The Intersection of PCMH, Pain Management and Performance Improvement

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The Intersection of PCMH, Pain Management and

Performance Improvement

Physicians Institute for Excellence in Medicine and

California Academy of Family Physicians

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The Intersection of PCMH, Pain Management

and Performance Improvement

Final Report | March 2015

Presented by Physicians Institute for Excellence in Medicine and

California Academy of Family Physicians

Supported by an educational grant from Pfizer

Executive Summary

The Intersection of PCMH, Pain Management and Performance Improvement is an initiative led by the Physicians’ Institute for Excellence in Medicine with grant support from Pfizer Independent Grants for Learning and Change. The California Academy of Family Physicians (CAFP) serves as a consultant in the

performance improvement components of the project. The focus of the initiative is the management of chronic pain within a medical home context.

This initiative included the development of a Request for Proposal, selection of an

independent panel to review letters of interest, invite full proposals, review grant proposals and select grantees. The initiative also included a 12-‐month timeframe for the work plans. Five grants were awarded; two to medical specialty societies and three to primary care associations. The grantees are located in Maine, Missouri, Wisconsin, Kentucky and New Jersey. Each of the grantees proposed work with multiple clinics or practices, selected process and clinical measures, and included education (combination of live, online and enduring) activities in their projects. The results for all five grants are detailed in the final section of this report.

Each grantee was able to show improvement on a spectrum of PCMH integration, adoption of technology to support PCMH, implementation of chronic pain management measures or metrics, and clinician knowledge-‐competence in managing patients with chronic pain.

[A larger version of this infographic is included in the Appendices.]

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The Intersection: Pain Management and Patient-‐Centered Medical Home

The focus of this initiative is the management of chronic pain within a Patient Centered Medical Home (PCMH) context. The initiative engaged the five grantees in a performance improvement construct as a platform for the intersection.

A 2008 study found that only 39 percent of family physicians were offering pain management services to their patients.1_{However, studies}

estimate that more than 100 million Americans suffer from chronic pain.2

Given that the PCMH model is designed to offer comprehensive and team-‐based approaches to the diagnosis and treatment of chronic conditions, the PCMH may be an ideal model to test effective approaches to chronic pain

management in primary care. Although not a research project in and of itself, the work of the grantees was designed to test this theory of care improvement.

The report released in 2013 by The Patient-‐Centered Primary Care Collaborative (PCPCC) cites a number of positive results from PCMH implementation, based on research from implemented projects and data reported by insurers. Specific to the issues of comprehensive and coordinated care, were lower

hospitalization rates, lower emergency department utilization, and increased utilization of primary care providers by patients with chronic diseases (from once a year to up to four times a year).3

“Our practice is familiar with quality improvement concepts and have used them to guide our processes over the years. However, when we applied rigorous

methodology per the study guidelines, we markedly improved how we care for chronic pain patients and how we document that care. We appreciate what the study has done for these patients and for our ability to deal with quality issues in general as we move into this new era of medicine.” – Physician QI champion

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Process: From Letters of Interest to Project

Implementation

The Physicians’ Institute (PIEM) has developed a unique system known as Collaborative Educational Grants (CEG). For this RPF, eligible organizations included primary care specialty societies, including family physicians, internal medicine physicians, nurse practitioners and physician assistants.

An initial RFP was issued, with a deadline for the submission of Letters of Interest. PIEM received 18 Letters of Interest and its independent grant review panel, using criteria set for scoring the LOIs,

selected eight of the letters to go forward to the Full Proposal Phase. PIEM received eight full proposals, and once again the independent grant review panel met, using criteria for scoring, and selected five grantees for the project. The budget cap was $250,000; PIEM and Pfizer awarded five grants.

The grantees then recruited practices and provided management and supportive services to their practices to engage in performance improvement projects in the area of chronic pain management. In this partnership with the Pfizer IGLG team, the organizations selected to participate in these CEGs not only received funding, but also were required to participate in the facilitated part of the CEG model. Following notification of selection, grantees signed a separate Letter of Agreement with PIEM that required them to:

1. Select at least two members of the grantee organization to participate in a 2-‐½ day live training on PCMH principles, effective chronic pain management strategies in primary care, and quality improvement techniques.

