abpmr pip form - cpmiohio.com · leon margolin md, phd/comprehensive pain management institute, llc...

1/23

ABPMRPIPFormCreated:01/09/2020•Lastupdated:02/23/2020

WhichABPMRPIPareyoucompleting?

Createmyownproject

Note:IfyoubeginoneoftheGuidedPIPprojectsandlaterwishtoswitchtoanothertopic,yourworkwillnotautomaticallytransferover.Inthatcase,werecommendcopyingallyourworktoaseparatefile(Wordorsimilar)beforeyou"Withdrawapplication"andstartover.

Pleasemakeaninitialselectionbelow.

CreatemyownPIP

1.)GeneralData

2/23

Startdate: 08/01/2019

Enddate: 02/23/2020

A)Describe,indetail,yourroleintheproject.

VoluntaryPracticeImprovementProject(PIP):

ImpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)onthepainreduction,functionalimprovementandcontinuityofcareofchronicpainpatients.

LeonMargolinMD,PhD/ComprehensivePainManagementInstitute,LLCsubmittedasarequiredformaintenanceofcertificationofAmericanBoardofPhysicalMedicineandRehabilitation

Background:OpioidepidemiccrisisaffectsthelivesofthousandsofAmericansonadailybasis.Since1999hundredsofthousandsofAmericansdiedfromoverdoses.OnanaveragedayintheUScloseto5,800peoplemisuseopioidsforthefirsttime,over1,000Americansonanaveragedaytreatedintheemergencydepartmentsforissuesrelatedtoopioidmisuse.Thesocietalandhealthcarecostofopioidepidemicisatleast55billiondollarseachyearanditcontinuestorise.Properscreeningofpainmanagementprogrampatients(includingSBIRTprotocol(Gcodes,POCUDSandNCV/EMG)fornarcoticmedicationsisextremelyimportantinpreventionofstreetdruguse.2018NationalDrugThreatAssessmentconductedbytheDrugEnforcementAdministration,showedthatprescriptiondrugssuchas“opioidswereresponsibleforthemostoverdosedeathsofanyillicitdrugssince2001”and“heroin-relateddeathsnearlydoubledfrom2013to2016”.Ohiooneofthestatemostlyaffectedbytheopioidcrisis.EfficientandethicalpainmanagementprogramthatusesappropriatetestingtodocumentorganicpathologyandscreenappropriatecandidatesforpainmedicationsandreferredotherpatientstoAddictionmedicineevaluationisextremelyimportantinthischallengingenvironmentoftheopioidepidemiccrisis.(basedHHS2017five-pointstrategy).Nationalandstateguidelinesrequireriskstratificationandclosemonitoringofpatientsonchronicopioidmedication.ThisstudyteststheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)onthefunctionalimprovementandcontinuityofcareofchronicpainpatients.

B)Datesofyourproject:

3/23

2.)Plan:Identifyanareainyourpracticethatneedsimprovement.

A)Whatistheproblemyouaretryingtosolve?

Whatdoyouwanttoimprove?Lookforinefficiencies,annoyances,orsafetyissues.Considercomplexissues,butfocusonsimplesolutions.

Nationalandstateguidelinesrequireriskstratificationandclosemonitoringofpatientsonchronicopioidmedication.ThisstudyteststheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)functionalimprovementandcontinuityofcareofchronicpainpatients.ThissfrequencyoftheSBIRTprotocol(GcodessuchasG0397),POCUDS(80307,80304)andminimallyinvasiveprocedures(76942,64450,64418,20533andothersimilarcodesisbasedonthe“PainManagementBestPracticesInter-AgencyTaskForceReport”,MedicareMLNandLCDOHL36029,Medicareguidelinesforthepresumptiveanddefinitivetesting.

Dr.MargolinmaintainsactivecertificationbytheABPM&R;inPM&R;andPainMedicine.Ourpractice,ComprehensivePainManagementInstitute,LLCestablishedcredibleevidencebasedprotocolsbasedonthethe“PainManagementBestPracticesInter-AgencyTaskForceReport”,MedicareMLNandLCDOHL36029,Medicareguidelines.

Ourpracticeisatertiaryreferralpracticethatgetsreferralforhighriskpatients.ThisisthereasonforconductingthisstudythatteststheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)functionalimprovementandcontinuityofcareofchronicpainpatientsforqualityofcaredocumentationandinformationforthethirdpartypayers.

MedicalNecessity:MostoftheComprehensivePainManagementInstitute,LLC(CPMI)patientsarecomplexhighormediumriskchronicpainpatientswithmultiplemedicalorpsychologicalcomorbidities(asreflectedintheNARXscoresheetenclosed).

After2011asaresultofregulatorychangesinthestateofOhio(includingHB93law),CPMIreceivedahighnumberofreferral/evaluationrequestsforhighriskchallengingpatientpopulation.ManyofthesechronicpainpatientsseenbytheCPMIsufferfromanxietyanddepression,and/ordrugseekingbehaviorandhadchallengesincompliancewiththeprimarycareprovidersprogram.Thestateandfederalguidelinesrequiredimplementationofthealternativetreatmentstoopioidmedicationsincludingminimallyinvasiveultrasoundguidedprocedures.

4/23

MedicareMLNdefinestheSBIRTscreeningastimespentonthestructuredlassessmentreview;theMLNdoesnothavedefinitivefrequencyparametersforsuchscreening.OurpracticesettheSBIRTprotocolbasedontheLCDOHL36029.LCDOHL36029setsthefrequency1-3timesin3monthsforthehigh-riskpatients(thevastmajorityofthesamplepatientsfallinthisoftherangehigh-riskpatientsthatarethemajorityofourpatients–94%asabove).Theother6%haveotherfactorsandelementsdiscussedbelow.Thisfrequencyisalsoconsistentwiththeindependentbillingandcodingreviewsthatthepracticehasconducted.

