Bree Collaborative Meeting November 14, 2018 | Puget Sound Regional - - PowerPoint PPT Presentation

Bree Collaborative Meeting

November 14, 2018 | Puget Sound Regional Council

Housekeeping

Web Access: listed throughout room

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Agenda

Chair Report September 26th Meeting Minutes

 Action Item: Approve minutes

Implementation Report Out: Qualis Health Dissemination for Public Comment: Lumbar Fusion Re-Review

 Action Item: Approve Lumbar Fusion Bundle and Warranty for Dissemination for Public Comment

Dissemination for Public Comment: Collaborative Care for Chronic Pain

 Action Item: Approve Collaborative Care for Chronic Pain Report and Recommendations for Dissemination for Public Comment

Topic Update: AMDG Opioid Prescribing Guidelines Implementation Open Public Meetings Act Review | Conflict of Interest Update on New Workgroups Next Steps and Close

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September 26th Meeting Minutes

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Dissemination for Public Comment: Lumbar Fusion Re-Review

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Kerry Schaefer, MS Strategic Planner for Employee Health, King County Bob Mecklenburg, MD Medical Director, Center for Health Care Solutions, Virginia Mason Medical Center

November 14th, 2018 | Bree Collaborative Meeting

Members

 Consumer

 Linda Radach, Patient Advocate  Providers and Surgeons  Co-Chair: Robert Mecklenburg, MD, Virginia Mason Medical Center  Jonathan Carlson, MD, PhD, Neurosurgeon, Inland Neurosurgery & Spine Associates  Farrokh Farrokhi, MD, Neurosurgeon, Virginia Mason Medical Center  Mark Freeborn, MD, Neurosurgeon, EvergreenHealth Spine & Neurosurgical Care  Michael Hatzakis, MD, Physiatrist, Overlake Medical Center  Andrew Friedman, MD, Physiatrist, Virginia Mason Medical Center  Administrators  Sara Groves-Rupp, Asst Administrator, Performance Improvement, University of Washington Medicine  Purchasers  Co-Chair: Kerry Schaefer, King County  Gary Franklin MD, MPH, Medical Director, Washington State Department of Labor and Industries  Marcia Peterson, Manager of Benefits Strategy and Design, Washington State Health Care Authority  Health Plans  Lydia Bartholomew, MD, Aetna

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Today’s Goal Disseminate for public comment

Workgroup meeting since January 2018  Responding to requested changes from community and new evidence

Scope. Expand inclusion criteria from single level lumbar fusion → current draft silent on levels of fusion Non-surgical care. Facilitate evidence-based, multidisciplinary non-surgical care to provide an alternative to inappropriate or unsafe surgery → done Expand to outpatient → “facility” replaces “hospital”

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Cycle I: Disability Despite Non- Surgical Therapy

Review: two changes

A) Specification of patient’s degree of functional impairment

Document with PROMIS-10 and Oswestry Disability Index with additional optional measures including the following patient reported outcome measures: Roland- Morris Disability Scale, EuroQual-5 Dimensions (EQ-5D), Short Form 36 (SF-36), Therapeutic Associates Outcome Score, a similarly peer-reviewed and validated patient-reported outcome.

B) Documentation of imaging findings confirming lumbar instability that correlate with patient’s symptoms and signs

Neural foraminal stenosis as the result of loss of foraminal height, associated with nerve root compression and concordant radiculopathy. Previous decompressive surgery requiring significant facetectomies for foraminal decompression that are expected to create instability in the spinal segment.

C) At least three months of structured non-surgical therapy delivered by collaborative team D) Documentation of severe disability unresponsive to non-surgical therapy E) Shared decision making

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Cycle II: Fitness for Surgery

Review: Three changes

A) Requirements related to patient safety

Pre-operative plan for management of opioid dependency, if patient has taken opioids for more than three preceding months as per Bree Collaborative Supplement to AMDG Guidelines.

B) Document patient engagement C) Optimal preparation for surgery

Perform pre-operative history and physical examination with additional testing as needed. Recommended guidelines 2016 guideline from the National Institute for Health and Care Excellence (NICE), and Anesthesia consultation per American Society of Anesthesiology Guidelines

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Cycle III: Spinal Fusion Procedure

Review: Three items of note

A) General standards for a surgical team performing surgery 30 fusions/surgeon/12 months; 60 fusions/facility/12 months Neurosurgeons must be board certified or board eligible and credentialed to perform spine surgery by their institution. Orthopedic surgeons must have completed a spine fellowship and credentialed to perform spine surgery by their institution. B) Elements of optimal surgical process Minimize use of opioids according to both the 2015 Agency Medical Directors Guideline and the 2018 Bree Collaborative Post-Op Supplement C) Participation in registries Hospitals must participate in a registry such as Spine COAP with results available to purchasers. Providers must maintain a registry of patients undergoing lumbar fusion and collect prospective patient reported outcome measures as part of an internal quality improvement program.