2. Serve as “guides” to the participating practices. “Project Leaders” participated in on-‐going consultation, in the form of teleconferences and webinar featuring PCMH-‐CAFP experts, and in monthly check-‐in activities with PIEM-‐CAFP, via email and conference call.

3. Recruit and select 5-‐10 multi-‐provider practices to engage in the project. The practices were all involved in some stage (beginning, middle, or post) of the PCMH recognition process governed by one of the three recognizing entities (NCQA, URAC, The Joint Commission).

4. Guide the practices, with the assistance of PIEM-‐CAFP consultants, through their “chronic pain management in primary care” project. Practices were not required to utilize the same approach to effective pain management – practices were encouraged to choose the type of pain and the improvement approach best suited to their needs.

“Even though our process is not complete, this has really focused us and started us down the right path of enhanced, more holistic pain

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5. At the end of the project, up to five practices were chosen as “best in class,” and were asked to participate in a video-‐reporting project. These videos highlighting the project experiences will be made widely available to the greater community via The Doctors channel, beginning in Spring 2015.

In addition to the processes described above, the teams from PIEM and CAFP met via conference call monthly during the project. We used a running notes document in GoogleDrive to capture updates on the grantees, ideas for webinar content, problem solve on issues brought up by grantees, and keep each other posted on work accomplished. Notes, questions or comments were added to the document between calls, with time on each call used to address the issues. This running document supported the team members who were not able to participate in a call as well.

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Our Five Grantees

Five groups were awarded grants to work with physician practices to design and implement a comprehensive learning and change strategy for a community-‐based patient centered medical home (PCMH) model. The grantees agreed to provide structured quality improvement,

education, peer, and technical support as part of the project goal. And the participating care teams within each grantee organization are working to improve clinical patient outcomes and process outcomes for pain management interventions.

! Kentucky-‐Chapter of the American

College of Physicians, The American College of Physicians and the

Bloomberg School of Public Health – Enhancing Effective, Safe Chronic Pain Management in PCMH-‐Recognized and ACO-‐Participating Primary Care Practices: A Kentucky ACP Chapter Quality Network Initiative

! Maine Quality Counts – Maine Quality Counts: Improving Chronic Pain Management in PCMH Practices

! Missouri Center for Healthcare Quality – Transforming Pain Management in Missouri FQHC Medical Homes

! New Jersey Academy of Family Physicians – Engaging the Care Team to Facilitate Comprehensive Pain Management in the Primary Care Setting

! Wisconsin Primary Health

Care Association and Pain Peer Learning Network – Community Health Pain Management Improvement Project

Commonalities Among the Grantees

All 5 have experience with PI and most have IHI knowledge All 5 are planning collaborative-‐style projects

All 5 cite PCHM experience

All 5 plan to recruit at least 5-‐6 practice teams All 5 plan live learning and webinar activities All 5 proposals discuss data

All 5 have similar timelines

“This process has helped our physician formalize/tighten up her care of patients with chronic pain. She has improved in her ability to monitor patients to ensure safe use of opioids. She …closely reviews urinalysis drug screens and has stopped prescribing hydrocodone to a couple of patients who violated the pain

management agreement. She refers many patients to me for behavioral health consultations for the problem of chronic pain.” – Behavioral Health Consultant

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Face-‐to-‐Face Meeting | January 23-‐24, 2014

We began our project with a live, in-‐person learning session at Atlanta, Georgia on Thursday-‐Friday, January 23-‐24, 2014. Representatives from all five grantees, their core team members, PIEM-‐CAFP faculty, and staff attended. [See Appendix A, Meeting Agenda-‐Notes]

Bob Addleton, EdD, PIEM, and Shelly Rodrigues, CAE, CAFP opened the meeting with introductions and expectations. The five grantees introduced their working teams [pictured right, Mia Croyle and Pam Crouse, WPHCA] and we outlined the next 18-‐months of the project, setting expectations for conference calls, webinars, and project reporting. Robert Kristofco, Pfizer Independent Group on Learning and Change, was present at the session as well.