CostEfficiencyoftheTesting:

Thecostofopioidepidemicismorethan55billiondollarsayearandkeepsrisingannually.PainManagementprogramslikeourpracticethatcarefullyscreenandtestpatienttoproperlydocumentorganicpathologyandutilizealternativetreatments,carefulmonitoringandSBIRTapproachnotonlypreventsignificantmorbidityandmortality,butsaveverysignificantcoststothehealthcaresystem.Insufficienttesting,monitoringandlackofalternativestoopoidmedicationscanpotentiallyresultineitherprescribingopioidmedicationstonotappropriatecandidatesthatcanpotentiallyoverdoseordivertmedicationstootherpeople,ornotprescribing5/9appropriatepainmedicationstopatientswhomaylookforalternatives“onthestreet”withsignificantrisksormorbidityandmortality.ThehostofhospitalizationincludingER,inpatientcare,ICU,detoxificationandmaintenanceprogramsisastronomicandcanbereducedbypatientscreeningtreatmentintheoutpatientprogramslikeourpractice(ComprehensivePainManagementInstitute).Thisapproachisalsosupportedbythe2017fivepointstrategybytheHHS.WhentheinsurancecarrierschallengethenecessityofSBIRTprotocol(Gcodes),itdeniescoverageforproceduresthatarerequiredbytheOhiostatelaw(pleasereviewMichaelStaplesattached)andcreatesa“catch22scenario”thatputsthepateintsandthestaffatrisk.Theseproceduresincludefacetofacetimespentbyphysicianandthenursepractitioners,morethat30minoftelecommunicationvideomaterial,structuredreviewofseveralassessmentsincludingpatient’shistoryandphysicalexamination(atleast20-25minaccordingtoMedicare),PADT(atleast15-20minasperASAM),COMM(atleast10-15min),FlowchartformbasedonSMBOAdministrativeRule4731-21-02(atleast10-15min),withdrawalassessmentform(atleast5-10min),pointofcareandconformationurineandsalivadrugscreenreviews(atleast10min),OARRSreviews(atleast10min),andseveraleducationalmaterials(atleast10min).Isummary,thedocumentedtimespentonSBIRT(Gcode)clearlysignificantlyexceedsthe30minuterequirementoftheGcodebilled.Inaddition,theinitialevaluationincludesadditionalassessmentssuchasSOAPP-RandORTandadditionaleducationalmaterials.DenialpaymentsfortheappropriatetestingandscreeningproceduresfordrugsandalcoholrequiredbythestateandnationalguidelineswouldnotonlysignificantlyimpactCPMI’sabilitytofunctionasabusiness,butwouldalsoputanextremelyvulnerablepatientpopulationatrisk.Ourpatientpopulationis

5/23

uniqueascomparedtomanyofourpeers.Ourpatientsareextremelycomplex;wetakeprideincreatingindividualizedtreatmentplanswhichdorequireasignificantamountoftestingandtimeforscreeningforsubstanceandalcoholuse.However,thisallowsourpatientstoachieveanextraordinaryleveloffunctionrelativetomanagingtheirpainandpreventmorbidityandmortality.Thequalityofcareweprovideresultedinseveralclinicalawards(i.e.PatientChoiceAward,MostCompassionateDoctorawardsforseveralyears,2019“Top10”OhiophysicianawardinPainMedicine)andreferralswegetfrommajorhospitalssuchasOSUMedicalCenter,Riverside,Grant,MtCarmel,AdinaHealthandUniversityHospitalsinClevelandandevenotherpainmanagementpractices.Manyofourpatientsareopioid-dependent,iftheirmedicationsarenottimelyreviewed,thiscancausepatientmorbidityincidenttoabruptlystoppingtreatment.

Itisdifficultformanypatientstofindalternativeproviders.Ifleftuntreated,patientsmayturntoillicitmeansofobtainingsubstitutemedicationswhichdrasticallyincreasestheriskofoverdoseanddeath(overdosedeathrateinOhioisthehighestinthenationandisupmorethan800%since2013).Thecostoftheopioidepidemicisestimatedasmorethe600billionnationwide,werunalowcostprogramthatsavedhundredsofthousandsofdollarstoMedicarebyidentifyingandreferringforaddictiontreatmentshundredsofpatientsusingourSBIRTprotocol.Webilledmuchlowerratesthancomparablehospitalbasedprogramsandchoselowercostcodes(i.e.Gcodesvs.officevisitandtimecodes).

Insummary,denialpaymentsfortheappropriatetestingandscreeningproceduresfordrugsandalcoholputsindangeraboutseveralhundredhigh-riskpatients(justinDecemberof2019wehadacaseofassaultbyadischargeddrugseekingpatientandanattemptedassaultbyanotherpatientouroffice).

RiskStratificationforthepatientinthesample1(pleaseseeNARXtablebelow):

NARXScoreanalysisofthepatientsinthesample.Ourtreatmentprotocol,includingtheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)isbasedonpatientriskstratification,NARXriskstratification(validatedbytheCMS)LCDOHL36029andstateandnationalguidelines.

PleasefindtheNARXscoredetailedvalidationandanalysisattached(attachmentNARXManual,NARXclinicalapplication).TherenofrequencyguidelinesfortheGcode,howeverNARXscore(thatshowstheriskofoverdoseanddeath)seemstobethegoldenstandardacceptedbytheCMSandMedicare.TheclinicalrecommendationsbytheCMSandSMBOattached(attachmentNARXManual,NARXclinicalapplication).

Only6%ofthesample1patients(3/50pts)arelowrisk(NARXbelow100)

6/23

Only16%arehighrisk(NARX100-189)Oddratioforoverdoseincreased10times(chapter12OverdoseRiskScorepage63attached).

Therestareveryhighrisk34%(NARXabove200)andextremelyhighrisk24%(NARXabove350).Oddsratiofordeathfromoverdoseis10-12timesaverage(seeclinicalapplicationoftheNARXscoreattachedpage67).Oddratioforoverdoseincreased10-12timesormore(chapter12OverdoseRiskScorepage63attached).

UndoubtedlythepatientwiththistypeofriskwouldrequirefrequentGcodescreeningandothertestingsuchasEMG.

Thevastmajorityofthe“sample1”patientswereonincreasedriskdoseoftheopioids(morethan20MME-increasedriskofdeathasperCDC2016guidelinesincreasedadjustedhazardratio(HR)foranyoverdoseanddeath)https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf,manypatientsobtainedoipidsfrommorethanoneprescriber,usedmultiplepharmaciesandmultipleclassesofopioidmedications,somealsousedsedativesorstimulatesthatgreatlyincreasedtheriskaccordingtheCDCguidelinesandNARXscoredatabase(pleasefindoriginalNRAXscorereportsforeachpatientattached).ThesetypeofriskypatientsclearlyrequirehighfrequencyofSBIRT(Gcodeuse)basedonthecriteriadiscussedabove.

