AIM Opioid Webinar Introduction to the Aim maternal opioid collaborative’s metrics and - PowerPoint Presentation

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AIM Opioid Webinar

Introduction to the Aim maternal opioid collaborative’s metrics and resourcesSlide2

Welcome

Thank you for joining us for our 1

st

AIM Opioid Webinar

Housekeeping:

Session is being recorded

Session will be posted under the opioid section of the AIM website:

https://safehealthcareforeverywoman.org/national-collaborative-on-maternal-oud/

We will have Q&A following our speakers’ presentations

Use chat box or raise hand at the end to ask a questionSlide3

Speakers

Amy Bross Ushry, RN, MPH

Elizabeth Krans, MD, MSc

Ronald Iverson, MD, MPHSlide4

Goals

Provide background on AIM opioid bundle and AIM opioid collaborative

Familiarize stakeholders with the implementation guide to the AIM opioid bundle

Provide an overview of other tools and resources from the opioid collaborative

Provide an overview of the AIM opioid metricsSlide5

Agenda

Introduction

Raquel Armstrong - 5 min

Background on Opioid Bundle and Collaborative Workgroups/ Walkthrough of AIM resources

Amy Bross Ushry - 10 min

What do I do first?  Walkthough of Implementation Guide

Dr. Elizabeth Krans - 10 minWalkthough of Opioid Metrics Dr. Ron Iverson - 10 min

Q&A - 15 minSlide6

What is AIM?

Alliance of over 30 partners and organizations dedicated to improving quality in maternal health

Goal is to eliminate preventable maternal mortality and severe morbidity in every US birth center

Developing and implementing

evidence-based maternal safety bundles

.

Utilizing data-driven quality improvement strategies.

Aligning existing safety efforts and developing/collecting resources.Slide7

AIM Opioid Bundle

Readiness

Provide patient and family education

Provide clinical and non-clinical staff education on SUDs

Establish clinical pathways with care coordination in place

Develop pain protocols

Provide staff education about reporting guidelines and requirements for substance abuse care

Identify local SUD treatment facilities that provide woman-centered careSlide8

AIM Opioid Bundle

Recognition & Prevention

Assess ALL pregnant women for substance use disorder

Identify polysubstance use

Evaluate for common co-morbidities

Provide smoking cessation resources

Identify each woman’s stage of recovery or readiness to changeSlide9

AIM Opioid Bundle

Response

Ensure that all patients with OUD are enrolled in treatment

Establish

communication between providers

Provide linkages to local resources

Incorporate family planning, breastfeeding education and lactation support for all postpartum women with OUD. Engage child welfare in developing safe care protocols tailored to the patient’s needsSlide10

AIM Opioid Bundle

Reporting & Systems Learning

Collect data

Monitor process and outcome measures

Multidisciplinary case review teams

Continuing education for staff

Engage child welfare, legal systems, and communitySlide11

Opioid Collaborative States

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States:

Maryland

Virginia

Ohio

IllinoisMassachusettsTennessee

OklahomaNew MexicoTexasNew JerseyNew YorkMaineVermontNew HampshireSlide12

Opioid Collaborative Goals

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Improve identification and care of women with OUD through screening and linkage to treatment

Optimize Medical Care of Pregnant Women with OUD

Increase access to MAT for pregnant and postpartum women with OUD

Prevent opioid use disorder by reducing the number of opioids prescribed for deliveries

Optimize the care of Opioid Exposed Newborns by improving maternal engagement in infant managementSlide13

AIM Opioid Timeline

13Slide14

Tools and Resources: Slide Decks

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Screening

Stigma

NASSlide15

OUD Screening Slide Deck

What is SBIRT?

Overview of:

4 P’s Plus

Integrated 5 P’s

Substance Use Risk Profile – Pregnancy

National Institute on Drug Abuse (NIDA) Quick Screen CRAFFTScreening vs. TestingBrief Intervention Models and LinksSlide16

NAS Slide Deck

Symptoms

Perinatal Factors that can influence NAS/NOWS outcomes

Upward trends in NAS diagnoses

Non Pharmacologic Intervention

Breastfeeding

Skin to Skin Swaddling Rocking Dimmed Lighting

Quiet EnvironmentCost and Length of StaySlide17

Stigma Slide Deck

What is Stigma

What sustains it?