Two terrific faculty members opened the meeting with clinical presentations on chronic pain and both pharmacological and non-‐pharmacological management of pain. The topic of PCMH was also discussed.

Charles Raison, MD, Associate Professor in the Department of Psychiatry, College of Medicine, and the Barry and Janet Lang Associate Professor of Integrative Mental Health at the Norton School of Family and Consumer Sciences, College of Agriculture and Life Sciences, University of Arizona, [pictured left] led a terrific presentation on the behavioral aspects of chronic pain. Penny Tenzer, MD, Associate Professor of Clinical Family Medicine, the Vice Chair of the Department of Family Medicine and Community Health at the University of Miami Miller School of Medicine and the Chief of Service for Family Medicine at the University of Miami Hospital, talked to our group about current evidence-‐based approach to chronic pain. Her presentation included a discussion of non-‐

pharmacologic and pharmacologic pain management and how to implement a performance improvement program in a primary care setting.

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The teams then presented their “storyboards,” introducing their organization and key members and described the goals of their individual project, aim statements, targeted practices, and an evaluation plan. These storyboards became part of the ongoing communication among the grantees and PIEM-‐CAFP team members.

CAFP faculty led afternoon performance improvement sessions with a brief description of the three components of PI including assessment,

intervention/engagement, and reassessment. Because the grantees came to the table with a strong understanding of performance improvement we were able to focused on measurement and core competencies. The session was dedicated to clinical competencies – how they are developed and the role assessment plays in building competencies. We asked the teams to write how they plan to use competencies in their PI project. We also discussed measurements and the types of measures we will use as part of the data collection process. Faculty spent time with each grantee, assisting them as they developed team aim statements and the led a demonstration on the PDSA cycle and how the practice could use it as a recruitment strategy.

Dr. Harry Gallis, consulting professor of medicine at Duke University, led a discussion on practice recruitment, challenges, and tips on team engagement. We closed the day with team time for the grantees to work on and finalize

their project plans.

At the end of the learning session, each team member signed and completed a Learning

Commitment form. We asked each team member to think about the first task when they return to their organization and to give us one word that summed up the first session. Our wordle below speaks volumes.

Story Board Presentations Six Slides Covering the Basics of Each Project

! Organization Name and Team

Demographics

! Project Lead and Team Members

! Aim Statement

! Target Practice Audience

! Plans Already in Place

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Webinars, Tools and Resources

As part of the learning

collaborative, we offered learning webinars every other month on a quality improvement topic or topic suggested by a participating grantee to enhance continued education on chronic pain management. The webinars were open to all participating grantees and physician practices. Each was an hour in duration and we saved

the last 15 minutes for Q&A and team time:

! February 2014 – Using Clinical Guidelines in Practice, Mike Speight, Telligen

! April 2014 – Getting Started: Keys to Success for the Care Team, Elaine M. Skoch, RN, MN, NEABC, PMCH-‐CCE

! June 2014 – Persistent Pain: Five Things to Remember About Managing Pain, Kate Galluzzi, DO ! August 2014 – “But It Hurts” Communication Skills and Treating Pain, Jenni Levy, MD

! October 2014 – Our October webinar was a “grantee report” opportunity. Each team discussed their individual report and shared lessons learned and success stories.

We polled our attendees and asked them to evaluate the learning objectives of each webinar, rate the usefulness of the materials presented, and rate the extensive knowledge of the topic by each speaker. We are proud to announce that all of our monthly webinars were rated with “high confidence” although some webinars, e.g. Dr. Levy’s Communication Skills and Elaine’s Skoch’s Keys to Success talks had high(er) praise in the comments section.

In addition to the educational activities, grantees were provided a number of tools and resources as samples that might assist with the work in their projects-‐practices. The tools included games to teach the PDSA cycle and hypothesis development, project timeline samples, project-‐planning forms, slide templates, competency-‐measurement builders, articles and links to clinical metrics. The grantees and PIEM-‐CAFP staff also used the Engyte cloud-‐based platform as a repository for these tools-‐resources and as a location to save and share files.