Riskstratificationofthesample2(sentbyaseparateemail)demonstratedsimilarresults.

UseofSBIRTGcodevs.useoftheE/Mofficevisitcodes.ManyoftheCPMIpatienthavemultiplemedicalcomorbiditiesanddependantonthetransportation(canscheduleonlyalimitednumberofvisits).Thereforeonmanyoccasionswehavetoscheduleminimallyinvasiveprocedureandtheofficevisitformedicalmanagementatthesamedate.ThisstudyshowtheadvantagesofusingSBIRT/GcodesratherinsteadofE/Mlevel3or4codesintheseencounters.Thisapproachprovidescostsavingtothethirdpartyinsurancepayersandputsemphasisonthescreeningandbriefinterventionapproachwhichiscrucialinmanaginghighriskpatientsonopioidmedications.CostsavingsecondarytouseofGcodeusevsmoreexpensiveofficevisit(E/M)codes:

AccordingtothenationalstandardsforPainMedicine(https://www.aapc.com/resources/em_utilization.aspx),officevisitcodes99213and99214combinedconstitutealmost100%ofthetotalvisitbillings(48.8%for99213+44.9%99214).ThesecodesaremoreexpensivethanGcodesandcanalsobecombinedwithtimecodes.

https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf

https://www.aapc.com/resources/em_utilization.aspx

7/23

Ourbillingdataanalysisbelowshowsthatinourpracticethesemoreexpensiveofficevisitcodes(99213and99214)constituteonly16-30percentofthetotalannualvisits.

OurpracticestartedtheappropriateuseofGcodessinceitsinceptionin2014(whichexplainsthe91%percentincreaseincomparisonto2013).

TheuseofthesecodeswasbasedonthecertifiedbillerandcoderreviewbelowandsavedMedicaretensofthousandsofdollars(asprovenbythebillingandcodingdatabelow).

Youcanseeclearlythatonlybetween16-30%ofourfollowupvisitswerebilledasthemoreexpensiveE/Mcodes99213,99214,therestwerebilledasGcodesinsteadofmoreexpensiveofficevisitcodes.

InotherwordsthatneedtocomparemyGcodeandofficevisitcodesbilledthatwouldshowthatbilledgreatlybelowaverageformoreexpensiveE/Mcodesfortheofficevisits.Thatclearlyexplainsthe79timestheGcodewasbilled-itwasbilledfor79followupvisitsinsteadofmoreexpensiveofficevisitcode.

----------Forwardedmessage---------От:DAVIDDEPPENDate:пт,8нояб.2019г.в13:17Subject:FW:PracticeNumbersRequested-UpdatedTo:LeonMargin

Herearetheupdatednumbersforyou:

2014:OfficeVisits–2330GCodes–5104TotalVisits-8239


2016:

8/23

OfficeVisits–1146GCodes–6621TotalVisits-7885




Thanks,DavidDeppenOfficeManagerPracticePro,LLCP:937-322-4911

Thisanalysisprovesasignificantcostsavingtothethird-partypayerofthisprotocolsince2014tillpresent.CrediblebillingandcodinganalysisandreviewfortheGcodeimplementation:

----------Forwardedmessage---------От:DavidDeppenDate:ср,12мар.2014г.в08:17Subject:RE:screeningGcodesTo:LeonMargolin,DavidGuido

HerearethecodesfromtheHCPCSbook:

9/23

G0396Alcoholand/orsubstance(otherthantobacco)abusestructuredassessment(e.g.,audit,dast),andbriefintervention15to30minutesG0397Alcoholand/orsubstance(otherthantobacco)abusestructuredassessment(e.g.,audit,dast),andintervention,greaterthan30minutes

NothingspeakstoonlytimeforMDsotimespentbyotherassociatesonthisservicecouldbeincluded.Theonlyitemthatwesuggestisthatsomewhereinthechartnoteitisdocumentedthatmorethan30minuteswasspentcoveringthisissueseparatelyfromotherservices.

Thanks,DavidDeppenPractice-ProLLC937-322-4911ImplementationoftheLCDOHL36029:OurstudyalsoprovidesaclearproofthatfrequencyoftheSBIRT/GcodemonitoringshoulddependonthecompliancewiththeprescribedopioidmedicationsandNARXscoreriskstratification,ratherthanrelianceontheself-reportedriskfactorslikealcoholordruguseintheinitialevaluationbythestafforbyapainpsychologist.

LCDOHL36029setsfrequencyofmonitoringthatdependsonprescribedopioidmedicationsandotherelements(seeExhibit21)andnotonlyontheinitialpsychologicalevaluationthatused:

◦Patienthistory,physicalexamination,andpreviouslaboratoryfindings;

◦Currenttreatmentplan;

◦Prescribedmedication(s)

◦Riskassessmentplan

TherationalforsuchscreeningLCDOHL36029definesas:

a.Identifiesabsenceofprescribedmedicationandpotentialforabuse,misuse,anddiversion;

b.Identifiesundisclosedsubstances,suchasalcohol,unsanctionedprescriptionmedication,orillicitsubstances;

10/23

c.Identifiessubstancesthatcontributetoadverseeventsordrug-druginteractions;

d.Providesobjectivitytothetreatmentplan;e.Reinforcestherapeuticcompliancewiththepatient;

f.Providesadditionaldocumentationdemonstratingcompliancewithpatientevaluationandmonitoring;g.Providediagnosticinformationtohelpassessindividualpatientresponsetomedications(e.g.,metabolism,sideeffects,drug-druginteraction,etc.)overtimeforongoingmanagementofprescribedmedications.