Consequences of stigma

Provider understating of addiction as a chronic disease

Provider beliefs about the efficacy of treatment

Language considerationsPolicy recommendations for addressing stigmaSlide18

Tools and Resources: Clinical Pathways

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Checklist

Screening Tool ChartSlide19

Clinical Pathways Checklist

This checklist is meant for use with patients who have been identified as having OUD

Expansion of checklist originally created by NNEPQIN

Antepartum

Inpatient (include ED/triage considerations and L&D admission)

PostpartumSlide20

Screening Tool Chart

Meant to assist decision-makers as they begin identifying the tools they want to use to implement a universal screening protocol

Provides links to each tool

Description

Pros and Cons

Sensitivity and Specificity

Includes screening tools for other substances such as alcohol and cannabisSlide21

Tools and Resources: Community Engagement

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Questions a State or PQC Should Be AskingSlide22

Questions a State or PQC Should be Asking

Treatment Services

Prescription Monitoring Programs

Child Welfare and Medication Assisted Treatment

Naloxone

Home Visiting ProgramsSlide23

Tools and Resources: Chart & Implementation Guide

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Collaborative Chart

Implementation GuideSlide24

Tools and Resources: Metrics

24Slide25

AIM Implementation Guide

Elizabeth E. Krans, MD, MSc

Assistant Professor of Obstetrics, Gynecology and Reproductive Sciences

Magee-

Womens

Research InstituteUniversity of PittsburghSlide26

Substance use during pregnancy

Pregnancy is a

critical window

for healthcare engagement

Enhanced investment in improving maternal and neonatal health outcomes

Improved healthcare access and enhanced resource availability

How can we maximize the effectiveness of healthcare services during pregnancy to improve long-term health outcomes for women and their children?Slide27

Improving the quality of obstetric care for women with substance use disorders

Patient safety bundle

A structured set of evidence-based practices that when performed collectively and reliably improves health outcomes

Instead of new guidelines, organizes

existing

guidelines to facilitates implementation and consistency in practice

Descriptive vs. prescriptive – allows for local customization and appropriate clinical judgementSlide28

Implementation of evidence-based practice

Every year, millions of dollars are spent to develop evidence-based interventions to improve health outcomes.

However, when these interventions are not incorporated into clinical practice, the potential to improve population health is not met.

Implementation processes are designed to

close this gap

and facilitate the translation of research findings into routine clinical practice.Slide29

Barriers to the implementation of evidence-based practice

Implementing evidence-based practice into healthcare settings requires stakeholder engagement at multiple levels.

Multiple barriers exist at provider- and system-levels

Educational/knowledge deficiencies

Time constraints

Organizational climate and cultural factors

Deficiencies in training and expertise

Negative attitudes Lack of adequate role models Slide30

Readiness – for every setting

To overcome barriers to evidence-based practice adoption, healthcare settings should

create a state, health system or community implementation team

.

An implementation team is often composed of

Administrative leadership

Healthcare providers (obstetrics, addiction medicine, psychiatry, pediatrics/neonatology, anesthesiology, social services)Payers (representatives from Medicaid HMOs)

Community stakeholders (local treatment program providers)A multidisciplinary implementation team can accelerate the adoption process and facilitate the sustainability of clinical practice change.Slide31

Clinical Champions

Clinical Champions have been the driving force behind the implementation of a wide range of change initiatives in healthcare.

Who are Clinical Champions?

leadership role in their clinical practice

express enthusiasm for the project

established relationship with administrative leadership

Well positioned to ensure participation from fellow providers, secure resources and overcome institutional obstacles.Slide32

Collaboration across healthcare settings

To achieve consistency in clinical practice across multiple healthcare settings, willingness to adopt evidence-based practices must be present at the organizational-level.

Organizational and administrative leadership need to visualize

how

evidence-based practices can be incorporated into existing clinical practice patterns.

Collaboration must occur across affiliated hospitals, health systems and/or perinatal collaborative partners.Slide33

Payer-provider relationships

Administrative and reimbursement related barriers can deter healthcare providers from offering new services despite proven effectiveness.

i.e. failure to reimburse for immediate postpartum long-acting reversible contraception insertion

Healthcare systems should initiate a relationship with payers (i.e. Medicaid HMO’s, managed care organizations) to address prior authorization and reimbursement-related needs.

i.e. removal of prior authorization requirements

to initiate mediation-assisted treatmentSlide34

AIM Bundle Implementation Guide

Clinical practice change for pregnant women with substance use disorders may be particularly challenging and there may be multiple barriers to the implementation of evidence-based practice.

AIM’s “Implementation Guide” provides guidance for the implementation process and highlights the bundle’s core components.

The goal of the bundle and associated resources is to facilitate high quality healthcare delivery for women with opioid use disorder and their children.Slide35

Ronald Iverson, MD, MPH

AIM OUD in Pregnancy MetricsSlide36

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

Overdose deaths are increasingSlide37

Substance use a common etiology of pregnancy associated mortalitySlide38

Pregnancy associated mortality in MA is increasing

Percent of Pregnancy-Associated Deaths Related to Substance Use by Year

Massachusetts DPHSlide39

Most substance-use associated pregnancy mortality is after delivery

Percent of Pregnancy-Associated Deaths Related to Substance Use by Time Period

Massachusetts DPHSlide40

MAT decreases maternal overdoses

MAT ReceivedSlide41

Maternal participation in NAS infant care improves outcomes

Grossman MR, Berkwitt AK, Osborn RR,et al. An Initiative to Improve the Quality of Care

of Infants With Neonatal Abstinence Syndrome.

