Multi-specialty healthcare provider establishes protocol to assess opioid prescriptions for older adult patients

Friday, June 14, 2019

The phrase “opioid crisis” doesn’t necessarily first bring to mind elderly nursing home patients, but many older adults are especially at risk for inappropriate use of pain medications, including controlled substances. Extended Care Specialists (ECS) of Fort Wayne., Ind., is a multi-specialty healthcare provider that serves a predominantly geriatric population and understands the unique challenges of working with this age group. ECS cares for patients in a variety of settings, including skilled nursing and long-term care facilities, independent and assisted living communities, and private residences, and often works with patients who are taking opioids post-surgery or for chronic pain.

Like many healthcare providers, the ECS team had no standard assessment tool for prescribing narcotics, so the group was eager to participate in Altarum Institute’s Advancing Responsible Opioid Prescribing training program as part of the Great Lakes Practice Transformation Network (GLPTN). Altarum’s program allowed four ECS nurse practitioners (NPs) to earn continuing medical education credits (CME), and gave ECS an opportunity to define and incorporate a standard opioid appropriateness assessment as part of applicable patient exams. With training from Altarum and support from Purdue Healthcare Advisors’ (PHA) Quality Improvement Advisor Polly Malloy, ECS ran a plan-do-study-act (PDSA) project to implement this change.

A need for flexibility

The ECS team found the PDSA approach to be especially helpful in defining the right assessment tool, establishing a process and monitoring its use, and gathering feedback from the NPs about this new resource. PDSA is a change improvement process that uses a trial-and-error methodology that allowed the ECS team to discover which tools and processes worked best for them. PDSA also gave ECS the flexibility to adapt their approach as needed, which was important since various regulations and guidelines impact the prescribing of opioids.

Both the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC) have established guidelines for opioid prescription and provided resources and incentives for providers to monitor prescribing practices. In Indiana, the Board of Pharmacy created the INSPECT online prescription monitoring program where providers can search for Indiana residents’ prescription histories for controlled substances. All Indiana providers are required to review a patient’s INSPECT history prior to prescribing narcotics and, beginning in July of 2019, providers must earn two opioid-related CMEs in order to renew their licenses.

The ECS team wanted to develop a plan for training staff and implementing an assessment instrument that would meet with recognized best practices, guidelines, and licensure requirements. Moreover, to gain buy-in from NPs to use the tool, ECS had to make the process integrate seamlessly with its electronic health record (EHR) system and routine process for patient evaluations. Achieving this integration definitely required some flexibility and trial-and-error.

Setting goals and changing processes

Kari Po, a project manager for ECS, was the lead team member for the PDSA project and worked closely with PHA’s Polly Malloy and ECS co-owner and project champion Cathy Yaggy, MSN, GNP-BC. According to Po, establishing a standard assessment tool for opioid prescription among ECS patients was critical because the company’s NPs prescribe narcotics on a regular basis to a large percentage of elderly patients. Some patients’ medical conditions (such as dementia) may prevent them from actively and accurately helping a provider assess their pain level. Many residents go to skilled nursing facilities and assisted living communities after having surgeries or with complaints of chronic pain, and some have had pain medications overprescribed.

For Po and the ECS team, implementing an assessment tool is doing their due diligence. As Po says of ECS’ NPs, “They don’t want patients to be in pain, but don’t want them to be addicted either.” Po went on to say, “All of our providers need any available tools to confirm their decision-making to have a patient on narcotics long-term rather than short-term.” Rather than second-guessing a provider’s decision to prescribe opioids, Po says the assessment provided a valuable resource to validate their decision-making process.

The team’s goal was to have the four NPs involved in the training program use a consistent assessment tool in conjunction with Indiana’s INSPECT resource by the end of the six-month project period. Po gathered baseline data for patients eligible for an opioid prescription assessment and monitored the percentage of eligible patients for whom the NPs had completed an assessment. ECS wanted all eligible patients to have an assessment for 100% compliance.

The first step was to select an appropriate assessment tool. ECS felt that the Diagnosis, Intractability, Risk, and Efficacy (DIRE) form developed by neurologist Miles Belgrade, MD, would best suit their purpose and work well within their practice; however, ECS still had challenges to overcome in implementing the DIRE form. Po says there was pushback from the NPs in the beginning simply because the form wasn’t part of the exam process they routinely used, and the form would be difficult to use as part of the patient’s chart unless included in the EHR. To overcome those obstacles, Po worked with ECS’ EHR provider to make the DIRE form a component of the clinic note.

Working to incorporate the DIRE assessment into the EHR, though, proved to be another stumbling block. The EHR vendor noticed a copyright on the DIRE form and refused to add it to the software without permission. Obtaining permission meant finding Dr. Belgrade. Fortunately, PHA’s Malloy was able to locate him and secure authorization for the EHR vendor to use the form.

Results and sustainability

Results from the six-month project have been overwhelmingly positive. At the project’s mid-point, 60% of eligible patients had the DIRE form completed and in their charts. By the end of the project, NPs had assessed 90% of eligible patients. But, as Po pointed out, “Providers didn’t really care about the specific statistics,” and needed to be prompted for feedback from Po and the ECS team. Po maintained regular communications with the NPs to monitor how the form was working for them and to remind them to use the form in conjunction with INSPECT. She also offered the providers incentive in the form of a billable CPT code attached to the DIRE form that allowed them to receive a financial benefit for this extra step.

Initial feedback from the clinicians who participated in the project has been positive. One NP who specializes in pain management has been extremely pleased with the new resource while other NPs expressed their appreciation for having the DIRE tool available and accessible. Even clinicians who were not part of the initial training have seen the DIRE tool in the EHR and have begun using it. Po is informally training staff who have expressed an interest in using the assessment.

These staff are ahead of the curve as ECS plans to roll out the DIRE tool and additional training later this year to all their providers involved with prescribing narcotics. ECS co-owner and project champion Yaggy said, “It was very helpful to choose and implement the DIRE tool in our EHR to prepare us for opioid prescribing requirements for the State of Indiana.” The full rollout of the DIRE assessment will ensure sustainability of the process and enable ECS providers to have a consistent and deliberate methodology for prescribing opioids – a process improvement that ultimately benefits patients.


Writer: Polly Malloy, 708-217-3019, pmalloy@purdue.edu

Tags: Process & Cost Improvement (Lean) , Quality Services

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