Opioid Use in Long-Term Care Evidence, Risks, and Management Katy Brown PharmD Program Manager Lead, Clinical Pharmacy Specialist This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-C3.6- Employee-Owned 07/17/17-2211
Disclosure • A portion of this material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 2
Objectives • Explain the evidence for the use of opioids in the treatment of persistent pain in older adults • List specific risks of chronic opioid therapy in older adults • Introduce the ADE Trigger Tool and review resources to assist long term care facilities with action planning to promote resident safety and improved outcomes • Review a case study and actionable next steps 3
Stats Among Institutionalized Elderly • persistent pain 49-84% • ¼ have daily pain • 41% moderate daily or excruciating pain Journal of Gerentology: MEDICAL SCIENCES 2006, Vol. 61A. No2, 165-196 Long-Term Effects of Analgesics in a Population of Elderly Nursing Home Residents With Persistent Nonmalignant Pain 4
OIG Report Adverse and Temporary Harm 1. Medication Events 2. Resident Care Events 3. Infection events 5
OIG Report • 22 percent adverse events • 11 percent temporary harm • 59 percent preventable • estimated cost to Medicare of $208 million in August 2011 6
OIG Report 7
5 Star Rating: Quality Measures & Opioid Safety *Percentage of short-stay residents who were successfully discharged to the community *Percentage of short-stay residents who have had an outpatient emergency department visit *Percentage of short-stay residents who were re- hospitalized after a nursing home admission Design for Nursing Home Compare Five- Star Quality Rating System: Technical Users’ Guide. January 2017 CMS 8
5 Star Rating: Health Inspection & Opioid Safety • § 483.75(g) – Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements • How it relates to VBP (SNFPPR) – Preventable harm! A Resource: Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. OEI-06-0900091. January 2012. 9
Value Based Purchasing & Opioids • Preventable harm (tools) • QAPI plan • CASPER reports (pain, falls) 10
5 Star Rating: Health Inspection & Opioid Safety • § 483.24 -- F675 – Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. • How it relates to VBP (SNFPPR) – Preventable harm! Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17. 11
5 Star Rating: Health Inspection & Opioid Safety • § 483.24(a) -- F676 – A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section. • How it relates to VBP (SNFPPR) – Preventable harm! Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17. 12
5 Star Rating: Health Inspection & Opioid Safety • § 483.24(b) -- F676 – The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: (1) Hygiene; (2) Mobility; (3) Elimination-toileting; (4) Dining-eating, including meals and snacks; (5) Communication • How it relates to VBP (SNFPPR) – Preventable harm! Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17. 13
5 Star Rating: Health Inspection & Opioid Safety • § 483.25(k) -- F697 – The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. • How it relates to VBP (SNFPPR) – Preventable harm! Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17. 14
5 Star Rating: Health Inspection & Opioid Safety • § 483.45(d) -- F757 – Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used — (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of these reasons. • How it relates to VBP (SNFPPR) – Preventable harm! Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17. 15
5 Star Rating: Health Inspection & Opioid Safety • § 483.45(f) -- F759 and F760 – The facility must ensure that its — – (1) Medication error rates are not 5 percent or greater; and – (2) Residents are free of any significant medication errors. • How it relates to VBP (SNFPPR) – Preventable harm! Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17. 16
5 Star Rating: Health Inspection & Opioid Safety • § 483.75(d)(1) -- F867 – The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. • How it relates to VBP (SNFPPR) – Preventable harm! Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17. 17
5 Star Rating: Health Inspection & Opioid Safety • § 483.75(d)(2) -- F867 – The facility will develop and implement policies addressing: (i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. • How it relates to VBP (SNFPPR) – Preventable harm! Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17. 18
Guidelines Resource: Can Fam Physician. 2010 Jun; 56(6): 514 – 517.Is the WHO analgesic ladder still valid? Twenty-four years of experience. 19
CDC Guidelines & Evidence Determine when to initiate or continue opioids for chronic pain • Sustained pain relief over time not established • Improved function and quality of life uncertain • Serious risks associated with opioids 20
Non-Pharmacological Management • Recognize the importance of non-pharmacologic approaches vs. the risk • Recognize the importance and efficacy of patient and caregiver education • Physical modalities: e.g., heat, ultrasound, cold • Role of physical therapy, exercise, splinting • Invasive procedures to manage pain: e.g. epidural injections, nerve blocks, surgical repair/replacement • TENS units/ electrical stimulation Source: AMDA Quality Prescribing of Opioid Analgesics 21
Recommend
More recommend
