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2018 Hospital Quality Symposium
July 31, 2018 – Santa Rosa
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Restroom Locations Electronic Devices Wi-Fi Code Evaluation CE/CME – must sign in Materials
HOUSEKEEPING
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All presenters have signed a conflict of interest form and have declared that there is no conflict
of interest and nothing to disclosefor this presentation.
CONFLICTS OF INTEREST
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Begin and end on time Be open-minded – respect all ideas and opinions Use technology sparingly and place on silent If you must take a call, please step out of the room
Be engaged – participate
Share & Learn!!
GROUND RULES
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Dr. Robert Moore, MD, MPH, MBAChief Medical OfficerPartnership HealthPlan of California
Welcome and Introductions from Partnership HealthPlan of California
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Mission:To help our members, and the communities we serve, be healthy.
Vision:To be the most highly regarded managed care plan in California.
About Us
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PHC is a County Organized Health Systems (COHS) Plan
Non-Profit Public PlanLow administrative Rate (less than 4 percent) allows for PHC to have a higher provider reimbursement rate and support community initiatives
Local Control and AutonomyA local governance that is sensitive and responsive to the area’s healthcare needs
Community InvolvementAdvisory boards that participate in collective decision making regarding the direction of the plan
How We Are Organized
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• Palliative Care Benefit starting January 2018
• Partnership Wellness and Recovery Program
• Whole Child Model (California Children’s Services Carve In), January 1, 2019
• NCQA Accreditation anticipated 2019
Major PHC Updates
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• Incentivize hospital performance ona set of meaningful measures (Hospital QIP)
• Find ways to support small + rural hospitals in PHC network
• Develop platforms for hospital-hospital collaboration
• Seek + disseminate new and current information
Ways PHC supports hospital quality
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Hospital Quality Improvement Program
• Pay-for-performance program started to support hospitals serving PHC members to improve quality and health outcomes.
• Substantial Financial Incentives; approximately $14 million awarded among 26 hospitals in 2016-17
• Five domains: Readmissions, Advance Care Planning, Clinical Quality: OB/Newborn/Pediatrics, Patient Safety, and Operations and Efficiency
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1. Where possible, pay for outcomes instead of processes
2. Actionable measures
3. Feasible data collection
4. Collaboration with providers in measure development
5. Simplicity in the number of measures
6. Representation of different domains of care
7. Align measures that are meaningful
8. Stable measures
Guiding Principles
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2018-19 Hospital QIP
• For 2018-19, we have outreached to 27 hospitals(increased from 26 in 2017-18)
• Hospitals located in: Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Napa, Shasta, Siskiyou, Solano, Sonoma, Tehama, and Trinity counties
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• Visit our website: www.partnershiphp.org
• Email us: [email protected]
• See handout to learn more!
For More Information about HQIP…
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Dr. Steve Pantilat, MD, MHM, FAAHPMKates-Burnard and Hellman Distinguished Professor in Palliative CareChief, Division of Palliative MedicineDirector, Palliative Care Quality NetworkUniversity of California, San Francisco
Ready for Palliative Care: Growing and Strengthening Palliative Care Teams for Improved Patient
Experience
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Division of Palliative Medicine
Ready for Palliative Care
Steven Pantilat, MDKates-Burnard and Hellman Distinguished
Professor in Palliative CareChief, Division of Palliative Medicine
Director, Palliative Care Quality NetworkUniversity of California, San Francisco
Twitter: @stevepantilat
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Division of Palliative Medicine
Life Expectancy: Good News, Bad News
0
10
20
30
40
50
60
70
80
90
30,000 BCE 20091,000 BCE15,000 BCE
Life expectancy
(years)
Death Rate: 100%
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Division of Palliative Medicine
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Division of Palliative Medicine
Palliative Care is medical care focused on improving quality of life for people with
serious illness
✮ ✮
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Division of Palliative Medicine
Extra Layer of Support
“Live as well as possible for as long as possible”
%focus
of care
0
100
Time DeathTerminal phase
Bereavement
Palliative care
Curative care
Hospice
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Division of Palliative Medicine
Live Well and Live Long with Palliative Care
Temel et al. NEJM 2010;363:733-42Pantilat Arch Int Med 2012;172:1172-3
Kavalieratos et al. JAMA 2016;316:2104-14El-Jawahri et al. JAMA 2016;316:2094-2103
Live just as long, and maybe longerGreater satisfaction with careBetter health for loved onesLess likely to get invasive care at end of life
Better moodLess pain and shortness of breath
Better quality of life If it was a drug, everyone would get it
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Division of Palliative Medicine
• Serious illness
Patients Appropriate for Palliative Care
“Would I be surprised if this patient died in the next year?”
