Summary
St. Claire Medical Group (SCMG) in Morehead, KY, has drastically reduced the number of chronic and acute pain patients who receive opioid prescriptions. The ability to successfully tackle that issue was created by implementing a shared vision developed by the SCMG physician leaders and hospital executives – with HSG assistance and facilitation. Achieving this quality improvement outcome was driven by the magnificent planning, implementation, and execution of the SCMG physicians. In the first year of the program, more than 1000 patients discontinued chronic opioid use, representing more than 30% of identified patients using ongoing prescriptions. Since the program’s inception, its breadth expanded to address utilization of opioids for acute pain in the peri-operative care area.
Challenge
SCMG leadership sought performance improvement initiatives that represented opportunities to improve patient outcomes – especially those linked to population health management concerns. Located in eastern Kentucky, SCMG’s population is situated in the heart of one of the largest regions of opioid addiction and overdose – and had scarce resources available to address the issue.
Taking on a project such as this as recently as two years before its inception would have been inconceivable as SCMG was relatively disjointed and lacked an organized physician leadership construct and a cohesive organizational structure and culture. As executives considered how to evolve the group into a multi-specialty practice that could ultimately manage population health, they explored options to create change and develop the momentum needed for the employed physician network investment to produce value.
Our Approach
Working with SCMG physicians and health system executives, a 3½ page shared vision document was developed, which defined their ideal future state (ten years in the future). While the development was more complex, the concept centered on how the group must evolve to meet the needs of the patients, the providers, the hospital, and the health system while becoming a group with which the physicians would be proud to be associated.
The resulting shared vision consisted of ten primary elements, which became a “constitution” for the group and a roadmap for the group’s evolution. Three of the vision elements particularly relate to this case study. The first element addressed the need to formally designate SCMG physician leaders, imbed these leaders in a revised organizational structure, and support these leaders with a formal physician advisory council to ensure the insights of the physicians could be harnessed.
The second element addressed pursuit and adoption of clinical best practices – particularly those impacting population health – and systematically incorporating those into daily patient management activities. The third element addressed provider well-being, acknowledging that building a great group was not possible if the providers did not feel respected, engaged and happy with the group.
Program Inception
Armed with the Shared Vision outcomes, the newly empowered physician leadership structure decided to tackle a long-term issue affecting both SCMG providers and the community – opioid use. In 2015, a CDC report indicated that Rowan County was among the counties with the most doses of opioid medications per person. Physicians in both the Emergency Department and the primary care practices were eager to take on the issue and developed a broad reaching opioid prescribing/utilization policy that was approved and implemented in mid 2016.
Addressing Chronic Opioid Use
Primary Care
When a newly recruited primary care physician leader joined SCMG, she faced several issues early in her tenure, including:
- A desire to identify and implement a performance improvement initiative based on the adoption of a clinical best practice that would produce favorable patient outcomes;
- A regional and health system concern that opioid utilization was too high;
- An initial review that revealed a wide variation in SCMG physician opioid prescribing without apparent justification for that variation; and
- An awareness that dealing with “drug seekers” on a daily basis was taking a toll on SCMG providers, who also perceived that they had no resources to help them effectively deal with the situation.
To address this challenge, the group utilized the following four-pronged system-based approach to promote success:
- Document and evaluate the variation among SCMG physician opioid prescribing and get the physicians to agree that the variation was not justifiable.
- Define a standardized, best process for helping patients with chronic opioid utilization that included development of opioid prescribing guidelines consistent with best practices, access to medical pain management expertise, creation of a controlled medication assessment clinic staffed by physicians trained in palliative care medicine, and the adoption of a standard opioid weaning protocol.
- Develop the resources required to implement the process.
- Achieve consensus agreement that all patients with recurring opioid prescriptions would be screened, and if advisable, enter the weaning protocol.
Project leaders who reviewed the data identified approximately 3200 patients with ongoing opioid prescriptions eligible to be included in the project. They theorized that at least half of these patients could be weaned from their opioid usage. Their impressions were borne out when
just over 1000 patients successfully discontinued their use of chronic opioids in the first year of the program. Patient and physician acceptance of the approach and resulting outcomes were very high. The primary care providers were gratified by the perceived improvement in patient care and were pleased that they and their patients became well-supported by appropriate resources to combat this significant public health issue.
The project continued to address and work with the remainder of the original 3200 chronic opioid use patients, monitor adherence to the established prescribing guidelines, and recruit newly identified patient participants into the program. Defining success beyond the first year in data-driven terms became difficult when the group transitioned to a new EHR – a data collection and reporting situation commonly encountered by many organizations.
Emergency Department
The Emergency Department had experienced its own issues with chronic opioid use – primarily patients on chronic opioid prescriptions presenting acutely for refills without a change in symptomatology. Concerns related to fragmented patient care and opioid overuse or abuse abounded, but the department lacked a uniform, standardized approach to the issue. The situation had devolved to the point of patients actively asking which physician was on duty, then deciding whether to stay for care depending on the response (which reputationally determined the likelihood of obtaining a new prescription).
The newly approved system policy stipulated that the Emergency Department would encourage continuity of care with the prescribing provider and would not refill prescriptions for opioid medications – unless a change in circumstances warranted it. The policy was unequivocally endorsed by the physicians and uniformly implemented – with excellent outcomes.
Addressing Acute Opioid Use
Emergency Department
The initial foray into opioid prescribing for acute pain was also taken on by the Emergency Department physicians during the inaugural implementation of the opioid stewardship policy. Emergency Department physicians actively sought alternatives for acute pain management and reserved opioid use to limited circumstances in which its utilization was felt to be warranted. This effort was enhanced by studies indicating that an NSAID and acetaminophen provided pain relief as effectively as opioids.
In the rare instances in which opioids were determined to be necessary, a very limited supply would be prescribed – usually only 2 to 3 days duration or enough to bridge until an arranged follow up appointment. The philosophical change was warmly embraced by all Emergency Department staff.
Perioperative Services
The opioid stewardship program recently expanded its reach to address opioid use for acute pain management in the perioperative period.
Bariatric surgery was the first surgical area to work on decreasing opioid use in acute perioperative pain management – initiating efforts in 2018. The outcomes that bariatric surgery experienced with patient and surgeon acceptance led the general surgeons to follow suit in early 2019. Buoyed by progressive amounts of literature support for effectively managing perioperative pain with non-opioid alternatives, the program’s expansion attained acceptance and success comparable to its predecessors. In fact, the surgeon’s have commented that they were amazed at the level of patient acceptance and shocked that it was so easy to send patients home on less opioids.
SCMG is now exploring options for future interventions while actively maintaining the gains achieved to date. The CMO, Dr. Will Melahn, indicates that the program would not have been conceivable, let alone achieve a modicum of success, had SCMG not developed a shared vision for the group that catalyzed changes in physician leadership and group culture.
To learn more about how a Shared Vision can help your network meet clinical quality objectives, contact Terry McWilliams.
SCMG Opioid Case Study.pdf