Moving Towards Safe Medications and Practices in a Rural Health System PRESENTED BY EILEEN KNUDSON PROGRAM DIRECTOR COMMUNITY HEALTH AND WELLNESS
Learning Objectives Identify seven key steps in implementing a successful medication safety and best practice protocol in a rural health system. Discuss the public health approach to addressing the opioid crisis and how the work of a hospital system fits. List key partners and organizations needed to drive change, practice, and procedure. Give examples of education and training you can acquire for your community and explore opportunities to deliver it. Describe program sustainability through a health system lens.
Tahoe Forest Health System Governmental Hospital District, • Critical Access Health System located in both Truckee California, and Incline Village Nevada. 250 million dollars a year in gross • patient revenue. Rated 4 stars by CMS •
Our Community Tahoe Forest Health System Service Area- 6 Counties CA- Truckee, Norden, Soda Springs, Floriston, Carnelian Bay, Homewood, Tahoma, Kings Beach, Tahoe City, Olympic Valley, Tahoe Vista NV- Incline Village, Crystal Bay Total Population – 37,342 (9 months) Male – 53%; Female – 47% Non-Hispanic – 83%; Hispanic – 17% Seasonal Influx as great as 100,000
Did you know? In 2016 alone, 63,632 Americans died from a drug overdose, with 42,000 from opioids. More Americans that died in the entire Vietnam War (1964-1975) Research shows that practicing physicians received fewer than 12 hours of pain management education in medical school. After as few as 5 DAYS of opioid medication use, 1 in 5 users runs the risk of becoming dependent. This risk increases with each additional day of use. A refill or second opioid prescription, doubles the risk of dependence. *2018 Prescription Nation 2018, Facing America’s opioid epidemic. National Safety Council
Step1: Define the Need and Make the Case Prioritizing the Need: Community Health Needs Assessment (CHNA) California Healthy Kids Survey (CHKS) Other data County/Hospital ED/Surveillance 2016 Placer County : 14 opioid overdose deaths (3.7 per /100,000 people), 45 opioid overdose ED visits, 52 hospitalizations, and 311,460 opioid prescriptions for a rate of 689.5 opioid prescriptions /1000 people* State the Case Aligned initiatives to meet Strategic Plan Looked to community partners TTFWDD advocated to TFHS Hospital Board Provided CME Education (Dr. Lev from San Diego) Media advocacy (local newspaper) https://www.youtube.com/watch?v=_tSDcKSJgrA *2018 CA Opioid Overdose Surveillance Dashboard https://pdop.shinyapps.io/ODdash_v1/
Initial Assessment Indicators include: Adverse Childhood Experiences (ACES) Scores by county ACES are stressful or traumatic experiences including abuse, neglect, or household dysfunction that are strongly related to development and prevalence of health problems including substance abuse. 16.4% of Placer and Nevada residents have 4+ ACES) (2008- 2013)* In Butte County 76.5% experienced at least 1 ACE. This is the highest rate among CA. counties. Community Health Needs Assessments *2014 A Hidden Crisis, Findings on Adverse Childhood Experiences in California , by the Center for Youth Health and Wellness https://centerforyouthwellness.org/wp- content/themes/cyw/build/img/building-a-movement/hidden-crisis.pdf
Community Health Needs Assessment 2017
Develop Partnerships Local: Tahoe Truckee Future Without Drug Dependence (TTFWDD) RX Committee Police/Sheriff/Pharmacy Tahoe Truckee Unified School District Regional;: AEGIS Treatment Centers (Hub and Spoke) Placer/Nevada County Medical Society Drug Safety Coalition Community Recovery Resources (CoRR)/ Western Sierra Medical Clinic County Court (Probation Drug Court) State: PRIME Community Prevention Initiative (CPI) technical assistance
Step 2 : Develop Chronic Pain Advisory Council Key Stakeholders: Physician Champion (recruit and write into job description), Internal Pharmacy, Clinical Social Worker, Primary Care Medical Providers, Administration, Care Coordinators, Community Partners, County Program managers, ED Director Educate and Train Key Stake Holders
Step 3 : Adopt Evidenced Based Practices Research Develop a Framework (National Safety Council) Develop Policies and Procedures (Safe Prescribe) Implement into workflow processes(EHR) Screening Tools SBIRT (DAST and AUDIT) PHQ9 Oswestry Scale (Pain Assessment) Urine Toxicology screen CURES Medication Agreement