• Metastatic cancer• Heart failure, COPD, ESRD, Cirrhosis and two admissions or ED visits in a year
• Stroke• Dementia w/aspiration pna• Parkinson’s disease, ALS• Anyone on a transplant list
• Utilization
• Function
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Division of Palliative Medicine
Challenge of Care for the Seriously Ill: What We Say
• “She’s not ready yet”• “She will lose hope”
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Division of Palliative Medicine
Most Important Issues at End of Life
Making sure family not burdened financially by my care: 67%
Being comfortable and without pain: 66%
Being at peace spiritually: 61%
Making sure my family is not burdened by tough decisions about my care: 60%
Living as long as possible: 36%
California HealthCare Foundation 2011
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Division of Palliative Medicine
Talking About Values and Goals
• “When you think about the future, what do you hope for?”
• “When you think about what lies ahead, what worries you the most?”
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Division of Palliative Medicine
Palliative Care Teams• Interdisciplinary
– Nurse, doctor, social worker, chaplain– Access to pharmacist
• 24/7 access• Sustainable jobs
– Burnout among highest in healthcare– Self care and resiliency
National Consensus Project Cinical Practice Guidelines for Quality Palliative Care, 3rd ed. http://www.nationalcoalitionhpc.org/ncp-guidelines-2013/
Dying in America. 2014 The National Academies PressKamal et al. JPSM 2016;51:690-6
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Division of Palliative Medicine
Inpatient PC team staffing: PCQNDiscipline Number of
staffFTE Credentialed
Chaplain 0.8 0.4 0.3Social Worker 1.2 1.0 0.5Registered Nurse 1.2 1.0 0.8Nurse Practitioner 1.3 1.1 0.9Physician 2.7 1.4 2.7
3+ Disciplines 84%
Mean FTE Median FTE FTE Range:
Chaplain, SW, RN, NP, MD 4.2 3.4 0.5 – 17.6Nurse, MD 3.0 2.3 0.3 – 11.9
Mean Median Range:
Staff/100 beds* 2.3 1.8 0.7 – 10.4
* Chaplain, SW, RN, NP, MD
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Division of Palliative Medicine
Challenge of Care for the Seriously Ill: What We Say
• “She’s not ready yet”• “She will lose hope”• “There is nothing more we can do”
• Simply not true• Feels like abandonment
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Division of Palliative Medicine
Better Words to Say
• “There is nothing more we can do”
• “Would you like us to do everything possible?”
“I wish there was something we could do to make your heart get stronger.”
“How were you hoping we could help?”