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Cycle IV: Return to Function

A) Standard process for rapid recovery post-operative care B) Standardized facility discharge process

Aligned with current WSHA toolkit with attention to home environment Follow-up call aligned with Bree’s Potentially Avoidable Readmissions Report Pain management aligned with 2015 Agency Medical Director’s Guideline and 2018 Bree Collaborative Post-Op Supplement

C) Arrange home health services as needed D) Schedule follow-up appointments

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Quality Standards

• 1. Standards for appropriateness
• 2. Standards for evidence-based surgery
• 3. Standards for ensuring rapid and durable return to function
• 4. Standards for the patient care experience

Proportion of patients with lumbar fusion surveyed using HCAHPS or OAS CAHPS.

• 5. Standards for patient safety and affordability

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Warranty

Review: two changes

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1. The facility performing the surgery must have an agreement with a hospital to manage complications following surgery. The facility will provide information and instructions to the patient to seek treatment at that designated hospital. 2. Definition of infection taken from Centers for Disease Control, 2018

7 days 30 days 90 days

• Acute myocardial

infarction

• Pneumonia
• Sepsis/septicemia
• Pulmonary embolism
• Surgical site bleeding
• Superficial incisional

surgical site infection

• Deep incisional surgical

site infection that may involve implant

• Mechanical

complications

Evidence table

Toward a community standard for quality

Facilitates transition from opinion-based to systems-based care delivery

• 1. Current draft has 117 citations
• 2. Search strategy: formal methodology drives international lit

search plus general submissions

• 3. Evaluated and graded by two credentialed appraisers according

to Strength Of Recommendation Taxonomy method

• 4. Subject to public comment and in public domain
• 5. Replaces high-variation institution-based medical policies

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Recommendation

Approve Lumbar Fusion and Warranty for Dissemination for Public Comment

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Disseminate for Public Comment: Collaborative Care for Chronic Pain

Leah Hole-Marshall, JD General Counsel and Chief Strategist, Washington Health Benefit Exchange

November 14th, 2018 | Bree Collaborative Meeting

Workgroup Members

 Chair: Leah Hole-Marshall, JD, General Counsel and Chief Strategist, Washington Health Benefit Exchange  Ross Bethel, MD, Family Physician, Selah Family Medicine  Mary Engrav, MD, Medical Director, Southwest WA, Molina Health Care  Stu Freed, MD, Chief Medical Officer, Confluence Health  Andrew Friedman, MD, Physiatrist, Virginia Mason Medical Center  Lynn DeBar, PhD, MPH, Senior Investigator, Kaiser Permanente Washington Health Research Institute  Mark Murphy, MD/Greg Rudolf, MD, President, Washington Society of Addiction Medicine  Mary Kay O’Neill, MD, MBA, Partner, Mercer  Jim Rivard, PT, DPT, MOMT, OCS, FAAOMPT, President, MTI Physical Therapy  Kari A. Stephens, PhD, Assistant Professor - Psychiatry & Behavioral Sciences, University of Washington Medicine  Mark Sullivan, MD, PhD, Professor, psychiatry; Adjunct professor, anesthesiology and pain medicine, University of Washington Medicine  David Tauben, MD, Chief of Pain Medicine, University of Washington Medicine  Nancy Tietje, Patient Advocate  Emily Transue, MD, MHA, Associate Medical Director, Washington State Health Care Authority  Michael Von Korff, ScD, Senior Investigator, Kaiser Permanente Washington Health Research Institute  Arthur Watanabe, MD, President, Washington Society of Interventional Pain Physicians

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Today’s Goal Disseminate for public comment

Workgroup meeting since January 2018  Responding to community and Bree member request to address gap in working with patients with chronic pain

Continues focus on opioid prescribing

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Built on existing Models

Collaborative care is a reaction to siloed model of care centered around clinical or provider need not patient need Conceptually based on 2001 Chronic Care Model developed by Wagner and colleagues Other models used in this report include:

VA Multi-Model Review four system components UW AIMS Center five principles Learning from Effective Ambulatory Practice six building blocks Bree Collaborative Behavioral Health Integration eight elements

Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving Chronic Illness Care: Translating Evidence into Action. Health Affairs 20(6):64–78.. Available: http://dx.doi.org/doi:10.1377/hlthaff.20.6.64. Wagner E. 1998. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice 1(August/September):2–4. Available: www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdm.pdf. Peterson K, Anderson J, Bourne D, Mackey K, Helfand M. Evidence Brief: Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain. VA Evidence-based Synthesis Program Evidence Briefs [Internet]. Washington (DC): Department of Veterans Affairs (US); 2011-. VA Evidence-based Synthesis Program Reports.2017 Jan. Advancing Integrated Mental Health Solutions. Principles of Collaborative Care. 2016. Accessed: November 2016. Available: https://aims.uw.edu/collaborative- care/principles-collaborative-care Behavioral Health Integration Workgroup. (2017). Behavioral Health Integration Report and Recommendations. Weir, V, ed. Seattle, WA: Dr. Robert Bree

• Collaborative. Available: www.breecollaborative.org/topic-areas/behavioral-health/.

Parchman ML, Von Korff M, Baldwin L-M, et al. Primary Care Clinic Re-Design for Prescription Opioid Management. Journal of the American Board of Family Medicine :

• JABFM. 2017;30(1):44-51.

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Five Focus Areas

Patient Identification and Population Management Care Team Care Management Evidence-Informed Care Supported Self-Management

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Goal: Patient at the heart of care

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Developed by Nancy Tietje, workgroup member

 Centered on the patient  Built on patient self-management in the context of biopsychosocial model  Goals are improved function, increased quality of life, and greater patient autonomy rather than primary focus on pain relief  Ideally, both acute and chronic pain will be managed and treated over time using a systems approach to allow patients to stay within primary care supported by the elements of collaborative care

Adapted from MultiCare’s vision mantra

• 1. Patient Identification and

Population Management

Identifying patients with persistent pain with life activity impacts Preventing the transition from acute to chronic pain with life activity impacts through screening with a brief, validated instrument for psychosocial barriers to recovery (e.g., STarT Back Tool for low back pain) Tracking patients in a registry and participating in performance improvement based on aggregation of data for collaborative care performance Use of a dashboard for patient progress Patient-reported outcome measures at initial visit and follow- up

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• 2. Care Team

Defined roles for care team members, care team coordination, and communication expectations Access to specialty pain or behavioral health consultation, if needed Patient point of contact for care team Standard workflow with planned interactions System supports (e.g. technology, training) Identifying, supporting and enhancing what patients are already doing to manage chronic pain with life activity impacts

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• 3. Care Management

Coordination of the collaborative care process including facilitation of care team access Identifying diverse resources and interventions that patients can use in managing chronic pain with life activity impacts, depending on motivations and preferences. Facilitation of referrals, if needed Management of medication Proactive outreach

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• 4. Evidence-Informed Care

Trauma-informed care Developing and improving pain management skills (e.g. relaxation) Conventional medical treatment options (e.g., NSAIDs as first line treatment rather than opioids, topical, heat and ice) Addressing pain amplifiers (e.g., sleep problems) Integrative health practices (e.g., massage, acupuncture) Movement and body awareness strategies

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• 5. Supported Self-Management

 Helping patients identify goals for resuming life activities and addressing barriers to making progress toward goals  Pain education including understanding of the cycle of pain  Addressing anxiety and anger  Removing barriers to physical activity  Helping patients shift thoughts from being reactive to creative  Focusing more on patient abilities, preferences, assets and existing efforts to restore life activities, and less on deficits and dysfunctions  Identifying and offering diverse resources to patients that may help them develop and sustain multiple personally helpful ways of managing chronic pain and increase participation in affected life activities.

 See Enhanced Chronic Pain Care Resource Grid in Appendix E.  May include educational resources (written, online, etc.), interventions that help people become more active, diverse services that enhance chronic pain self- management skills within or external to health care settings, and care management services that help patients develop and implement a personalized plan to manage chronic pain and reduce impacts on life activities.