“We experienced a shift in perspective as we included different team members. Initially we had much more of a “policing” type attitude and we were very focused on adherence and aberrant use. Once we brought in behavioral health staff we shifted to more of the mental health aspects of chronic pain. It really was an eye-‐opener about how much who is on the team matters.” – Team Member

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Ongoing Communication

After the in-‐person meeting in Atlanta 2014, PIEM-‐CAFP staff continued to monitor grantees’ progress and to provide technical assistance as needed. The project coordinators had bi-‐monthly check-‐in calls with the grantees and grantees provided a brief email update in the months between calls. Based on the grantees preferred date and times, staff sent a reminder email and check-‐in with the teams and took copious notes during the call. This was our way to support our teams in any way we can so we were there to help if they hit any bumps in their QI road. The notes were compiled in a shared drive so that all members of the executive could read and discuss the status of each grantee, which we did during our regular executive calls. This served as a great opportunity to troubleshoot, identify champions, and generate content ideas for future educational webinars.

The continuous check-‐in process allowed both parties to follow progress and outcomes and tackle barriers if they wee identified. As an example, Kentucky-‐ACP collected baseline measures and held their own education webinar on pain

assessments and mental health

screenings. One barrier they encountered was that one of the practices in the project experienced major staff changes but was able to obtain additional support from the Pharmacy Director and care coordination specialist from their ACO to continue work. As we followed Kentucky

SAMPLE CHECK-‐IN CALL NOTE

NEW JERSEY AFP 2/10/2014

CARI from New Jersey Academy

Things are going well. We have a premature week because we are having a team meeting this week. We are in process of scheduling meeting with PI. Three practices confirmed and will be

participating. At face to face, we had overwhelming response we needed to get more specific to identify practices that will be invested.

Focusing on risk factors -‐ We have talked to principal investigator, Dr. Faistl FP and Board Certified in Addiction Medicine and he recommended that we should focus no lower back and knee pain and a specific focus (in addition to evidence based guidelines) chronic pain overall and also a focus on risk factors associated with patients who may have had abuse on specific pain medications. He believes that a lot of practices will got through motions of psychosocial and family health but they don’t use information appropriately for pain medication addiction. How do you use these assessments that they had and tying that into pain medication and is there more risk or higher risk for those patients.

We would start with our PI and internal team and collect information team. Once we have the laid out we have our expert panel to go through presentations and it leads us enough time that if we have to adjust things, we can use expert faculty for speakers.

No problem with recruitment – we have three confirmed but at least 2 that went through extra step and we don’t think these two will be able to project engagement so we have two that are on the B list. We are thinking we have to say no to some practices. We were going to ask them to choose 3 of the four 4 domains. We are thinking we may go specific in that area. We may get rid of utilization bucket. We want to focus on patients and may just want them to focus on those 3. Practices are doing an assessment of the patient. More finalized on mapping it out on Thursday. Question: We scheduled the 27th_{on February. Call and get a}

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through their project, we saw the organization focus more on tailored interventions. They had site visits with each practice, tailored their educational webinars, and held one-‐on-‐one coaching calls realizing that their teams needed more hands-‐on help. [See Appendix B, Kentucky-‐ACP Check-‐In Call Report]

PIEM-‐CAFP staff members were also invited as guests to grantees’ learning session as an observer and onsite resource. CAFP staff attended learning sessions for the New Jersey Academy of Family Physicians, Wisconsin Primary Health Care Association and Pain Peer learning Network [pictured left], and the Missouri Center for Healthcare Quality.

“Patients with chronic pain are universally perceived as ‘difficult patients’ and we found that there was a negative vibe throughout the clinic that we were working against. As a provider it is a challenge to maintain a positive hopeful attitude with each patient.” – Health Care Provider

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Video Stories

In order to showcase project successes and lessons learned at the practice level with the broader provider community, a video series was produced which highlighted four practices that participated in this project. Grantees were asked to nominate practices with successes in their performance

improvement projects to share their story, challenges, outcomes, lessons learned, and provide guidance for other practices.

The four practices were located in Maine, New Jersey, Missouri and Kentucky. A videography team traveled to each of the four practices, which enabled members of the practice to fully engage in telling their stories. The video series is being hosted on a mini-‐site on the Doctors Channel

http://www.thedoctorschannel.com/; it launches April 2015 and will be available. Several screen shots are included in this report from those videos that illustrate the team approach to the stories captured in these videos.