Alltheseelementsandfactorsareclearlydocumentedinourrecordsandevaluatedinourstudy.Wewouldliketoillustratetheimportanceofthisapproachusingtheexamplesbelow:

PatientexamplesthatshowanefficientSBIRTimplementationthatenablessuccessfulpatientparticipationintheprogramandtimelydetectionofaberrantdrug-seekingbehavior.Example#1:DS.Thispatient-reportedthelastdrink26yearsago,however,thispatientmeetscriteriaforahigh-riskpatientwithachronicpainsyndromesecondaryfailedbacksyndrome(s/p4backsurgeries).ThisisanexampleofSBIRTscreeningdirectedtowardscompliancewiththeprescribedopioidsubstancesandconfirmationofthelackofthenonprescribednarcoticsubstancesasperSMBO,OhioBoardofPharmacyandNARX,CDC,andLCDOHL36029WewillanalyzethenecessityandthefrequencyfotheSBIRTandGcodescreening(SBIRT/Gcode)codeatleast79SBIRT(Gcode)performedsince2015)andtheimpactonpatientcomplianceandparticipationintheprogram.CaseReview:Thisisapatients/p4backsurgeriesthatrequireschronicpainmanagement.HisenclosedBoardofPharmacyNARXscoredefineshimasahighriskpatient:NarcoticScore470SedativeScore170OverdoseRiskScore190(Oddsratioforoverdoseanddeathisabout10timeshigherthanaveragepleaserefertotheNARXscorereviewmaterialenclosed).Inaddition,heiscurrentlyon60MMEdaily(3timesthedangerousdosethresholdperCDCguidelines),hehasreceivedmorethan150prescriptionsfrom5differentprescriberusing2differentpharmaciesincludinghigh-risksubstanceslikeOxycodone,MorphineSulphateandFentanyl(thatisresponsibleforalargenumberofoverdosesanddeath).Sincethisisahigh-riskpatientonchronicopioidmedications,herequiresfrequentfollow-upvisitsandcompliancemonitoring.Ourpracticemonitoredthepatientcompliancewithatleast79screeningsandbriefinterventionsperformedoverthespanofthelast3-4years.ThisnumberisconservativeforthistypeofpatientandrequiredbytheSMBO,OhioBoardofPharmacyandNARX,CDC,andLCDOHL36029.Thescreeningsarerelatedtocontinuousexposuretodifferentnarcoticsubstancesandnottohispriordrinkinghistoryasdescribedabove.Ofnote,thischartwasreviewedbytheBoardofPharmacyin2015andfoundfullycompliantasdocumentedonthechart.Thisexampleshowshowefficientandcost-effectiveuseoftheSBIRTscreening(G0397code)usesaves

11/23

enforcescomplianceforthehigh-riskpatientsandsavesfundsforthird-partypayers.Inaddition,thispatienthasbeencomingtoourpracticeforcloseto5years(despitemultiplecompetingprovidersjustafewmilesaway)andevenvolunteeredavideotestimonial(togetherwithcloseto70otherpatients).Example#2:LH,ontheinitialinterviewwiththepainpsychologist–thepatientdidnotreportanyhistoryofalcoholordrugabuse.HerenclosedBoardofPharmacyNARXscoredefineshimasaveryhigh-riskpatient:NarcoticScore451SedativeScore290OverdoseRiskScore370StimulantScore20(Oddsratioforoverdoseanddeathisaboutatleast12timeshigherthanaverageormorepleaserefertotheNARXscorereviewmaterialenclosed).Additionalriskfactormorethan100MMEwithaverage40MMEdaily(pleasefindtheoriginalNARXreportenclosed).Recentlypatientisgetting60MMEdaily.TheseareverydangerousdosesaccordingtotheNARXandCDCguidelinesattachedthatrequiresfrequentSBIRT(Gcodescreenings).

Thepatientreceivedmorethan82prescriptionsforseveraltypesofmedicationsincludingPercocet,Oxycodone,Morphine,Hydrocodone,Phentermine,Lyrica,andGabapentinfrom7prescribersand5pharmacies.44screeningsandbriefinterventions(SABIRT/Gcode)performedoverthespanofthelast3-4yearsforsuchriskpatientisareasonablerequirednumberasperSMBO,OhioBoardofPharmacyandNARX,CDC,andLCDOHL36029.Thescreeningsarerelatedtocontinuousexposuretodifferentnarcoticsubstances.Thisexampleshowshowefficientandcost-effectiveuseoftheSBIRTscreening(G0397code)usesavesenforcescompliancefortheveryhigh-riskpatientsonmultiplecontrolledsubstancesandsavesfundsforthethird-partypayers.

Example#3:LHCaseReview:Thisisapatientwithspinalstenosisrequireschronicpainmanagement.Inaddition,thepatientreportedbeingavictimofphysicaldomesticabuse(additionalriskfactor)andrequiredchronicbenzodiazepinetherapy(alprazolam).Pleasefindtheurinescreenreportenclosed.Thepatienthadmultipleprescriptionsofalprazolam(potentbenzodiazepine)combinedwithopioidswhichisahigh-riskregimenforovermedicationanddeathandrequiresSBIRTinterventionseachtimethecombinationsareprescribed,accordingtotheCDCguidelines(enclosed).Pleasefindthelistoftheprescriptionsenclosed.Infact,completelyignoredtheenclosedabnormalurinedrugscreen(dated11/22/2017enclosed)whichpositivefornonprescribedbenzodiazepine(whichaveryhigh-riskfactorasperenclosedCDCguidelines)andthefollowuppainpsychologyreport(January18)thatconditionedpatientclearanceforopioidswithclosedmonitoring(SBIRTprotocol/Gcodes).26screeningsandbriefinterventions(SBIRT/Gcodes)performedoveraprolongedperiodoftimeforsuchaveryhigh-riskpatientaremedicallynecessaryandrequiredbytheSMBO,OhioBoardofPharmacy

12/23

andNARX,CDC,andLCDOHL36029.Thescreeningsarerelatedtocontinuousexposuretoacombinationofbenzodiazepinesnarcoticsubstancesandnottopatient’spriordrinkinghistory.Thisexampleshowshowefficientandcost-effectiveuseoftheSBIRTscreening(G0397code)usesavesenforcescomplianceforthehigh-riskpatientsonopioidsandbenzodiazepinesandsavesfundsforthethird-partypayers.Cases1-3showthatdespitetheinitialdenialofpriorriskfactors(i.edrinkinghistory)ontheinitialpsychologicalinterview,NARXscoreandstructuredassessmentanalysiscanhelptoimplementproperSBIRT/Gcodescreeningforsafetyandcompliance.