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Appendix E: Enhanced Chronic Pain Care

Resource Grid – Health care resources

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Appendix F: Managing Complex Pain

Infographic – Rewiring the Pain Neuromatrix

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Appendix G: Managing Complex Pain

Infographic - Reversing The Persistent Pain Cycle

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Recommendation

Approve Collaborative Care for Chronic Pain Report and Recommendations for Dissemination for Public Comment

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Break

Topic Update: AMDG Opioid Prescribing Guidelines Implementation

Gary Franklin, MD, MPH Medical Director, Washington State Department of Labor and Industries

November 14th, 2018 | Bree Collaborative Meeting

Workgroup Members

 Gary Franklin, MD, MPH (Co-Chair), Medical Director, Washington State Department of Labor and Industries  Charissa Fotinos, MD, (Co-Chair), Deputy Medical Officer, Health Care Authority  Andrew Saxon, MD, (Co-Chair), Director, Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System  Jane C. Ballantyne MD, FRCA, Professor (retired) of Anesthesiology and Pain Medicine, Director, University of Washington Pain Fellowship  Chris Baumgartner, Director Prescription Monitoring Program, Washington State Department of Health  David Buchholz, MD, Medical Director of Provider Engagement, Premera Blue Cross  Pamela J. Davies MS, ARNP, ACHPN, BC, Teaching Associate, University of Washington Medical Center  Deborah Fulton-Kehoe, PhD, MPH, Senior Research Scientist, University of Washington  Frances Gough, MD, Chief Medical Officer, Molina  Dan Kent, MD, Chief Medical Officer, United Healthcare  Kathy Lofy, MD, Chief Science Officer, Washington State Department of Health  Jaymie Mai, PharmD, Pharmacy Manager, Washington State Department of Labor and Industries  Joseph O. Merrill, MD, MPH, Acting Assistant Professor, Internal Medicine  Attending Physician, Adult Medicine Clinic, Harborview  Mark Murphy, MD, Addiction Medicine, Multicare Health  Yusuf Rashid, PharmD, Vice President, Community Health Plan of Washington  Shirley Reitz, PharmD, Pharmacist, OmedaRx, Cambia Health  Greg Rudolf, MD, Pain Services, Swedish  Mark Stephens, Principal, CareSync Consulting, LLC  Mark Sullivan  David Tauben, MD, Chief of Pain Medicine, University of Washington Medical Center  Gregory Terman MD, PhD, Professor, Department of Anesthesiology and Pain Medicine and the Graduate Program in Neurobiology and Behavior-Co-Chair Peri-op Workgroup  John Vassall, MD, FACP, Physician Executive, Qualis Health  Michael Von Korff, ScD, Senior Investigator, Group Health Research Institute

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Postoperative Prescribing Supplement

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Completed formatting of the Prescribing Opioids for Postoperative Pain – Supplemental Guidance. Available on the AMDG website along with the Robert Bree Collaborative website.

Perioperative Guideline Summary

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Perioperative guideline summary drafted. Formatting pending feedback on content.

Review of October 10th Meeting

Review 2015 AMDG sections on tapering and treatment of opioid use disorder Scoping

Assessment The state of the screening tools to identify dependence and addiction. Tapering Use of adjunctive treatments including pharmacological and non-pharmacological treatments Treatment of opioid use disorder if tapering fails or if

• pioid use disorder is more definitely identified

Establish working subgroups, review workgroup membership

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Interim Steps

Key informant interviews of national experts for emerging best practices Completing the evidence review of tapering Funding and planning a state-of-the-are conference next fall

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Meeting December 5th

 Data from Labor and Industries and Health Care Authority

 Jaymie Mai, PharmD, Pharmacy Manager, Washington State Department of Labor and Industries  Charissa Fotinos, MD, Deputy Chief Medical Officer, Washington State Health Care Authority

 Literature on Assessment Tools

 Michael Von Korff, ScD, Senior Investigator, Kaiser Permanente Washington Research Institute

 Literature on Tapering

 Michael Sullivan, MD, PhD, Professor, Psychiatry; Adjunct Professor, Anesthesiology and Pain Medicine, University of Washington Medicine

 Next Steps

 Conference planning  Workgroups

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Open Public Meetings Act Review Conflict of Interest

November 14th, 2018 | Puget Sound Regional Council

Open Public Meetings Act

Required training every four years https://youtu.be/9yTtVGToW1A

More information: http://www.atg.wa.gov/open-government-training

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Conflict of Interest Form

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Update on New Workgroups

Ginny Weir, MPH Director, Bree Collaborative

November 14th, 2018 | Puget Sound Regional Council

New Workgroups

Opioid Prescribing (Continued) Maternity Bundle Palliative Care Shared Decision Making Harm to Self and Others (Volk)

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Maternity Bundle

 Chair: Carl Olden, MD, Family Physician, Pacific Crest Family Medicine  Members:

