Transcript Legislating Pain Care: Freeze or Thaw?

Implementing HB 2976
Steps for clinics to take to prepare to
implement the law
June 7, 2011
UW Project ROAM
1
Disclosures
• Mary Catlin has no financial disclosures that
would constitute a conflict of interest
• There will be no unannounced discussion of
off label use of FDA approved drugs or devices
UW Project ROAM
2
Objective of the legislation is to reduce
suffering and to save lives
• Review what the legislation asks of you
• Propose steps your facility can take to
implement the law
UW Project ROAM
3
ESHB 2876, rules CR-103P
• http://www.doh.wa.gov/hsqa/Professions/Pai
nManagement/meetings.htm - site to access
rules from all five boards of health
UW Project ROAM
4
Medical Preamble: “don’t worry be
happy”
– “These rules..are not inflexible rules or rigid
practice requirements and are not intended…to
establish a legal standard of care outside of the
context of the medial quality assurance
jurisdiction.” “ …A reasonable course of action”
– A practitioner who differs from the rules should
document justifications
UW Project ROAM
5
Implementing the Rules implies
• Continuing Education
• Determining if your practitioners or site are
pain management specialists/clinic
• A system for identifying and tracking patients
• Forms and tools
• Documentation template
• A way to seek consultations
UW Project ROAM
6
Three levels of continuing education
recommendations for
• Prescribers of long acting opioids
• Providers exempt from consultation
• Persons serving as pain management
consultants
UW Project ROAM
7
Continuing Education for Prescribers
Note: “should”
WHO
WHAT
WHEN
Physicians
WAC 248-919-858
4 hours CE on long acting
opioids or methadone
Once in a lifetime
Osteopaths
4 hours CE on long acting
opioids or methadone
Once in a lifetime
Nurse Practitioners
4 hours CE on long acting
opioids or methadone
Once in a lifetime
Physician Assistants
WAC 248-918-808
4 hours CE on long acting
opioids or methadone
Once in a lifetime
Dentists
4 hours CE on long acting
opioids or methadone
Once in a lifetime
UW Project ROAM
8
Continuing Education to be Exempt
from Consultation (Accredited CE)
WHO
WHAT
WHEN
Physicians
WAC 248-919-858
12 hours CE with 2 hours
on long acting opioids or
methadone (Category 1)
Within 2 years
Osteopaths
12 hours CE with 2 hours
on long acting opioids or
methadone
Within 3 years
Nurse Practitioners
12 hours CE with 2 hours
on long acting opioids or
methadone
Within 2 years
Physician Assistants
WAC 248-918-812
12 hours CE with 2 hours
on long acting opioids or
methadone and the
sponsoring MD has CE
Within 2 years
Dentists
12 hours CE 2 in opioids to
include methadone
Within 2 years
9
Continuing Education for Pain
Management Specialists
WHO
WHAT
WHEN
Physicians
18 hours of CE in pain
management
Within last 2 years
Nurse Practitioners
18 hours of CE in pain
management
Within last 2 years
Osteopaths
18 hours of CE in pain
management
Within last 3 years
Physician Assistants
No definition as a specialist
But sponsoring MD can be
NA
Podiatrist
18 hours of CE in pain
management
With in last 2 years
UW Project ROAM
10
Examples of opportunities for
education
• PCSS-B training on buprenorphine. http://www.pcssb.org/ (Physicians
Clinical Support System). SAMSHA funded
• American Academy of Pain Medicine
http://www.painmed.org/CME/Calendar_MeetingsEvents.aspx (meetings
from multiple org for multiple professions)
• American Academy of Family Practice Self study learning link series
http://www.aafp.org/online/en/home/cme/selfstudy/learninglink/pain1.html
#Parsys66612
• MQAC is preparing videos, webinars, fliers and extensive educational
material that will be available soon
•
Project ECHO Telemedicine Clinics with UW specialists Contact Kent
Unruh for more information [email protected]
UW Project ROAM
11
Project ECHO for Chronic Pain and Addiction:
Discussion with UW Specialists and
Community Providers
and free CME
Other requirements for specialists
beyond CE refer to the rules
• Board certified, eligible, sub-specialty, certificate
OR
• Credentialed AND
• Work in multi-disciplinary pain clinic or academic
research facility AND
• Three years of experience AND
• 30% of patients chronic pain
• AND or OR varies by profession; PA not
specialists but NP can be
UW Project ROAM
13
UW Project ROAM
14
Forms to have on hand
• Pain agreement – include your fax/phone as last
page so ED, and recipients can inform you easily
• Release of information meets CRF 42 Part 2 plus
HIPPA (examples on Project Roam website)
• Pain guidelines or clinical pathway (AMDG)
• List of EDs, urgent care facilities and pharmacies,
acceptable pain specialists
• Morphine equivalent dose calculator
UW Project ROAM
15
AMDG Guidelines
Include tools and
morphine equivalent
dose calculator
Computer will need excel
software installed.
