Policy Action Plan Presentation

Peggie L. Powell, MSN APRN FNP-BC

NURS638 Health Policy, Leadership & Advocacy

Virginia Commonwealth University

Learning Objectives1. Identify a health policy issue that is linked to quality

and safety in health care and relate it to a theoretical model of policy design.

2. Formulate a plan to galvanize support from identified stakeholders.

3. Conduct an environmental scan and SWOT analysis of the identified health policy issue in relation to the current practice area.

4. Examine the economic impact of the health policy issue.

Health Policy Issue Introduction

• US drug overdose death rate has increased by 137% since 2000 1

• 40 people die every day due to a prescription opioid overdose 2

• 80% of overdose deaths are unintentional 3

• HB 2167 Opioids and buprenorphine; Boards of Dentistry and Medicine to adopt regulations for prescribing 4

Health Policy Issue’s Relevance to Quality & Safety

• DNP Project: RIOSORD tool to screen for risk of overdose and guide naloxone prescribing

• RIOSORD = validated tool, reliability in both the VHA and IMS populations 5

• EBP approach to:

– improve patient outcomes

– increase quality of care

– encourage safe opioid use

– promote safe opioid prescribing practices

Implication of Policy Inaction

• 14.7% increase in overdose deaths in Virginia from 2013 - 2014 1

• In 1999, ~23 people died from abuse of fentanyl, hydrocodone, methadone, and oxycodone 6

• 1,578% increase to 386 individuals by 2013 6

Theoretical Frame of ReferenceKingdon’s Streams Model

An issue gains traction on the policy agenda only when the three separate streams of activity couple with a choice opportunity. 7

Problem Stream: Defining the problem

Window of Opportunity

Policy Stream:Developing a solution

Politics Stream:Working the politics

Time

Integrating Health Policy Issue & Theory

Problem Stream Policy Stream Politics Stream

• America’s prescription opioid epidemic

• Increasing rates of overdose deaths

• Increased media coverage of the epidemic

• Drug related deaths surpass MVA deaths in Va since 2013 5

• 2014 – Va BOP, naloxone protocol established 8

• 2014 – Va DBHDS, REVIVE! Program 6

• 2015 – VDH recommends SAMHSA toolkit

• 2016 – CDC Opioid Guideline• 2016 – Va CVS, dispense naloxone

without rx • March 2017 – Va BOM emergency

guidelines for opioid prescribing (acute and chronic pain) 9

• 2013 – Va Delegate John O’Bannon, protection for use of naloxone 8

• 2015 – Va General Assembly, expand access to naloxone

• 2016 – Va General Assembly,BOM licensees to obtain 2 hours CME 9

• 2016 – Gov. Terry McAuliffe andHealth Commissioner Marissa Levine, opioid addiction a public health emergency in Va 6

• 2016 – US Surgeon General, TurnTheTideRx campaign 10

Window of Opportunity

• RIOSORD tool – screen for risk of overdose, increase access to naloxone• Publish DNP project results, influence on naloxone prescribing • Increase knowledge on RIOSORD tool – presentations; draft letter to CDC

and/or Va BOM

Stakeholder Analysis

• Future impact of the prescribing regulations → monitor prescription opioid overdose death rate

• Stakeholders relevant to health policy issue:

– government officials

– professional organizations

– professional sector

– public sector

• There are a total of 21 stakeholders.

Stakeholder Identification

• Government officials credited with commanding attention to the opioid crisis

• Lack of opioid prescribing guidelines partially responsible for the opioid epidemic

Government

Officials

Professional

Organizations

Professional

Sector

Public

Sector

U.S. Surgeon General

Dr. Vivek Murthy

Centers for Disease Control

and Prevention

Physicians Patients

Governor Terry McAuliffe

(D)

Virginia Department of

Health Professions

Dentists

Virginia Secretary of Health

and Human Resources

Dr. William A. Hazel, Jr.

