Transcript care management

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Rx for Drug-Seeking Patients
in the ED
The Monterey County Prescribe
Safe Initiative
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AIM:
Be the Catalyst for Change in your Community
OBJECTIVES:
• Why change is important
• How we made change in Monterey County
• How to pitch the story in your community
• Provide practical tools and resources to get started
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Tools and Resources
www.chomp.org/for-healthcare-professionals/prescribe-safe
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Scope of the Problem
• Opiate use in the U.S.
▫ 80% of the world’s prescription opiate supply
▫ 99% of the world’s hydrocodone supply
▫ From 1997 to 2007, the milligram per person use of
prescription opioids in the U.S. increased from 74
milligrams to 369 milligrams, an increase of 402%
(enough to supply every American adult with 5mg of
hydrocodone every 4 hours for a month)
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Scope of the Problem
• 7 Million Americans use prescription drugs
recreationally annually (2.3% of the U.S. population)
• 50 Million Americans have used recreationally at
least once during their lifetime (16.1% of the U.S.
population)
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Scope of the Problem
• Increased adverse medication events related to
prescription drug misuse
▫ Estimated > 700,000 ED visits per year related to
prescription drug misuse alone
• Approximately 10% of all patients on chronic opiates
account for 40% of all overdoses
▫ Usually on high daily doses
▫ Getting drugs from multiple prescribers
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Scope of the Problem
• Death from opiate overdoses have increased 300% since
the 1990s
• We lose more years of productive life in the US to
prescription drug overdose than motor vehicle accidents
• Prescription drug related deaths exceed motor vehiclerelated deaths in 29 states and Monterey County
• Prescription drug related deaths now outnumber those
from heroin and cocaine combined
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Scope of the Problem
• Gateway: Nearly 1/3 of people aged 12 and over
who used drugs for the first time in 2009 began by
using a prescription medications non-medically
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Street Value
www.streetrx.com
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DIVERSION
• Selling drugs for consideration (sex, addicted
physicians)
• Medicine cabinet parties
• Prescription fraud
• Insurance fraud
• MRI forgery black market
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An Experiment
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An Experiment (circ. 2005)
• Frequent Users of the ED Group (FUG)
• The Team:
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ED physicians
ED nurse
Administration
Addictionology
Hospitalist
Pain management physician
Psychiatrist
Behavioral health nurse
Social worker
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EDRVP
Emergency Department
Recurrent Visitors Program
2013
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EDRVP Purpose
• Adequately meet the needs and improve the overall
care of patients recurrently seeking care in the ED for
chronic medical problems, including, but certainly
not limited to, opiate or benzodiazepine addiction
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Change Concept
• Apply care management concepts:
▫ Identify and engage recurrent visitors
▫ Remove barriers to more appropriate care
 Barriers to self-management
 Establish PCP or referral to more appropriate specialist
 Address socioeconomic barriers to care and refer to
community resources
 Engage payer in the process
• Apply evidence-based and safe standards of care
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Criteria
• Frequency
▫ ≥ 4 visits in 1 month
▫ ≥ 6 visits in 3 months
▫ ≥ 12 visits in 12 months
• Using the ED as a PCP office for non-emergencies
▫ Chronic condition management
▫ Repeat imaging and laboratory
▫ Medication refills
• Seeking pain medication refills and/or + CURES test
• Abusive or out of control behavior
• Provider or outside referral
▫ Pharmacy
▫ Insurance company
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Care Management Process
• Screen all referrals using criteria
• Review (prior 6 month chart review)
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Utilization patterns
Visit reason
Diagnostics
PCP
Medications refills
• Engage patient, family, providers, insurance
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Care Management Process
• Draft Plan of Care (POC)
• Advisory Council review of POC (monthly meeting)
• Communication with Patient
▫ Letter to patient and providers
▫ POC uploaded in electronic medical record (green dot)
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Tracking Board “Green Dot” Alert
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Advisory Council
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ED Physician
Urgent Care Physician/Addictionologist
ED Director
CHI ED Transition Care Manager and Referral
Coordinator
Social Worker
Clinical Specialist Behavioral Health Services
Hospitalist Coordinator
CCAH Care Management Supervisor
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Health Information Technology Enablers
• High utilizer reports
• Electronic referral process
• Auto-population of POC
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Monterey County Prescribe Safe Initiative
• Launched in February 2014
• Modeled after the San Diego Collaborative
• Aim: Develop a broad-based coalition
representing those interested in dealing with the
epidemic of prescription drug abuse in Monterey
County
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County-Wide Engagement
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Monterey County Prescribe Safe Initiative
Strategic Objectives
• Establish county-wide ED Pain Medication
Prescribing Guidelines
• Develop resource tools to support ED efforts
• Community physician education
• “CURES Party”
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CURES Report
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Results
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Enrollees into Program
100
80
60
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0
2006
2007
2008
2009
2010
2011
2012
2013
2014
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Resources
• FUG:
▫ Periodic Committee meeting
▫ 0.2 FTE Assistant Director of ED
▫ Annual Cost: $50,000
• EDRVP
▫ Advisory Council meeting
▫ 0.5 FTE TCM
▫ Annual Cost: $75,000
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Future
• More of the same for the CHOMP EDRVP
• County-wide EDRVP Program
• Engage local pharmacies
• Engage local health plans
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Take Home Messages
• A national epidemic with local implications (including
your community)
• Exhaust the behavior – push in the same direction
▫ Use CURES
▫ Countywide medical community prescribing practices
▫ Engage the neighborhood
• Do it because it is the right thing to do AND there is a
return on investment
• You’re behind – catch up by visiting our website
QUESTIONS?
Thank you
Anthony Chavis, MD
831-644-7466
[email protected]
Reb Close, MD
831-625-4900
[email protected]