Example#4:JMPatientchartreviewshowsthatthepatientwasprescribedonOctober20,201630tabletsofOxyCodone5/APAP325for15days(pleaseseeBoardofPharmacydatabaselistofmedicationsenclosed).On11/2/16ourpracticeperformedarandomurinescreenthatwasNEGATIVEforprescribedOxyCodone(pleasefindtheurinescreenenclosed).TheurinescreenwasreviewedbyDoctorofPharmacologyconsultantanddiscussedwithpainpsychologist,bothofthemrequestedtightmonitoringbecauseofconcernformedicationdiversion(whichisconsideredafelonybythestateofOhioandfederallaw).Inaddition,thefollow-upnotedated11/02/16statesthatdidnotbringmedicationsbottleforpillcountandthepatientstatesshehasalotofPercocetathomethatsupportsthisconcern.Unfortunately,thepatientwasnotcompliantwiththereasonablemonitoringandselfdischargedherself.Ofnote,thispatienthasahighNARXscore(Narcoticscore371,Sedativescore150,Overdoseriskscore170),shereceivedopioidmedicationsfrom7prescribers,using4pharmaciesbasedontheBoardofPharmacydatabase.Insummary,ourmanagementofthecasewasappropriateandmandatedbythefederalandstatelaw,SMBO,OhioBoardofPharmacy,DEAandCDCregulations.Examplesofproperuseofinformedconsentandrespectforpatientautonomy.InthepreviouspartofthestudydedicatedtotheEMG/NCVprotocol,weintroducedtheuseofinformedconsentinourpractice.Thefollowingexamplesanalyzetheuseoftheinformedconsentbythepatients.

Example#5ST

Teresaisahigh-riskpatients(pleaseseetheenclosedBoardofPharmacyNARXscoredefinesherasahigh-riskpatient:NarcoticScore441SedativeScore200OverdoseRiskScore340(Oddsratioforoverdoseanddeathisabout10timeshigherthanaveragepleaserefertotheNARXscorereviewmaterialenclosed).TheBoardofPharmacyalsomentionedmorethan5opioidsorsedativeprovidersfrom4pharmacies.PropertestingsuchasNCV/EMGtestingisnecessaryforsuchapatientfordocumentationoforganicpathology.Thispatientalsohasbeencomingtoourpracticeforseveralyears(despitemultiplecompetingprovidersjustafewmilesaway)thattestifiesforthequalityofcareshehasreceived.

13/23

Thispatient“firstrefusedtheneedleEMG,thenlefttheboxuncheckedandthenagreedtotheneedleEMGtest”.TeresarefusedtheneedleEMGin2014,laterwhenthepatientrequiredprolongedcarein2016andin2017sheagreedtotheneedletesting.In2016shegaveverbalconsent(notmarkingthecheckboxisirrelevantbasedontheAANEMethicalguidelinesenclosed)and2017shegavebothverbalandwrittenconsentwhichisalsoconsistentwiththeguidelines.PatientinformedconsentforandagainstthetestingwasrespectedeachtimeasperAANEMandMedicareconsentpolicy.The2014and2016testswerebothcarpaltunnelevaluationexemptbytheAANEMpolicyandprovidedcredibleinformationevenwithouttheneedletesting.Inaddition,incompliancewiththeOHLCDthisanalysisshowsthatinthisandothercasesweneverSOLELYontheNCSdatabutonthedetailedanalysiswedescribed.

Example#6MS…patienttestimonialdifferencebetweenEMGandprocedureMarkisahigh-riskpatient(pleaseseetheenclosedBoardofPharmacyNARXscoredefineshimasahigh-riskpatient:NarcoticScore381SedativeScore160OverdoseRiskScore210(Oddsratioforoverdoseanddeathisabout10timeshigherthanaveragepleaserefertotheNARXscorereviewmaterialenclosed).Infact,Markrecentlyhadaurinescreenpositiveforuseofillicitmarijuana(asperPharmacologydoctorattached).BoardofPharmacyalsomentionedmorethan4opioidsorsedativeprovidersfrom2pharmacies(totalmorethan50prescriptions).PropermonitoringtestingsuchasNCV/EMGtestingandalternativeproceduresarenecessaryforthispatient.Thispatientalsohasbeenseenatourpracticeforseveralyears(despitemultiplecompetingprovidersjustafewmilesaway)thattestifiesforthequalityofcareshehasreceivedClosefollowupthatincludedaninterviewbypainpsychologistandpsychologicalassessmentshelpedtoaddresspatientanxieties.ThispatientinitiallyrefusedtheneedleEMGtesting.Eventhoughthetestiscalled“needle”EMG,thetestisperformedusingarecordingprobe(andnotaneedle)inaconventionalsense(nothingisinjectedthroughtheEMG“needle”).Thereforeit’squitenaturalforapatienttorefusetheneedleEMGtestingthatdoesnotdirectlyreliefthepain(andalsoinvolves6-12probesticks).Atthesametimethepatientagreedtothenerveblockinjectionthatinvolvedonesmallneedlestickthatprovidesimmediatepainreliefthroughmedicationsinjectedthroughtheneedle.

PatientinformedconsentforandagainstthetestingwasrespectedeachtimeasperAANEMandMedicareconsentpolicy.The2014and2016testswerebothcarpaltunnelevaluationexemptbytheAANEMpolicyandprovidedcredibleinformationevenwithouttheneedletesting.

B)Whatdata(objectivemeasurements)doyouhavethatsupportsthisasaproblem?

Reviewyourrecordsorbegintrackinghowoftentheissueisoccurringandunderwhatconditions.

14/23

Sample1andSample2:RigorouscategoricaldatabasedonPADT,FunctionalFlowchartforms,initialandfollowupevaluationforms,informedconsentandmedicalnecessityforms(examplesemailedtoKendall),OARRS(OhioPMR)etc.Studydesign:Retrospectivereviewof155charts(pleaseseethelistoftheselectedchartsenclosed)thatstudiestheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)onthetreatmentdecisionmaking(suchaschoosingnonopioidadjuvantmedicationsandopioidmedications,painreductionandfunctionalimprovementasdocumentedbyPADTformsandperformanceofproperclinicalassessmentasallthecomplianceandparticipationintheprogram(lengsofparticipationinmonths).Pleaseseetheattachmentbelow.Whenpainreductionwas30%-50%wedefineditasa“moderate”,above50%a“significant”andmorethan70%averysignificantpainreduction.WhenfunctionalimprovementasdocumentedbyPADTincluded2parametersormore,wecalleditsignificant,ifonlyoneparameterwecalledit“moderate”functionalimprovement.If3orfunctionalparametersimprovedwecalledaverysignificantimprovement.POCUDStestingUseofthePOCUDStestingperformedincompliancewiththestateandfederalguidelinesaspartofthepatientmonitoringprogramusingtheriskstratificationscalediscussedabove.Datashowssignificantimpactofthetestingonthepatienttreatmentplanandcompliance.