Pantilat JAMA 2009;301:1279-81
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Division of Palliative Medicine
Evolution of US Healthcare in the 21st Century
Volume Value
Palliative CareIncreases quality and lowers costs
for the most seriously ill people
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Division of Palliative Medicine
Meeting the Needs of Patients and Families
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Division of Palliative Medicine
Hospital Acute Illness
Palliative Care teams
SNF/LTC/Telehealth
Outpatient/Telehealth
Home/Telehealth HomeEnd of Life
Hospice
Palliative Care
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Division of Palliative Medicine
Advance care planning
time
+ Primary Palliative Care
+ PC as primary focus of care
+ Consultative PC
Intensity of PC needs
Population Approach to Palliative CareSystem of Care for People with Serious Illness
PC Education
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Division of Palliative Medicine
System of Care for Seriously Ill Patients and Families
ER
Specialty Clinics
Hospice
SNF PCHome PCHospital
Patient&
Family
Primary carePalliative Care
SNF/LTC
Telehealth
Social support services
Case Management
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Division of Palliative Medicine
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Division of Palliative Medicine
Conclusions/Recommendations
• Palliative Care improves care for people with serious illness in every way that matters
• All clinicians should provide primary palliative care
• Be ready to care for people with serious illness by developing a system of care
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Division of Palliative Medicine
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Claire Manneh, MPH
CHPSO Patient Safety Organization
Session 1 – Dry Creek BallroomBringing Patient Safety Event Reports to Life: Sharing data with CHPSO
Leigh Burns, RD, CDE
Marin General Hospital
Session 2 – Sonoma MountainCommunity Partnerships for Better Health: An interactive discussion drawing from PRIME complex/palliative care program development
Cathie Markow, RN, MBA
California Maternal Quality Care Collaborative
(CMQCC)
Session 3 – Chalk HillCMQCC’s Strategy for Helping you Meet NTSV Goals: Improving Maternal Health Outcomes
Share & Learn Sessions
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Lunch Discussion12:00 – 12:30
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What operational or performance areas are missing from the current Hospital QIP measurement set, and should be prioritized for inclusion in the 2019-20 measurement year?
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What are some meaningful measures your hospital is reporting on? What improvement activities have resulted from reporting on these measures?
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One area we have tried to address is infections and/or sepsis. CMS and The Joint Commission have a Severe Sepsis and Septic Shock Early Management Bundle (SEP-1), as part of the National Hospital Inpatient Quality Measures, which monitors whether key interventions have occurred within 3 hours of presentation of severe sepsis or within 6 hours of presentation of septic shock.
What are your thoughts on this measure? What other methods may be used to measure performance in this area?
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Are there any emerging or existing challenges you have related to quality, that you are not finding resources (education, peer groups, etc.) to address?
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What platforms does your hospital have to measure and address patient satisfaction?
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TeamSTEPPS for Patient Safety and Staff Satisfaction
Julia Slininger, RN, BS, CPHQVice President, Regional Quality NetworkHospital Quality Institute
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TeamSTEPPS for Patient Safety and Staff Satisfaction
Julia Slininger RN, BS, CPHQ, VP Regional Quality Network, HQI
Partnership HealthPlan of CaliforniaHospital Quality Symposium
7/31/18 & 8/2/18
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Advancing Quality and Patient Safety in California
A collaboration of California Hospital Association
Hospital Council of Northern and Central California Hospital Association of Southern California Hospital of San Diego and Imperial Counties
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TEAMSTEPPS 05.2Mod 3 2.0 Page 65
Communication
It’s a Jungle in there!
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Human ErrorNear Misses
AdverseEvents
System Design
Human Behaviors
Reported Near Misses
Known Adverse Events
The Iceberg Model
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TEAMSTEPPS 05.2Mod 3 2.0 Page 67
Communication
To Err is Human The IOM Report published in 2000 recommended
interdisciplinary team training to increase patient safety and quality healthcare delivery.
• The greatest factor in the occurrence of errors, near misses, and other incidents is “communication” Poor Hesitant Absent Unwelcome
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Quality/Patient Safety Culture
• JUST Culture• Improvement Interventions
• Performance Measurement
Team Training• Leadership• Communication• Mutual Support
Human Factors• Science• Situation• Systems
Health Care Reliability
Organizing
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TEAMSTEPPS 05.2Mod 3 2.0 Page 69
Communication
Patient Safety: the Final Frontier
Team Strategies and Tools to Enhance Performance and Patient Safety
This program goes where no program has gone before. Beyond evaluation and improvement of systems Beyond quality improvement models Beyond human factors and crew resource
management
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Destination: Patient Safety
TeamSTEPPS takes us To a new environment Using a new language That builds teams Brings more joy and meaning to the workplace and Saves Lives
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Communication
Team Training? Really?