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Outcomes

All five of the state-‐based projects demonstrated improvements through their diverse initiatives. A subset of these individualized outcomes are detailed below:

Kentucky Project: Performance measure data was collected from

each practice at the beginning of the initiative and follow-‐up data was collected after four months. Each participating physician provided data for 25 chronic pain patients for both the baseline and follow-‐up data sets. Results of the performance measure data show a significant improvement in each of the three measures included in the initiative.

The results showed that use of pain assessments, depression screenings, controlled substance agreements, and urine toxicology tests increased significantly after the program. Sixty percent of the patients at baseline and 84% of the patients in the post-‐program period received depression screening; use of a pain assessment increased from 26% to 75% of patients; and use of the controlled substance agreement and urine drug tests were also increased from 57% to 80%.

60.16 26.29 56.8 84.46 74.5 80.08 0 10 20 30 40 50 60 70 80 90

Screening for clinical eepression Assessment and management

of chronic pain agreement forms and urine Increase use of opioid toxicology tests

Baseline Follow-‐up

“Upon completion of the baseline measurement, the majority of practices indicated that they were extremely surprised by the practice’s results, and did not realize “how bad we were,” or “how much improvement we need.” – Team Member

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Missouri Project: All practices chose to implement the PEG Pain Screening Tool. One particular practice was highlighted as making the most progress with this project. Their team was fully engaged from the beginning with an active physician champion, a supportive medical director and chief operations officer, and a registered nurse that led their PCMH recognition application effort. They created a set of policies for their pain management services. Their approach was to present their pain management program to new patients seeking services location and engage them in the bio-‐psychosocial model immediately. At the present time there are 45 patients in their pain management program; 28 of these patients

responded to a survey regarding their satisfaction with the treatment they received, and 64% expressed “complete satisfaction”.

Wisconsin Project: The Wisconsin staff trained and supported their practices in the use of a common set of Lean tools.

! Practice 1 established a pain registry and a peer review committee that meets as a regular monthly standing

meeting and will continue

to review cases upon referral while establishing a process to systematically review all cases in the chronic pain registry on an annual basis.

! Practice 2 developed two new templates for their EMR, one for the initial visit and one for follow-‐up visits to better organize care and remind them of the best practice assessment and management strategies. Following testing, health educators are embedded in the care team to screen patients for alcohol and drug misuse via a universal Screening Brief 5 Intervention and Referral to Treatment (SBIRT) protocol and each pain patient completes a screening tool for depression and anxiety, and the team is currently planning to spread this process to scale. ! Practice 3 adopted a pain assessment and tracking tool for all pain patients. They decided to

have one RN serve as the primary gatekeeper of all activity related to patients identified as having with chronic pain. The RN meets with patients outside of their regular appointments with providers and focuses on their pain management strategies. She is able to track referral patterns and notice unusual activity early and is also able to closely coordinate referrals.

! Practice 4 developed protocols for the assessment and management of patients with chronic pain that emphasized enhanced patient self-‐care and self-‐management activities. They designated a v-‐code to be added to the patient’s problem list in their EMR and created a searchable “smart phrase” so patients would be reliably identified in a way that would allow them to run reports for quality assurance.

! Practice 5 developed an EMR template for patients with chronic pain, which shifts a large burden of tracking and organizing the care from the individual provider to the protocol-‐driven EHR. They also designed care to be more team-‐based; for example, the medical assistants have

Six Participating Health Centers

100% completed PDSA Improvement Cycles 100% increased use of guidelines

100% implemented systems changes 80% integrated guidelines in EMR

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reviewed according to protocol

New Jersey Project: Performance improvement activities focused on the following areas: measure use of evidence-‐based guidelines in practice, use of standardized systems for treatment of patients presenting with chronic back or knee pain and enhancing satisfaction for patient with pain. The

Maine Project: The organization was able to provide expert physician consultants for the participating practices. In the first six months of the project, significant improvements were documented in all six measures – the graphics below show baselines and six-‐month measurement.