Ultrasoundguidedprocedures.Ultrasoundguidedprocedures(peripheralnerveblocks,triggerpointinjectionsandothers).Theminimallyinvasiveproceduresarecosteffectivealternativestotheopioidmedicationsrequiredbytheguidelines.Allthepatientreceivedtheinformedconsentandthemedicalnecessityforms.Statisticalanalysisshowsastrongimpactoftheseproceduresonthepatienttreatmentplanandcompliance.Analysisofsample3–dischargedpatients:Wehavereviewedthechartsofpatientpositivelyscreenedfornoncompliancewiththepatientcontract(illicitsubstanceabuse,failedpillcounts,doctorshopping,urinescreensnegativeforprescribedmedicationsandotherissues)usingtheSBIRTprotocol(Gcodes)thatwediscussed.

Sample1andSample2:RigorouscategoricaldatabasedonPADT,FunctionalFlowchartforms,initialandfollowupevaluationforms,informedconsentandmedicalnecessityforms(examplesemailedtoKendall),OARRS(OhioPMR)etc.Studydesign:Retrospectivereviewof155charts(pleaseseethelistoftheselectedchartsenclosed)thatstudiestheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533

15/23

andothersimilarcodes)onthetreatmentdecisionmaking(suchaschoosingnonopioidadjuvantmedicationsandopioidmedications,painreductionandfunctionalimprovementasdocumentedbyPADTformsandperformanceofproperclinicalassessmentasallthecomplianceandparticipationintheprogram(lengsofparticipationinmonths).Pleaseseetheattachmentbelow.Whenpainreductionwas30%-50%wedefineditasa“moderate”,above50%a“significant”andmorethan70%averysignificantpainreduction.WhenfunctionalimprovementasdocumentedbyPADTincluded2parametersormore,wecalleditsignificant,ifonlyoneparameterwecalledit“moderate”functionalimprovement.If3orfunctionalparametersimprovedwecalledaverysignificantimprovement.POCUDStestingUseofthePOCUDStestingperformedincompliancewiththestateandfederalguidelinesaspartofthepatientmonitoringprogramusingtheriskstratificationscalediscussedabove.Datashowssignificantimpactofthetestingonthepatienttreatmentplanandcompliance.

Ultrasoundguidedprocedures.Ultrasoundguidedprocedures(peripheralnerveblocks,triggerpointinjectionsandothers).Theminimallyinvasiveproceduresarecosteffectivealternativestotheopioidmedicationsrequiredbytheguidelines.Allthepatientreceivedtheinformedconsentandthemedicalnecessityforms.Statisticalanalysisshowsastrongimpactoftheseproceduresonthepatienttreatmentplanandcompliance.Analysisofsample3–dischargedpatients:Wehavereviewedthechartsofpatientpositivelyscreenedfornoncompliancewiththepatientcontract(illicitsubstanceabuse,failedpillcounts,doctorshopping,urinescreensnegativeforprescribedmedicationsandotherissues)usingtheSBIRTprotocol(Gcodes)thatwediscussed.

Statisticalanalysis(dataintableformatsentbyaseparateemail):Sample1NARXScore(riskstratification)andSBIRTprotocolscreeningeffectivenessanalysisThetablebelowhowtheaverageNARXscoreschangeswithMonthsinProgram:Table1MonthsNARXAverage/Max/Pts

Short(1month)3084506Medium(>1month,<2years)27139013Long(2years)30977023

NARXScore(riskstratification)andSBIRTprotocolscreeningeffectivenessanalysisresults:

16/23

Enforcingandmonitoringpatientcomplianceisamajorchallengeforpainmanagementprograms.TheaverageandthemaximumNARXscoresreflectthehighriskandtheveryhighriskprofileofourpatientpopulation.OurSBIRTprotocolandothertestsandtreatmentdescribedinthestudyiseffectiveinmonitoringandenforcingthehighriskpatientcomplianceforprolongedperiodsoftime(morethan23months).

FunctionalImprovementAnalysisThetablebelowcomparesMonthsinProgramvsFunctionalImprovement(basedonthePADTandothertools).Giventhelownumberofpatientsinthe‘lessthan2yeargroup,these3groupsarecombined.Table2ModerateSignificantVeryTotalLessthan2years1676292years5120262182655

Table3%ofRowTotalsforthetableaboveModerateSignificantVeryLessthan2years55.2%24.1%20.7%>2years19.2%3.8%76.9%

Forexample,ofthe26patientswith2yearsoftreatments(forwhomwealsohaddataonFunctionalImprovement),20ofthemor76.9%showedVerySignificantImprovement.Performingachi-squaretestonTable3(combiningthefirst2columnstoenhancethetest)showsthereisasignificantdifferencein‘monthsofTreatment.(p<.01)FunctionalImprovementAnalysisResults:Thereisasignificantrelation(at.05level)betweenMonthsinProgramandFunctionalImprovement.TheSBIRTprotocolandothertreatmentsinourprogramshowedastrongstatisticallysignificantimpactonthepatientfunctionalimprovement–whichisthemainoutcomemeasureofthepainmanagementprogram.

PainReductionanalysisTable5ModerateSignificantVeryTotalPtsLessthan2years2242282years175426Total399654

17/23

Table6%ofRowTotalsforTableaboveModerateSignificantVeryLessthan2years78.6%14.3%7.1%>2years65.4%19.2%15.4%

Mostpatientshadonlymoderatepainreduction(72.2%).Ofthepatientsintheprogramfor2years,15%(4outof26)hadVerySignificantpainreductionwhile65%ofthe2-yearpatientshadModeratePainReductionPerformingachi-squaretestonTable5(combiningthelast2columnstoenhancethetest)showsthereisasignificantdifferencein‘monthsofTreatment.(p=.02).PainReductionanalysisresults:Wedemonstratedaverysignificantpain(p=.02)reductionovertimeinourprogram.Astimeparticipationintheprogramincreases(morethan2years),thepainreductionbecomesmoresignificant.

