in the ED The Monterey County Prescribe Safe Initiative 1 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 ID: 704665
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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
CommunityOBJECTIVES:Why change is importantHow we made change in Monterey CountyHow to pitch the story in your communityProvide practical tools and resources to get started
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Tools and Resources
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www.chomp.org/for-healthcare-professionals/prescribe-safe
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Opiate use in the
U.S.
80% of the world’s prescription opiate supply
99%
of the world’s hydrocodone supplyFrom 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)
Scope of the Problem
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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)
Scope of the Problem
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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 aloneApproximately 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 1990sWe lose more years of productive life in the US to prescription drug overdose than motor vehicle accidents
Prescription drug related deaths exceed motor vehicle-related 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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Selling drugs for consideration (sex, addicted physicians)
Medicine cabinet parties
Prescription fraudInsurance fraudMRI forgery black market
DIVERSION
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An Experiment
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An Experiment (circ. 2005)
Frequent Users of the ED Group (FUG)
The Team:
ED
physicians ED nurseAdministration Addictionology Hospitalist
Pain management
physician
Psychiatrist
Behavioral
h
ealth nurse
S
ocial 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 visitorsRemove 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 monthsUsing the ED as a PCP office for non-emergenciesChronic condition managementRepeat imaging and laboratory
Medication refillsSeeking 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)Utilization patternsVisit reasonDiagnosticsPCPMedications refillsEngage 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 PatientLetter to patient and providersPOC uploaded in electronic medical record (green dot)
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Tracking Board “Green Dot” Alert
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Advisory Council
ED Physician
Urgent Care Physician/Addictionologist
ED
DirectorCHI ED Transition Care Manager and Referral CoordinatorSocial WorkerClinical Specialist Behavioral Health ServicesHospitalist CoordinatorCCAH Care Management Supervisor
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Health Information Technology Enablers
High utilizer reports
Electronic referral processAuto-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 EngagementSlide27
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”27Slide28
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CURES Report
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CHOMP
Results
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Resources
FUG:
Periodic Committee meeting0.2 FTE Assistant Director of ED
Annual Cost: $50,000
EDRVPAdvisory Council meeting0.5 FTE TCMAnnual Cost: $75,000
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Future
More
of the same for the CHOMP EDRVP
County-wide
EDRVP ProgramEngage local pharmaciesEngage local health plans
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Take Home Messages
A
national
e
pidemic with local implications (including your community)Exhaust the behavior – push in the same directionUse CURESCountywide medical community prescribing practices
Engage the neighborhoodDo 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
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Questions?Slide43
Thank you
Anthony
Chavis
, MD
831-644-7466Anthony.chavis@chomp.orgReb Close, MD831-625-4900Reb.close@gmail.com