Virginia Prescription

Monitoring Program

Nurse Practitioners

Virginia State Health

Commissioner

Dr. Marissa Levine

Board of Medicine

Physician Assistants

Senator A. Benton “Ben”

Chafin, Jr. (R)

Senate District 38

Board of Dentistry Pharmacists

Delegate Todd E. Pillion (R)

House District 4

Board of Nursing Health Insurances

Board of Pharmacy

Medical Society of Virginia

Stakeholder DifferentiationHigh Influence, Less Interested High Influence, Highly Interested

Board of Pharmacy

Board of Dentistry

U.S. Surgeon General Dr. Vivek Murthy

Governor Terry McAuliffe (D)

Virginia Secretary of Health and Human Resources Dr.

William A. Hazel, Jr.

Virginia State Health Commissioner Dr. Marissa Levine

Senator A. Benton “Ben” Chafin, Jr. (R)

Delegate Todd E. Pillion (R)

Centers for Disease Control and Prevention

Virginia Department of Health Professions

Virginia Prescription Monitoring Program

Board of Medicine

Medical Society of Virginia

Low Influence, Low Interested Low Influence, Highly Interested

Patients Board of Nursing

Physicians

Nurse Practitioners

Physician Assistants

Dentists

Pharmacists

Health Insurances

Stakeholder Mobilization

Patients

• Over the next three months, all patients on chronic opioid therapy will be educated on the new prescribing regulations, medications not to co-prescribe with an opioid, and reasons to prescribe naloxone.

Healthcare Providers

• Over the next six months, co-prescribers of high risk medications will be asked to wean patients off benzodiazepines and/or hypnotic sleep medications.

Environmental Scanning

Social

Opioid prescribing higher in Mecklenburg County 11

More likely to use opioids: older adults (>40 yr), women, and

non-Hispanic whites 11

Technological

EPCS

Mandatory in July 2020 for Virginia 12

Drugfreeva.org

Website/app to fight heroin and prescription opioid use

Environmental

6% increase in overdose deaths from 2014-2015 in

Virginia 11

38.7% increase in heroin overdose

deaths 11

Economics

Education & income less in Mecklenburg

County 13

Unemployment rate is greater 13

Sept 2017:

Unemployment rate 5.1% (Meck. Co.) vs.

3.6% (Virginia) 13

Political

Controlled substance education for providers 9

April 1, 2017

Virginia Medicaid ARTS program launched 14

October 25, 2017

President Trump declares opioid crisis a public health

emergency 15

SWOT Analysis

• Delineates perspectives on action of the emergency opioid prescribing regulations

• Without regulations prescribing practices may not change and the overdose death rate would continue to climb, worsening the crisis.

Helpful to achieving the objective

Harmful to achieving the objective

Inte

rnal

Ori

gin

(a

ttri

bu

tes

of

the

org

an

izati

on

)

Strengths

Improved prescribing practices

Addresses both acute and chronic pain

Includes treatment for addiction

May increase recognition of opioid

misuse

May reduce death rates from overdose

Reduction in # of opioid prescriptions

Reduce amount of opioids on street

Increased access to naloxone

Weakness

Does not address management of

established patients

Time consuming for providers and other

health care professionals to become

educated on treatment of pain and

identification/referral for addiction

No control over illicit opioid use or

availability

Ex

tern

al

Ori

gin

(a

ttri

bu

tes

of

the

envir

on

men

t)

Opportunities

Introduce pain management and addiction

treatment education to health care

provider curricula

Mandatory training for providers,

pharmacists, and other healthcare

providers

Restructure chronic opioid therapy

initiation (do not start with an opioid)

Reduce concomitant use of high risk

medications (i.e., benzodiazepine and

opioid)