Statisticalanalysis:Sample2NARXScore(riskstratification)andSBIRTprotocolscreeningeffectivenessanalysisThetablebelowhowtheaverageNARXscoreschangeswithMonthsinProgram:Table7NARXScorevsMonthsinProgramAverageMaxNumberPatients<2years3174809>2years29259031

NARXScore(riskstratification)andSBIRTprotocolscreeningeffectivenessanalysisresults(sample2):Enforcingandmonitoringpatientcomplianceisamajorchallengeforpainmanagementprograms.Aswehaveobservedinsample1,inthesample2theaverageandthemaximumNARXscoresreflectthehighriskandtheveryhigh-riskprofileofourpatientpopulation.OurSBIRTprotocolandothertestsandtreatmentdescribedinthestudyiseffectiveinmonitoringandenforcingthehigh-riskpatientcomplianceforprolongedperiodsoftime(morethan23months).

FunctionalImprovementAnalysis:ThetablebelowcomparesMonthsinProgramvsFunctionalImprovement(basedonthePADTandothertools).Giventhelownumberofpatientsinthe‘lessthan2-yeargroup,these3groupsarecombined.

18/23

Table8MonthsinProgramvsFunctionalImprovementSignificant/VerySig/Total<2years5611>2years82533

Table9%ofRowTotalsforthetableaboveSignificantVery<2years45.5%54.5%>2years24.2%75.8%

ThetablebelowcomparesMonthsinProgramvsFunctionalImprovement(basedonthePADTandothertools).Giventhelownumberofpatientsinthe‘lessthan2-yeargroup,these3groupsarecombined.

FunctionalImprovementAnalysisResults:Allthepatientsinthesamplestayedintheprogramfor6monthsorlonger,mostofthepatientsfor2yearsorlonger.Allthepatientsachievedfunctionalimprovementat6monthandcontinuewithasignificantorverysignificantimprovementafterthat.

PainReductionanalysisTable10MonthsinProgramvsPainReductionModerateSignificantVerySigTotal<2years4509>2years0211132

Thedifferencebetweenthe“<2years”groupandthe“2years”groupisstatisticallysignificant(binomialtest,P<.01)Table11%ofRowTotalsforAboveTableModerateSignificantVery<2years44.4%55.6%0.0%2years0.0%65.6%34.4%

PainReductionanalysisresults:

19/23

Wedemonstratedaverysignificantpain(p=.01)reductionovertimeinourprogram.Astimeparticipationintheprogramincreases(morethan2years),thepainreductionbecomesmoresignificant.

Sample3(dischargedpatients):NARXSCORESandDISCHARGEREASONDischargeReasonNumberPatients%TotalPatients3months6Months12Months2yearsAvNARX#PtsCOC1435.9%724136714THC25.1%20001601METH25.1%2000801ETOH1230.8%225344211FENT12.6%1000501ADLTERATIONOFURINE37.7%30002363BUP512.8%40014865

TwothirdsofallDischargereasonswereforCOCorFPC.Dividingthepatientsin3groups,COC,FPC,ALLOthers,thereisnosignificantdifferenceinAverageNARXScoreamongstthe3groups(ttestat.05level).

Dischargedpatientanalysisresults:Datashowsthehighcomplexityandthehighriskstatusofourpatients.Mostdischargedpatienttestedpositiveforcocaine(COC)andETOH(35.9and30.8percent),thehighestNARXscorewasassociatedwithbuprenorphine(486).MostpatientpositiveforFentanylaretreatedintheinpatientsetting,wehadonlyonechartinthesample–theresultsareinconclusiveforFentanyl.

Conclusion:

TheuseoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)showasignificantdocumentedpositiveeffectonincreasingoverallpatientsafety,encouragementofsafecontrolledsubstanceprescribingforpractitioners,maintainingcompliancewithStateandFederallawsandregulations,reductionofpatientoverdosedeaths,earlydetectionandinterventionofsubstanceusedisorder,andimprovingoverallstandardsofcare.

Thevastmajorityofpatientsinthesamplefitthehigh-riskprofilewhichrequiresfrequentSBIRT

20/23

monitoring.CPMISBIRTprotocolisassociatedwitheffectivelong-termmonitoringofcomplianceofthechronicpainpatientsonopioidmedicationsandeffectivediagnosticsofaberrantdrug-seekingbehaviorandreferraltoAddictionMedicineevaluation.

Ourprotocolisbasedonthe“PainManagementBestPracticesInter-AgencyTaskForceReport”,MedicareMLNandLCDOHL36029,Medicareguidelinesforthepresumptiveanddefinitivetesting,MedicareCPTcodedefinitionsandshowsastrongimpactonthe:

Thisstudyhasimportantconclusionsforthethirdpartypayersandclinicians.SBIRTprotocol(GcodessuchasG0397)ismandatoryforacompliantpainmanagementpractice.WithoutproperimplementationoftheSBIRTprotocol(GcodessuchasG0397)asafeandcompliantpainmanagementprogramishardlypossibleandpatientandstaffareexposedtosignificantrisks.

Alcohol/substanceabusestructuredassessmentsandbriefinterventionsof30minutesorlonger,undercodeG0397(SBIRTprotocol)performedatComprehensivePainManagementInstitiute,LLCbyDr.Margolinarebasedontheacceptedguidelinesand"HHSPainmanagementbestpracticesinter-agencytaskreport".TheenclosedreportbyMichaelStaples,CMBIitshowshighcompliancewiththeOhioPainClinic(PMC)licenserequirements,OhioRevisedandAdministrativeCodesandexceedingminimumstandardofcare.TheSBIRTprotocolisclearlydocumentedonallthechartsinthestudyandcompliantwiththeMedicareMLN#andLCDOHL36029.

ThisstudyshowsasignificantpositiveimpactoftheSBIRTprotocolonpainreductionandfunctionimprovementiswelldocumentedinthisstudy.