Pediatrics.

2017;139(6):e20163360Slide42

AIM OUD Bundle goals

Improve

identification and care of women with OUD through screening and linkage to treatment

Optimize

Medical Care of Pregnant Women with OUD

Increase

access to MAT for pregnant and postpartum women with OUD

Prevent

opioid use disorder by reducing the number of opioids prescribed for deliveries

Optimize

the care of Opioid Exposed Newborns by improving maternal engagement in infant managementSlide43

Reporting & Systems Learning:

health system

Develop mechanisms to collect data and monitor process and outcome metrics

Inpatient and outpatient

Data dashboard measures

Outcome

Process

Create multidisciplinary case review teams

Evaluate patient, provider and system-level issues.

Develop learning opportunities for providers and staff

Use data and events to educate teamsSlide44

AIM Outcome measures

SMM

SMM without transfusions

Pregnancy Associated Opioid Deaths

Average length of stay for newborns with Neonatal Abstinence Syndrome (NAS) Slide45

AIM Process measures

Percent of women with OUD during pregnancy who receive medication assisted treatment (MAT) or

behavioral health treatment

Percent of outpatient sites with OUD screening for all pregnant patients

Percent of OEN receiving mother’s milk at newborn discharge

Percent of OEN who go home to biological motherSlide46

AIM Structure measures

Does your delivery site have a universal screening

protocol for OUD?

Does your delivery site use post-delivery and discharge pain management prescribing practices for routine vaginal and cesarean births

focused on limiting opioid prescriptions?

Does your delivery site have OUD specific pain management and opioid prescribing guidelines?Slide47

AIM State Surveillance measures

Percent of newborns diagnosed as affected by maternal use of opiates

Percent of newborns diagnosed with NASSlide48

AIM Glossary

Newborn

Neonatal Abstinence Syndrome (NAS)

Opioid Use Disorder (OUD)/Pregnant woman with OUD

Medication Assisted Treatment (MAT)

Opioid Exposed Newborn (OEN)

Mother’s milk at dischargeScreeningTestingOngoing OUD trainingSlide49

GLOSSARY / NOTES

TERM

DEFINITION

1. Newborn

Infant admitted at 0 days old, transfer admission up to 1 week old, or readmission from home/ER/clinic up to 1 week old *Admitted at less than 7 days old

2. Neonatal Abstinence Syndrome (NAS)

Refer to ICD 10 Code P96.1 Neonatal Withdrawal Symptoms from Maternal Use of Drugs of Addiction

3. Opioid Use Disorder (OUD)/ Pregnant Woman with Opioid Use Disorder

Clinical Criteria:

All women delivering at your hospital with:

• positive self-report screen or positive opioid toxicology screen during pregnancy and assessed to have OUD, or

• Patient endorses or reports misuse of opioids / opioid use disorder, or

• using non-prescribed opioids during pregnancy, or

• using prescribed opioids chronically for longer than a month in the third trimester

4. Medication Assisted Treatment (MAT)

Medication Assisted Treatment (MAT): the use of FDA- approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders (SAMHSA, 2018)

5. Opioid Exposed Newborn ≥ 35 weeks (OEN)

Clinical Criteria:

All infants of mothers with opioid use disorder if mother has:

• positive self-report screen or positive opioid toxicology screen during pregnancy and assessed to have OUD, or

• Patient endorses or reports misuse of opioids / opioid use disorder, or

• using non-prescribed opioids during pregnancy, or

• using prescribed opioids chronically for longer than a month in the third trimester, or

• if newborn has an unanticipated positive neonatal cord, urine, or meconium screen for opioids.

● if newborn affected by maternal use of opioids including NAS

Using ICD-10 data will not be as accurate as clinical criteria above and will require a linkage of mother and baby discharge codes for best estimate and so is not recommended for routine use. Log created from hospital data form is preferred method of data collection.

If using ICD-10 data, check both infant and maternal diagnoses:

Newborn affected by maternal use of opiates

P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction

P04.49 Newborn affected by maternal use of other drugs of addiction

P04.14 Newborn affected by maternal use of opiates (new in October 2018)

And Maternal codes for Opioid abuse, dependency, or use: F11.xx

*Note: For process measures that use OEN ≥

35 weeks as the denominator, this is limited to those OEN ≥ 35 who were discharged home (i.e. exlclude those who were discharged to another NICU/ death, etc)*

6. Mother's milk at discharge

Mother's Milk at Discharge: Any ongoing plan for use of some mother's milk after discharge

7. Screening

Screening: Verbal and written questions regarding opiate use. Screening tests include NIDA, 4Ps, 5Ps and others; refer to AIM screening tool guide

8. Testing

A biologic test of serum, urine, hair for presence of opioids

9. Ongoing Opioid Use Disorder (OUD) Training

Structured education completed every 2 yearsSlide50

Thank youSlide51

Questions?