Increase ability for providers to identify

addiction and refer for treatment

Incorporate EHR technology to

electronically prescribe controlled

substances

Threats

Provider resistance Reduced patient satisfaction Need for increased monitoring; time

consuming

Continued increase in overdose death

rate due to illicit use

Availability of heroin and fentanyl

Cost of health care provider training

Possible lack of funding by President

Trump

Financial & Economic Impact

$78.5 billion every year at least 16

$28.9 billion for added health care

& substance abuse treatment

costs 16

>14% of aggregated costs funded by public health insurance

programs 16

~25% of aggregate economic burden funded by state

and local government 16

Learning Objectives1. Identify a health policy issue that is linked to quality

and safety in health care and relate it to a theoretical model of policy design. (Slides 3-7)

2. Formulate a plan to galvanize support from identified stakeholders. (Slides 9-11)

3. Conduct an environmental scan and SWOT analysis of the identified health policy issue in relation to the current practice area. (Slides 12-13)

4. Examine the economic impact of the health policy issue. (Slide 14)

References1. Rudd, R. A., Aleshire, N., Zibbell, J.E., & Gladden, R.M. (2016, January 1). Increases in drug and opioid overdose deaths: United States, 2000-2014.

Morbidity and Mortality Weekly Report, 64(50);1378-82. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm2. American Public Health Association. (2017). Prescription drug overdose. Retrieved from https://www.apha.org/topics-and-issues/prescription-

drug-overdose3. Dowell, D., Haegerich, T. M., & Chou, R. (2016, March 18). CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR

Recommendations and Reports; 65(1): 1-49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e14. Opioids and buprenorphine; Boards of Dentistry and Medicine to adopt regulations for prescribing, H. B. 2167, 2017 Regular Session Va.

Legis. (2017). 5. Zedler, B., Saunders, W., Joyce, A., Vick, C., & Murrelle, L. (2015). Validation of a screening risk index for overdose or serious prescription opioid-

induced respiratory depression. Poster session presented at the 2015 American Academy of Pain Medicine Annual Meeting, National Harbor, MD.6. Virginia Department of Behavioral Health & Developmental Services. (2014). REVIVE! Opioid overdose and naloxone education for Virginia.

Retrieved from http://www.dbhds.virginia.gov/individuals-and-families/substance- abuse/revive7. Multiple Streams. (n.d.). Retrieved September 22, 2017 from the Political Frames Wiki: https://politicalframes.wikispaces.com/Multiple+Streams8. Lowe, J. (2014, May 21). REVIVE! opioid overdose prevention for the Commonwealth of Virginia [PowerPoint slides]. Retrieved from

http://www.vrha.org/webinars_31_24881083.pdf9. Virginia Board of Medicine. (n.d.). Announcements. Retrieved September 23, 2017 from https://www.dhp.virginia.gov/medicine/10. U.S. Department of Health & Human Services. (n.d.). The Surgeon General’s call to end the opioid crisis. Retrieved from http://turnthetiderx.org/11. Centers for Disease Control and Prevention. (2016b, December 16). Opioid overdose. Retrieved from

https://www.cdc.gov/drugoverdose/index.html12. Haggerty, E. (2017, September 29). Digital transformation in e-prescribing. Health IT Outcomes. Retrieved from

https://www.healthitoutcomes.com/doc/digital-transformation-in-e-prescribing-000113. Virginia Labor Market Information. (n.d.). Labor force data. Retrieved October 28, 2017 from

https://data.virginialmi.com/vosnet/lmi/default.aspx?pu=1&plang=E14. Department of Medical Assistance Services. (n.d.). Addiction and Recovery Treatment Services. Retrieved from

http://www.dmas.virginia.gov/Content_Pgs/bh-home.aspx15. Johnson, C. K. & Colvin, J. (2017, October 25). Trump readies opioid plan, but some worry it won’t be enough. Associated Press News. Retrieved

from https://www.apnews.com/215d3940a6a141a980ffd9518ec0b9d5/Trump-readies-opioid-plan,-but-some-worry-it-won%27t-be-enough16. Florence, C. S., Zhou, C., Luo, F., & Xu, L. (2016). The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United

States, 2013. Medical Care, 54(10), 901-906.

Questions