www.agencymeddirectors.wa.gov/
UW Project ROAM
16
MED dose converter
AMDG on-line tool
www.agencymeddirectors.wa.gov
– Lingua franca for Rx history:
• “Current MED is …
Opioids used are: ...”
- Modify EMR to include this
UW Project ROAM
17
Forms to have on-hand cont.
• Taper protocols or resources
– Opioids
– Benzodiazepines
• Patient education sheets
-Informed consent materials
-How to safe guard medications
-Photo ID needed to pick up medications
-Copy of patient agreement
UW Project ROAM
18
Forms: Review visit template
• “Review visit” note contents from the WAC
– Change in pain relief, physical and psychosocial function, quality
of life using standardized tools (AMDG)
– Compliance with prescribed meds and the MED
– (Practical Note: Urine tests)
– Opioid Risk Tool and aberrant behaviors
– Escalating doses
– Decision to continue, taper, stop, or change meds
– Diagnosis
– Plan
– Efforts to seek consultation or other therapies
Review visit – automatic scheduler
UW Project ROAM
19
http://www.cpain.com/
UW Project ROAM
20
Project ECHO Intake form with required
elements
UW Project ROAM
21
Pain Agreement
• Rules say use for high risk – simpler to use for all
or define high risk?
–
–
–
–
–
One prescriber, one pharmacy
Agree to urine/serum testing
Take medications as prescribed, safe guard them
No early refills
Agree not to use alcohol or “other medically
unauthorized substance”
– Violations may result in tapering, or dc of medication
UW Project ROAM
22
Authorizations to share information
• Agree to share AGREEMENT with ED, urgent
care and pharmacies
• Agree that other practitioners should report
violations
• Physician may notify authorities of illegal acts
UW Project ROAM
23
Sharing information
• Pharmacy Monitoring Program up by January.
• Emergency Room EDIE spreading
UW Project ROAM
24
If you don’t have EDIE
• Need to have a way of easily informing
providers that their patient has been seeking
pain medication.
• Prescription Monitoring Program will help
UW Project ROAM
25
Consultation
• Suggested: pediatric visits, hx substance
abuse, psych co-morbidities
• Mandatory consult when patients are on
greater than 120 MED doses
UW Project ROAM
26
Exemption from Consultation
•
•
•
•
Patient is being tapered
Acute pain in a person on chronic opioid therapy
Pain and function are stable, dose not escalating
You tried! Document reasonable attempt to get a
consultation and why they are on 120 MED or
more.
• But you can call into Project ECHO every Wed and
alternate Fridays for a free consult.
UW Project ROAM
27
Project Echo contact Kent Unruh
[email protected] or [email protected]
• PI Dr. John Scott
• Specialists include Dr. Joe Merrill, Addiction
Medicine Specialist, Pain Specialist Dr. David
Tauben, Psychiatrists Dr. Christina Flores, Dr.
Mark Sullivan and others
• Addiction focus every other Friday and pain
central focus every Wednesday.
• Grant funded research project. Try it it’s free!
UW Project ROAM
28