SBIRTprotocolismandatoryforthecompliantoperationofapainmanagementclinicprovidingmedicalmanagementtothepopulationwithasignificantpercentofhigh-riskpatientsinthehigh-riskarealikeOhio.Denialcoveragefortheseservicesbythird-partypayorsordefiningthemas"unallowablecosts"putsthepracticeinnoncompliancewiththeguidelinesdescribedabovemakingtheethicaloperationofthepracticeimpossibleandputtingpatientsandstaffatconsiderablerisk.

Denialpaymentsfortheappropriatetestingandscreeningproceduresfordrugsandalcohol(suchasoftheSBIRTprotocol(GcodessuchasG0397)requiredbythestateandnationalguidelines)wouldnotonlysignificantlyimpactCPMI’sabilitytofunctionasabusiness,butwouldalsoputanextremelyvulnerablepatientpopulationatrisk.Ourpatientpopulationisuniqueascomparedtomanyofmypeers.Ourpatientsareextremelycomplex;wetakeprideincreatingindividualizedtreatmentplanswhichdorequireasignificantamountoftestingandtimeforscreeningforsubstanceandalcoholuseandothertestsandproceduresdescribedinthisstudy.However,thisallowsourpatientstoavoidriskofmorbidityandmortality(Ohiohasthehighestrateofopioidmortalityper1000populationinthecountry)andachievesignificantpainreliefandimprovementintheleveloffunctionrelativetomanagingtheirpain.

21/23

Manyofourpatientsareopioid-dependent,iftheirmedicationsarenottimelyreviewed,thiscancausepatientmorbidityincidenttoabruptlystoppingtreatment.

Ifleftuntreated,patientsmayturntoillicitmeansofobtainingsubstitutemedicationswhichdrasticallyincreasestheriskofoverdoseanddeath(overdosedeathrateinOhioisthehighestinthenationandisupmorethan800%since2013).

Thequalityofcareweprovideresultedinseveralclinicalawards(i.e.PatientChoiceAward,MostCompassionateDoctorawardsforseveralyears,2019“Top10”OhiophysicianawardinPainMedicine)andreferralswegetfrommajorhospitalssuchasOSUMedicalCenter,Riverside,Grant,MtCarmel,AdinaHealthandUniversityHospitalsinClevelandandevenotherpainmanagementpractices.

Insummary,denialpaymentsfortheappropriatetestingandscreeningproceduresfordrugsandalcohol(oftheSBIRTprotocol(GcodessuchasG0397)andotherservicesinthisstudymakesthethirdpartypayerresponsiblefortherisktoseveralhundredhigh-riskpatientsandourstaff.

Ourpracticeisattheforefrontofthe“opioidepidemic”fight.Wehopetothethird-partypayersasanallyinthisfightactingincompliancewiththeHHS5pointstrategy.

C)Whatisyouropportunitystatement?Statethegoalyouhopetoachieve.

Basedonrecordreviewormeasurementofcurrentperformance,determinewhatkindofimprovementyouhopetomakeandsetatimeframetoachieveit.

OurgoalistoshowasignificantcorrelationtheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(CPTcodes76942,64450,64418,20533andothersimilarcodes)onthefunctionalimprovement,painreductionandcontinuityofcareofchronicpainpatientsbasedonrigorousretrospectivechartreviewof155chronicpainpatients.

22/23

E)WhatInstituteofMedicine(IOM)QualityDimensionswillbeaddressedbyyourproject?

PatientSafety

CareDeliveryEfficiency

CareDeliveryEffectiveness

D)Whatistheunderlyingcauseoftheperformance/qualityproblem?

Gatherandbrainstormwithotherphysiciansandstaffonyourunit/team.What’scausingthisissue?Howdidyoudeterminethecause?

TheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(CPTcodes76942,64450,64418,20533andothersimilarcodes)arecrucialforachronicpainmanagementprogram.

Thisstudyshowsthatourprotocolisindeedassociatedwithsignificantfunctionalimprovementandpainreductionandeffectivecompliancemonitoringwhilemaintainingahighlevelofcompliance.

Thisisacost-effectiveandcost-savingprogramforthirdpartypayors.

Ourdatashowsthatdenialoftheseservicesordefiningthemas"unallowed"wouldinterferewithpatientcare,compliancewiththestateandfederalstandardsandputpatientsandstaffatrisk.

3.)Do:Describethedesiredoutcomesandtherequirementsneededtoachievethem.

A)Whatchange(s)didyouimplement?

Youcanimplementonechange,oryoucanchoosetodoseveralatatime.Bespecificaboutthechangesyoumade.

WeimplementedtheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(CPTcodes76942,64450,64418,20533andothersimilarcodes)basedonthestudyresults.

Wehaveenhancedmonitoringandpatienteducationwithadditionaltools,printededucationalmaterial,30minrecordedvideopresentationonccomplianceandseveraleducationalvideosonthepracticeYouTubechannel.

23/23

4.)Study/Check:Describethemeasurementusedtoassessthesuccessoftheplan.

A)Didyouachieveyourgoalortargetreportedinyouropportunitystatement?Whatdatadoyouhavetosupportyourconclusion?

Thisisasimpleyesorno,andcitetheevidence.Afterthetimeframeindicatedinyouropportunitystatement,reviewyourperformance.(It’sgoodpracticetocheck-inatleastmidwaythroughyourproject,too,toseewhetheradjustmentsneedtobemade.)Didyoumeetthegoalyouset?

Yes,pleaserefertothedataabove.

5.)Act:Change(s)toyourpracticeasaresultofthisproject.

A)Willyoucontinuewiththechangesyouhaveimplemented?

Ifyouachievedyourgoal,describehowyouwillsustainyoursuccess,orhowitledtonewideas.Ifyoudidnotachieveyourgoal,howcouldyoutryagainwithnewtactics?Whatwillbeyournextprocesschangetokeeptheimprovementevolutiongoing?

Wewillcontinuetoimplementthestudyresultsinthefutureusingthecomprehensiveassessmentandmonitoringtoolsdescribedinthestudy.

OurgoalwillbethecontinuationofthesuccessfulimplementationoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(CPTcodes76942,64450,64418,20533andothersimilarcodes)basedonthestudyresults.

Oursecondgoalwouldbesharingdatawiththird-partypayors.

abpmr pip form - cpmiohio.com · leon margolin md, phd/comprehensive pain management institute, llc...

Documents