62 54 73 9 32 0.05 92 87 98 32 33 10 0 20 40 60 80 100 120 Medical usage

agreement toxicology Urine

screen

PDMP Pill count Behavioral

health consultaoon Chronic opioid misuse measure Jun-‐14 Jan-‐15

10 Physician Practices Chart Review Improvement Practices use evidence guidelines 30%

Practices employ a Pain Tool 30%

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Lessons Learned

In-‐person meetings are important. We have learned important lessons during our journey. Our Kentucky team reminded us that practice visits and the in-‐touch coaching time helped their project tremendously. In-‐person meetings allowed for better identification of data collection strategies and optimizing workflow efficiency. It also brings the whole team together because it motivates other healthcare team members to be part of the project in addition to the physician champions. That said, it is important to involve members in all stages of the QI project. The Kentucky team invited each

participating champion to be a part of their advisory group, which brought high levels of enthusiasm and engagement through the course of the initiative.

Consultants play a vital and intermediary role. Some of our grantees had consultants who visited each practice and played a role in patient education, problem solving and facilitating links to outside

resources. On a macro-‐level, PIEM staff also served as outside consultants and as the resource network grew, staff could share lessons learned with other grantees and share best practices so no one had to recreate the wheel. The exchange of change packets and resource guides were fluid among all participating organizations.

Engaging QI champions. The Kentucky project involved the practice QI champions in the early phase of the program increased the engagement and enthusiasm of the participating practices and ensured that educational focus of the project was relevant to their top chronic pain management priorities.

Data are key. Consistent measures are crucial. Maine Chronic Collaborative similarly conducted

extensive visits across all eight participating sites. In addition, they developed a self-‐assessment tool that would enable practices to measure their progress in line with the ten identified elements of their change package. That way, the cohort has the same set of measures that collected to enhance data analysis. On the flip side, our practices in Wisconsin recruited diverse health centers with different systems that made common measures -‐-‐ and data collection -‐-‐ very challenging.

(Lack of) Time is a barrier. Time constraints and competing priorities for participating health centers and consultants/ staff continued to be a challenge. Our Wisconsin grantee experienced big challenges with coordinating group calls for their participating health centers. One of our Missouri teams wished they could have included a pharmacist in their consultant team from the beginning because so much of the pain management work revolves around pharmacy referral. That would have been a big time-‐saver.

Education is ongoing. Physicians, health care team members, and even practice coaches asked for additional training in their role in supporting participants. One of our teams in New Jersey asked if their on-‐going pain management work might align in the future with other educational initiatives like the

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combined to continue the length of a QI project and continue ongoing training for all members of the care team.

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References

1. Bazemore AW, Petterson S, Johnson, N, et al. What services do family physicians provide in a time of primary care transition? JABFM. 2011:24; 10:635-‐636.

2. Debono D, Hokesema L, Hobbs R. Caring for patients with chronic pain: pearls and pitfalls. Journal of the American Osteopathic Association.2013: 113:5; 620-‐627.

3. Neilsen M, Langer B, Zema C, et al. Benefits of implementing the primary care patient centered medical home: a review of cost and quality results, 2012. Patient-‐Centered Primary Care Collaborative, Washington, DC, 2012.

The Intersection of PCMH, Pain Management and Performance Improvement

The Intersection of PCMH, Pain Management and

Performance Improvement

Physicians Institute for Excellence in Medicine and

California Academy of Family Physicians

The Intersection of PCMH, Pain Management

and Performance Improvement

Final Report | March 2015

Presented by Physicians Institute for Excellence in Medicine and

California Academy of Family Physicians

Supported by an educational grant from Pfizer

Table of Contents

Executive Summary

The Intersection: Pain Management and Patient-­‐Centered Medical Home

Process: From Letters of Interest to Project

Implementation

Our Five Grantees

Face-­‐to-­‐Face Meeting | January 23-­‐24, 2014

Webinars, Tools and Resources

Ongoing Communication

Video Stories

Outcomes

Lessons Learned

References

The Intersection: Pain Management and Patient-‐Centered Medical Home

Face-‐to-‐Face Meeting | January 23-‐24, 2014