The vehicle for all these helpful interventions is usually a multidisciplinary team of healthcare workers at various professional levelsSo, like, Nike? Just Do It?• Physicians don’t learn teamwork in Med School• Nursing education lacks assertiveness training• Executives are most attentive to the “big picture”• Patients/families are sometimes not listened to
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Communication
Assumptions Fatigue Distractions HIPAA
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What Do You See?
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The process by which information is exchangedbetween individuals, departments, or organizations
The lifeline of the Core Team
Effective when itpermeates every aspect of an organization
Communication is…
Assumptions Fatigue Distractions HIPAA
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TeamSTEPPS ToolkitTOOLS and
STRATEGIESBrief
Huddle DebriefSTEP
Cross MonitoringTask Assistance
FeedbackAdvocacy and Assertion
Two-Challenge RuleCUS
DESC ScriptCollaboration
SBARCall-Out
Check-BackHandoff
OUTCOMES
Shared Mental Model
Adaptability
Team Orientation
Mutual Trust
Team Performance
Patient Safety!!
BARRIERS
Inconsistency in Team Membership
Lack of Time Lack of Information Sharing Hierarchy Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and
Follow-Up with Co-Workers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity
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Multi-Team System (MTS) for Patient Care
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TeamSTEPPSTM ProgramKey Attribute…
SIMULATION TRAINING!
A picture paints…Practice makes…
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Team Structure Video
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Mutual Support
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Mutual Support
Mutual support involves members:1. Assisting each other 2. Providing and receiving feedback3. Exerting assertive and advocacy behaviors when
patient safety is threatened4. Practicing Situation Monitoring
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Situation Monitoring
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Components of Situation Monitoring:
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TEAMSTEPPS 05.2Mod 4 2.0 Page 84
Leading Teams
84
Leadership Holds a teamwork
system together Ensures a plan is
conveyed, reviewed, and updated
Facilitated through communication, continuous monitoring of the situation, and fostering of an environment of mutual support
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Building Blocks for a Patient Safety Culture
Leadership
Teamwork
Standardization
Accountability
A Just Culture
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Communication
A “Just” Culture
Justice
Understanding
Safety
Trust
“Julia Slininger”
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Communication
Justice
Doing the Right Thing
For the right reason
Involving the Right People
Including support systems
Accountability
To the patient, to the team, to oneself
“Sorry” works
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Communication
Understanding
Human Factors
“I’m Safe” checklist
Mutual Support
I’ve Got Your Back
Care for the Caregiver
NQF Safe Practice #8
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“Following serious unintentional harm due tosystems failures and/or errors that resultedfrom human performance failures, the involved caregivers (clinical providers, staff, and administrators) should receive timely andsystematic care to include: treatment that isjust, respectful, compassionate, supportive medical care, and the opportunity to fully participate in event investigation and risk identification and mitigation activities that will prevent future events.” [Frankel, 2006; MCPME, 2006a; MCPME, 2006b; IHI, 2009; MITSS, 2009]
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90
I = IllnessM = MedicationS = StressA = Alcohol and DrugsF = FatigueE = Eating and Elimination
I’M SAFE Checklist
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Safety- first and foremost!
Communication
Brief and Debrief
Safety Walk Rounds
Reward error and near miss reporting, AND
Standardization
It’s about systems, not individuals
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Communication
Trust
Leadership walks the talk
For all the preceding points
Available (“office hours”?)
Rewarding Teamwork
Call it out publically (at meetings?)
Protection from the bus
“I know I will not be thrown under”
Staff satisfaction = Staff retention
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A Shared Mental Model is…
The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication
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Shared Mental Model?