“Solving the Opioid Crisis With A Public Health Approach ” “Prescription Nation 2018” National Safety Council
Primary Actions (Public Health Approach) Primary Actions : Focus on personal, community and other risk factors Implementing Safe Prescribe Guidelines within the Health System Educating providers: Project Echo and CME presentations Implementing PDMP(CURES) program Example: partnering with TTFWDD Tahoe Truckee Future Without Drug Dependence (Drug Free Communities Coalition) Goals: reducing access, training Medical providers, sponsoring educational programs in the schools such as BOTVIN LifeSkills Training; a specific prescription drug prevention curriculum, supported prescription drug takebacks
Secondary Actions (Public Health Approach) Diagnose and treat addictions and substance use disorders Care Coordination Chronic Disease Self management pain support programs Project Echo SBIRT/PHQ9 Medication Assisted Therapies (MAT)
Tertiary Actions (Public Health Approach) Prevent Life-Threatening Adverse Outcomes Average 15 known opioid overdose victims in our community per annum Naloxone Implementation (EMT) Prescribed Naloxone with Medication Assisted Therapy program Needle Exchange Programs (Roseville )
Step 4: Education and Training Partnered with Community Prevention Initiative (CPI): Dr. Lev (San Diego Safe Prescribe)2015 Cultivating Champions: 2014, 2015, 2016 Recruited staff to attend National RX Summit and presented to TFHS Board Provide CME (ongoing) since 2015 CME’s: Chronic Pain, CDC Guidelines for Opioid Best Practice Prescribing, Medication Safety, Medication Assisted Therapy, PDMP PDMP with Dept. of Justice specific to sign-up Medical Providers 2016 SBIRT Training 2013 Attended State/National Opioid Conferences 2017 Implemented Project ECHO with UC Davis 2017 Staff Education: Workflow Processes (Ongoing) 2017
TFHD Step 5: Care Coordination Acute Hospital Care Coordination & Navigation Minimize our readmission into the Coordinate care and services acute care hospital. for our chronically ill Streamline follow up population. Navigating care. patients through the system during their coarse of illness. Population Health Post Acute Services Maximize services to assist our Develop Community patients in achieving optimal Health and Wellness level of function. programs that keep us healthy. Improve access to care and address disparities
PRIME Initiative GOAL: To address high risk Medi-Cal patients with evidenced based protocols and preventative screening tools. PRIME: 5 year initiative that began in 2016 Addressing 2 projects Million Hearts and Chronic Pain Receive PRIME incentive payments based on achievement
Chronic Pain Screening and Treatment Alcohol and Drug misuse (SBIRT/CRAFFT Screening) Assessment and Management of Chronic Pain (Medication Agreement and Annual Urine Toxicology screen Pts on Opioids checked in PDMP/CURES Screening for Clinical Depression : Use of PHQ 9 Screening tool Treatment of Chronic Pain with Multi-modal Therapy
Referral Process for Positive Screens
Wellness Programming Support Free Community Peer Support Programs : Chronic Pain and Chronic Disease Management Evidence Based developed by Stanford University School of Medicine Taught by Care Coordinator (peer) 6 week FREE skills workshop Appropriate use of medications Skills to maintain wellness focus, and improve quality of life Strategies for maintaining and improving strength, flexibility, and endurance How to deal with frustration, fatigue, isolation and poor sleep Healthy Eating
Step 6: Program Sustainability Develop a Population Health Approach Leverage Utilize Track Outcome Utilize and Licensed Track Measurements Evidence prioritize Practitioners Leverage response and utilize data based high risk to help existing to screening patients capture opportunities treatment tools (Care revenue capture . coordinatio revenue n) (BH counseling counseling, SBIRT RVU)
Revenue Enhancing Opportunities Billing opportunities: Increase RVU’s for SBIRT Reschedule patient to capture SBIRT >15 visit Counseling Services Chronic Care Management Program (20 min/Month) DHCS Prime Initiative Partnering with State funded Agencies (AEGIS) Partnering with Drug Free Communities grantees
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