Moving Towards Safe Medications and Practices in a Rural Health - - PowerPoint PPT Presentation

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

Step 5: Care Coordination

TFHD

Post Acute Services Maximize services to assist our patients in achieving optimal level of function. Acute Hospital Minimize our readmission into the acute care hospital. Streamline follow up care. Population Health Develop Community Health and Wellness programs that keep us

• healthy. Improve

access to care and address disparities Care Coordination & Navigation Coordinate care and services for our chronically ill

• population. Navigating

patients through the system during their coarse of illness.

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

• f 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

Utilize Licensed Practitioners to help capture revenue Leverage existing

• pportunities

capture revenue (BH counseling counseling, SBIRT RVU) Leverage and prioritize high risk patients (Care coordinatio n) Utilize Evidence based screening tools

.

Track response to treatment Track Outcome Measurements and utilize data

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

Grant Opportunity : AEGIS

 2017 CHNA : 34% respondents use substance

 Supports Meds & Behavior Therapy Services  Meds: Suboxone waivered clinician

 Provide Methadone and Buprenorphine  Includes random urine testing

Behavior Therapy Services

 Hired Clinical Psychologist (Fall 2017)

Step 7: Demonstrate Success: Patient Testimonials

Patient also attended: AA, Community Outreach Recovery Resource, and Drug Court. As a result, screening markedly improved and patient reports success in abstinence Patient: 59 year old female Diagnosis: Alcohol & Substance Use Disorders History: Court recommended therapy following incarceration for multiple DUI offense Pre and Post Screening: 8/31/17 2/1/18 Pre Post PHQ-9: 6 DAST-10: 8 AUDIT: 39 4 Treatment: 16 sessions focused on: Acceptance and Commitment Therapy, Emotional Processing and Awareness of triggers. .

QUESTIONS?

Thank you

 Contact:

Eileen Knudson, RN Prime Program Director Tahoe Forest Hospital eknudson@tfhd.com (530)412-1571