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Transforming concepts in patientsafety: a progress reportTejal K Gandhi, Gary S Kaplan, Lucian Leape, Donald M Berwick, Susan Edgman-Levitan, Amy Edmondson, Gregg S Meyer, David Michaels, Julianne M Morath, Charles Vincent, Robert Wachter
(1) Medical education must be redesigned to prepare new physicians and other health professionals to function in these new cultures;(2) care must be delivered by multidisciplinary teams working in integrated care platforms; (3) healthcare workers need to work in safe environments and find joy and meaning in their work;(4) patients must become full partners in all aspects ofdesigning and delivering healthcare and (5) transparency must be a practiced value in everything we do.
BMJQS-2017-007756Published online July 18, 2018
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Coaching Workshop
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You are assigned to coach day shift staff in the Emergency Department (ED) on teamwork skills. When you arrive at 0900, the department is very busy and there is no evidence that teams have been formed. You locate the coordinating team nurse in the department for an update, and she tells you, “We’re not doing teamwork today, the ED is just too busy. I have made the assignments, and we are going to manage things “the good old fashioned way today.”
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Communication
A staff member comes to you complaining of being put on a team in the Surgery Clinic with a “slacker.” She says, “Joan makes herself scarce and almost never offers to help her teammates, even when she has down time. I’ve had it!”
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You observe a confrontation at the desk area, where a physician has just reprimanded an Intensive Care Unit nurse for moving his patient to the ward without notifying him. The nurse is upset and embarrassed but later states that she has experienced this side of Dr. Pool before. She decides it is not worth discussing with him because he never listens anyway.
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Coaching TipsDo…
Actively monitor and assess team performance Establish performance goals and expectations Acknowledge desired teamwork behaviors and skills
through feedback Coach by example; be a good mentor
Do not… Coach from a distance Coach only to problem solve Lecture instead of coach
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John Kotter
Strengthening our Patient Safety CultureTogether!
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Opioid Use Disorder Treatment in the Hospital: Moving from Stigma to Science
Dr. Diana Coffa, MDDirectorUCSF Family and Community Medicine Program at San Francisco General Hospital
103
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Hannah Snyder, MDClinical Instructor, UCSF at ZSFG
Project Director, SHOUT
Diana Coffa, MDAssociate Professor, UCSF at ZSFG
Project Mentor, SHOUT
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A Brief Intro
• The opioid epidemic affects hospital and ED patients
• Buprenorphine and methadone maintenance saves lives
• Treatment should be available in every hospital and ED
• SHOUT and ED-Bridge resources can help get you begin
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OUD Impacts Your County
Urban Institute. California County Fact Sheets: Treatment Gaps in Opioid-Agonist Medication Assisted Therapy (OA-MAT) and Estimates of How Many Additional Prescribers Are Needed. https://www.urban.org/policy-centers/health-policy-center/projects/california-county-fact-sheets-treatment-gaps-opioid-agonist-medication-assisted-therapy-oa-mat-and-estimates-how-many-additional-prescribers-are-needed
Sonoma County:• 22 overdose deaths in 2016• 5.7/100 misuse opioids• 1.0/100 have OUD
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OUD Impacts Your County
Urban Institute. California County Fact Sheets: Treatment Gaps in Opioid-Agonist Medication Assisted Therapy (OA-MAT) and Estimates of How Many Additional Prescribers Are Needed. https://www.urban.org/policy-centers/health-policy-center/projects/california-county-fact-sheets-treatment-gaps-opioid-agonist-medication-assisted-therapy-oa-mat-and-estimates-how-many-additional-prescribers-are-needed
Humboldt County:• 26 overdose deaths in 2016• 6.2/100 misuse opioids• 1.1/100 have OUD
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OUD Impacts Hospitals
https://hcup-us.ahrq.gov/reports/statbriefs/sb219-Opioid-Hospital-Stays-ED-Visits-by-State.jsp
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Chief Complaints
• Overdose, withdrawal• Cellulitis/abscess, endocarditis/osteomyelitis• Unrelated
• Often not engaged in care elsewhere
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OUD Complicates Treatment
• 25-30% of admitted patients leave AMA
• Craving
• Fear of mistreatment
• Financial and social pressures
• Withdrawal
• Reduced adherence
• Increased readmission
Lianping Ti et al. Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systematic Review AJPH, December 2015
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Drug Related Death Rate per 1000 Post Discharge
2
31.7
14.9
10.6
0.
