING ................................................2 Introduction ................................................................................................................................................. 3 CDC Guideline for Prescribing Opioids for Chronic Pain...................................................................................... 4 CHAPTER TWO: CLINICAL QUALITY IMPROVEMENT (QI) OPIOID MEASURES AND PROTOCOLS .....................................................................................7 Clinical Quality Improvement (QI) Opioid Measures and Protocols ......................................................... 8 QI Measures ................................................................................................................................................. 8 QI Implementation Steps ........................................................................................................................... 11 Step 1: Obtain Leadership Support and Identify a Champion(s) ......................................................................12 Obtain leadership support as a critical first step ...........................................................................12 Identify a champion(s) to drive the change process .....................................................................12 Form a change team or at least engage key staff ..........................................................................12 Obtain needed resources and determine readiness ......................................................................12 Step 2: Assess Current Approach to Opioids and Identify Areas for Improvement ...............................13 Assess current policies and practices ............................................................................................13 Complete the self-assessment questionnaire ................................................................................13 Collect data on your patient population and opioid therapy .........................................................14 Determine access to specialists and other resources ...................................................................14 Identify areas to improve upon .......................................................................................................14 Step 3: Select and Prioritize Guideline Recommendations to Implement ..............................................15 Determine which Guideline recommendations to implement .......................................................15 Prioritize what will be implemented ................................................................................................15 Step 4: Define System Goals....................................................................................................................................... 18 Set measurable goals ......................................................................................................................18 Step 5: Develop a Plan, Implement, and Monitor Progress ................................................................................19 Develop a plan for implementing selected Guideline recommendations .....................................19 Implement the changes ...................................................................................................................19 Monitor progress using QI measures and other data ....................................................................19 II Quality Improvement and Care Coordination CDC National Center for Injury Prevention and Control | 2018 CHAPTER THREE: PRACTICE-LEVEL STRATEGIES FOR CARE COORDINATION ............ 21 Use an Interdisciplinary Team-Based Approach ..................................................................................... 22 Establish Opioid Policies and Standards ................................................................................................................ 23 Standard treatment agreement for all providers to use .............................................................. 23 Policy on the threshold dosage levels for the patient population ............................................... 24 Prescription refill or renewal Policy ............................................................................................... 24 Policy for frequency of monitoring patients on long-term opioid therapy .................................. 25 Policy for frequency of urine drug testing (UDT) .......................................................................... 25 Policy and procedures for checking the prescription drug monitoring program (PDMP) ......... 26 Use EHR Data to Develop Patient Registries and Track QI Measures .................................................... 27 REFERENCES………………............................................................................................................... 28 APPENDICES ..................................................................................................................................