 Anaya Balter, RN, CNM, MSN, MBA, Clinical Director for Women’s Health, Health Care Authority  David Buchholz, MD, Medical Director for Provider Engagement, Premera  Angela Chien, MD, OB/GYN, EvergreenHealth  Andrew Castrodale, MD, Family Medicine, Coulee Medical Center  Neva Gerke, LM, CPM, MSM, Midwives Association of Washington  Lisa Humes-Schulz, MPA, Planned Parenthood of the Great Northwest and Hawaiian Islands  Ellie Kauffman, MD, Medical Director, OB COAP  Carolyn Kline, MD, OB/GYN, Overlake  Dale Reisner, MD, OB/GYN, Swedish  Janine Reisinger, MPH, Director, Maternal Infant Health Initiatives, Washington State Hospital Association  Vivienne Souter, MD, Research Director, OB COAP

 Meetings: January 8th 3:00 – 4:30pm | second Tuesdays

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Maternity Bundle

 Addressing racial and income disparities.  Process and patient outcome metrics.  Addressing preventable complications.  Inclusion and exclusion criteria.  Pre and post-natal care.

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Palliative Care

 Chair: John Robinson, MD, SM Chief Medical Officer First Choice Health  Members:

 Lydia Bartholomew, MD, Senior Medical Director, Pacific Northwest, Aetna  George Birchfield  Mary Catlin, MPH, Senior Director, Honoring Choices, Washington State Hospital Association  Randy Curtis, MD, MPH Professor of Medicine, Director, University of Washington Palliative Care Center of Excellence  Leslie Emerick, Legislative Consultant, Home Care Association of Washington  Kerry Schaefer, MS, Strategic Planner for Employee Health, King County  Richard Stuart, DSW, University of Washington  Cynthia Tomik, LICSW, Manager Palliative Care & Hospice, Evergreen Health  Gregg Vandekieft, MD, MA, Medical Director for Palliative Care, Providence

• St. Peter Hospital

 Hope Wechkin, MD, Hospice and Palliative Care Specialist, EvergreenHealth Palliative Care

 Meetings: January 4th 10:00 – 11:30am | second Fridays

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Shared Decision Making

 Chair: Emily Transue, MD, Associate Medical Director, HCA  Members:

 David Buchholz, MD, Medical Director of Provider Engagement, Premera  Dan Lessler, MD  Sharon Gilmore, RN, Risk Consultant, Coverys  Leah Hole-Marshall, JD, General Counsel and Chief Strategist, WA Health Benefit Exchange  Andrew Kartunen, Program Director, Virginia Mason  Dan Kent, MD, Chief Medical Officer, Community Plan at United Health Care  Karen Merrikin, JD, Consultant, Health Care Authority  Randy Mosley, MD, Hospitalist, Confluence Health  Martine Pierre Louis, MSW, Director, Interpreter Services, Harborview  Jonathan Sugarman, MD

 Meetings: TBD

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Harm to Self and Others (Volk)

 Chair: Kim Moore, MD, Associate Chief Medical Officer, Franciscan Health System  Members:

 Ann Allen, Member, Washington Chapter of the National Association of Social Workers  G. Andrew Benjamin, JD, PhD, ABPP, Psychologist, University of Washington Medical Center  Kate Comtois, PhD, MPH, Professor, Department of Psychiatry and Behavioral Sciences, Harborview Medical Center (Member Suicide Care Workgroup)  Laura Groshong, LICSW, Psychotherapist and mental health advocate  Ian Harrel, MSW, Chief Operating Officer, Behavioral Health Resources  Lucy Holmans, JD, LMHC, Member, Washington State Psychological Association  Kelli Nomura, Behavioral Health Administrator, King County  Mary Ellen O'Keefe, ARNP, MN, MBA, Clinical Nurse Specialist - Adult Psychiatric/Mental Health Nursing, President Elect of Association of Advanced Psychiatric Nurse Practitioners  Jennifer Piel, MD, JD, Psychiatrist, Department of Psychiatry, University of Washington Medical Center  Julie Rickard, PhD, Program Director, American Behavioral Health Systems – Parkside (Member Suicide Care Workgroup)  Jeffery Sung, MD, Member, Washington State Psychiatric Association (Member Suicide Care Workgroup)

 Meetings: January 17th 3:00 – 4:30pm | Second or Third Thursdays

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Next Meeting:

Wednesday, January 23rd, 2018 12:30 – 4:30 Puget Sound Regional Council 5th Floor Board Room 1011 Western Avenue, Seattle WA