10.
20.
30.
40.
No hospital admission 28 days after discharge 1-3 months 3 months-1 year
White S et al. Drugs-Related Death Soon after Hospital-Discharge among Drug Treatment Clients in Scotland: Record Linkage, Validation, and Investigatio Risk-Factors.; PLoS One. 2015; 10(11): e0141073
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Withdrawal Management
• Adjunctive medications
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Withdrawal Management
• Adjunctive medications• Methadone 20-30mg
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Withdrawal Management
• Adjunctive medications• Methadone 20-30mg• Buprenorphine taper
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Detox Doesn’t Last
Chutuape, M et al. One-, three-, and six-month outcomes after brief inpatient opioid detoxification. The American Journal of Drug and Alcohol Abuse. Vol 27:1, 2001.
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A Chronic Disease Requires Chronic Meds
A thought experiment
117
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Withdrawal Management
• Adjunctive medications• Methadone 20-30mg• Buprenorphine taper• Maintenance Opioid Agonist Therapy
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Log Dose
Opi
oid
Effe
ct
Ceiling Effect
100% Agonist (methadone, heroin)
Partial Agonist (buprenorphine)
Antagonist (naloxone, naltrexone)
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Methadone BuprenorphineMechanism Full opioid agonist Partial agonist, often
paired with naloxone
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Methadone BuprenorphineMechanism Full opioid agonist Partial agonist
Location of care OTP (aka methadone clinic)
Clinic w/ X waivered provider (primary care, prenatal, psychiatry, or addiction)
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Methadone BuprenorphineMechanism Full opioid agonist Partial agonist
Location of care OTP Clinic
Retention Higher Lower unless ≥16 mg
Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD002207. DOI: 10.1002/14651858.CD002207.pub4
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Methadone BuprenorphineMechanism Full opioid agonist Partial agonist
Location of care OTP Clinic
Retention Equivalent Equivalent at doses ≥16 mg
Opioid negative urine
Equivalent Equivalent at doses ≥16 mg
Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD002207. DOI: 10.1002/14651858.CD002207.pub4
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Prevents Morbidity, Promotes Recovery
• Reduce injection and illicit drug use
• Increased abstinence
• Promotes return to work and family obligations
• Reduce HIV and HCV transmission
• Reduce bacterial infections
• Reduce criminal behavior
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Decreased Mortality
0.
10.
20.
30.
40.
In methadone Out of methadone In buprenorphine Out ofbuprenorphine
All cause mortality per 1000 person years
Sordo Luis, Barrio Gregorio, Bravo Maria J, Indave B Iciar, Degenhardt Louisa, Wiessing Lucas et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies BMJ 2017; 357 :j1550
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Barriers to Treatment
• Stigma regarding OUD patients• Stigma regarding OUD medications• Insufficient providers• Long wait times, psychosocial requirements
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Why Start in the Hospital?• Patients are ready for change
• Fear of bad outcomes• Forced abstinence allows time for thinking• Desire to reconnect with family, old life• Respect and kindness from providers
• 67% of hospitalized people who use drugs state that they would like to cut back or quit
Englander et al. J Hosp Med. 2017 May; 12(5): 339–342
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Hospital Initiation of Buprenorphine
72
16
65
123 7
0
20
40
60
80
Received MAT in 6 moafter discharge
In MAT at 6 months Days in MAT over 6months
% P
atie
nts
Linkage Detox
Num
ber o
f Day
s
80
70
60
50
40
30
20
10
0
Liebschutz et al. Buprenorphine Treatment for Hospitalized, Opioid-Dependent Patients. JAMA Intern Med. 2014 Aug; 174(8): 1369–1376.
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ZSFG Experience
• 53 methadone starts referred over 8 months• 37% had intake at on site methadone clinic
• 14 buprenorphine starts over 3 months• 79% had at least one MAT visit in 90 days• 4 through a facility (SNF, jail)
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Why Start in the ED?
• Frequent site of care for patients with OUD• Often otherwise not engaged in care• Clinical monitoring for rapid induction
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ED Initiation of Buprenorphine
0
0.5
1
1.5
2
2.5
3
0
10
20
30
40
50
60
70
80
90
Brief intervention Referral to bup Buprenorphine% in treatment on day 30 Opioid use (days/week)
D’Onofrio et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA. 2015 April 28; 313(16): 1636–1644. doi:10.1001/jama.2015.3474
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Highland Experience• 2/2017-2/2018
• 209 patients contacted by linkage coordinator• 110 patients received buprenorphine• 90 patients attended first appointment at on site clinic• 82% follow up
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Is it Legal?
• Methadone• If used to treat addiction, must be in a federally licensed
opioid treatment program
• Buprenorphine• If used to treat addiction, prescriber must have a DEA
waiver• 8 hours of training for MD, 24 hours of training for
NP or PA
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DEA Makes Exceptions• If patient is admitted for any other reason than addiction
• Methadone and buprenorphine can be dispensed for
addiction in the hospital
• Including new starts
• If the patient presents to ED or urgent care in withdrawal
• Legal to provide 72 hours of methadone or
buprenorphine to treat withdrawal
• On discharge, regular rules apply
Drug Enforcement Administration/Department of Justice, 2017, §1306.0
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Worst Case Scenario
Return to use • Death rate is likely reduced because tolerance has not been
lost• Prior quit attempts predict future success
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• Continue home dose• Even if NPO• Even if pain management required• Even if surgery planned
• Confirm last dose
Patients on Home OAT
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Harm Reduction
• Universal naloxone prescribing• OUD• Chronic opioids• Stimulants
• Safe injection practices• Clean needles and works• Avoid injecting alone• Use test doses
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Models of care
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Preparing Your Hospital• Develop a team
• Hospital leadership • Clinician champion• Pharmacy• Nursing• Linkage navigator
• Train prescribers, nurses, pharmacy• Guideline, order set • Just prescribe it!
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Providing discharge medications
• If a team member has an x-license• Prescribe sufficient medication until next appointment
• If no team member has an x-license• Next day outpatient follow up• Next day ED follow up• Have an in-house buprenorphine team that provides
discharge rx
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• PCPs or addiction specialists with x-licenses
• Hubs/Opioid Treatment Programs
https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator
Finding a Primary Care Provider with an x-license:
Discharge toOutside Provider
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• With x-license
• Bridge clinic can see patients the day after discharge
• Then daily to weekly until maintenance care is established
• Without x-license• Bridge clinic must see
patients daily• Medication can be
dispensed, not prescribed • No more than 72 hours• Utilizes the 72 hour
emergency exception in DEA regulations
Develop a bridge clinic
• https://www.deadiversion.usdoj.gov/21cfr/cfr/1306/1306_07.htm
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Use Telemedicine
SHOUT - Support for Hospital Opioid Use Treatment
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Myths and Realities
• To solve the opioid epidemic we just need to decrease prescribing
• Medication is substituting one addiction for another• Medication is unsafe• It's an outpatient issue• Need an X waiver or special training• Need a perfect discharge plan
144
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Key Points
• Medications save lives
• Buprenorphine and methadone both work
• Inpatient initiation is straightforward and within scope
• Preventing mortality is the primary goal
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Support from SHOUT and ED-Bridge
WebinarsEvidence based guidelines
Clinical Support—Poison Control and UCSF WarmlineToolkit with resources for implementation
Coaching calls, site visitsTraining templates to modify for your organization
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www.projectshout.org www.ed-bridge.org
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Closing Remarks
Partnership HealthPlanof California
148