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The Other Side of the Opioid Epidemic

The number of opioid prescriptions per person in the U.S. peaked in 2010. And it has dropped every year since through 2015. This sounds encouraging, but according to the Centers for Disease Control and Prevention (CDC), the level in 2015 was still three times higher than in 1999. And while the U.S. makes up 5% of the world’s population, we consume 80% of the opioid pain relievers manufactured.

So, prescribers are becoming more and more reluctant to write prescriptions for the drugs for fear of investigation, or worse, prosecution and prison. This after increasing attention on the opioid epidemic that has led to policies aimed at curbing prescriptions and dosages, as well as insurers limiting the number of pills they’ll authorize.

In March 2016, the CDC issued stricter guidelines for doctors who prescribe opioids. The guidelines urge doctors to use caution when prescribing opioids at any dosage, especially when increasing dosages, including justifying dosages greater than 90MME per day.

Is this a case of throwing the baby out with the bathwater?

What About Chronic Pain Sufferers?

What about the patients for whom pain is genuine, and often chronic (estimated to be between 25-100 million people in the U.S.)? What about those whose need for pain relief is real? Chronic pain is the primary reason people go on disability. And in addition to overall quality of life, chronic pain negatively effects work, family, and social networks. According to an article posted on the Psychology Today website (11/24/2015), the suicide rate among people with chronic pain is known to be roughly twice that for people without chronic pain.

Is there an epidemic of chronic pain that’s getting little attention in the face of the opioid epidemic?

Chronic pain sufferers are often dependent on opioids to function and live normal day-to-day lives. But being dependent (in order to function) is not the same as being addicted.

Patients who have legitimate needs for opioids are finding it increasingly difficult to get access to their prescriptions; they experience everything from having to drive long distances to find providers willing to prescribe, to having to sign contracts, to being urine tested, to being tapered to lower doses than they need.

What’s the Answer?

These patients, and their doctors, say that the answer to the opioid epidemic is not taking away the medication of every patient out there. It’s addiction treatment. They say there are those who legitimately need pain medication as well as the many options for chronic pain management available to providers. Appropriate use of the correct intervention at the right time must be part of the conversation.

In Idaho, where a “Don’t Punish Pain” rally was held in Boise in March 2018, attendees wanted to have chronic pain sufferers added to a list of cancer and hospice patients. This would enable them to get their pain prescriptions without limitations. Protesters hope that future legislation reflects their needs.

But providers in Idaho write higher than the national average number of opioid prescriptions. According to the National Institute on Drug Abuse, in 2015, Idaho providers wrote 76.4 opioid prescriptions per 100 people. That’s approximately 1.3 million prescriptions. In the same year, the average U.S. rate was 70 opioid prescriptions per 100 people. And in some Idaho counties the rate is even higher.

In an April 2018 interview with CNN, the head of the U.S. Food and Drug Administration, Dr. Scott Gottlieb, suggested mandatory training on pain management and opioid prescribing for the nation’s physicians. He said that current standards are based on outdated training, which is not mandatory and that we need to “re-educate a generation of physicians.”

Idaho is already making efforts in that arena with prescriber education via University of Idaho’s ECHO Program. ECHO uses a team of specialists in a learning and guided practice model – communicating through video conferencing technology to connect with providers throughout the state to conduct virtual clinics. Its first clinic (bi-monthly March through September 2018) is focusing on opioid addiction and treatment. http://www.uidaho.edu/academics/wwami/echo

Chronic pain sufferers and the providers who treat them hope that the pendulum that has swung so far in one direction will come back toward center. They hope that with more research and increasing calls for mandatory education, not only in opioid prescribing but in pain management, the right balance of treating people who suffer from chronic pain will be achieved.

Idaho’s Rural Doctor Shortage

SHOSHONE – “Keith Davis became Lincoln County’s only doctor at the stroke of midnight.

It was a late summer night in 1985, and Davis had recently completed his residency, the last month of it spent working at Shoshone Family Medical Center. The center’s lone doctor, Royal “R.G.” Neher, M.D., was retiring, and he needed a replacement.

Davis had interviewed at clinics in slightly larger cities in Idaho and Washington. But neither city offered the same opportunity for long-term employment that Shoshone did. So when the clock chimed midnight on Aug. 1, Neher stepped down and Davis took his place.

On his first day, Dr. Davis saw 52 patients and delivered a baby with nurse practitioner Janet Sandy. Almost 33 years later, he and Sandy are still seeing patients together at their office on Apple Street. And almost 33 years later, Davis is still the only doctor in a county the size of Rhode Island.

With just one practicing physician, Lincoln County is one of seven counties in south-central Idaho that’s a federally designated Health Professional Shortage Area (HPSA) for primary care physicians. And it’s not just the Magic Valley – a recent report by the Association of American Medical Colleges placed Idaho 49th in the nation for the number of physicians per capita.

Camas, Cassia, Gooding, Jerome, Lincoln, Minidoka, and Twin Falls Counties are all HPSA-designated in primary care. Blaine County isn’t, but one of its towns, Carey, is. Low-income residents in Jerome and Gooding Counties are particularly underserved, according to data from the U.S. Department of Health and Human Services.

There aren’t necessarily fewer doctors today than in the past. Davis has been the only practicing doctor in Lincoln County for more than 30 years, and Neher ran a one-man operation there for decades before him. But as the average age of the rural Idaho physician increases – and many begin considering retirement – a new question has emerged: who will replace them, and how?”

READ THE ENTIRE ARTICLE …

 


 

“The Brave New World of Patient-Centered Care”

– Dr. Susan Frampton’s Address to the Idaho Healthcare Summit

Dr. Susan Frampton opened her keynote address at this year’s Idaho Healthcare Summit with a tale of her bout with Lyme disease and how she was able to leverage technology on a Friday night to work with her primary care practitioner. She’d had the disease before, knew its symptoms, and wanted to start the prescription she knew she needed that weekend. Using the technology on her smartphone and a call with her physician’s nurse, she ultimately got the prescription called in within 12 hours of initiating the first contact. It was a story of patient-centered care.

This set the stage for the rest of her talk about keeping the patient at the center of care as the healthcare landscape changes. Her keynote address, “Brave New World of Patient-Centered Care: Trends in Policy, Practice, and Payment,” framed areas of opportunity in patient-centered care – where it’s going and what patients are asking to be delivered. She spoke at the fourth annual Idaho Healthcare Summit in Boise on May 17, 2018.

Healthcare Consumerism

 Dr. Frampton’s discussion focused on the rise in “consumerism” in healthcare: regulatory trends like direct access lab testing and direct to consumer advertising and genetic testing; patients turning to consumer-based rating services like Yelp to find doctors and hospitals; and Uber partnering with physician offices to transport patients. She said that virtual health (telemed services, texting, email) is becoming the 20th century house call and that payers are beginning to cover these services. She emphasized that meeting patients where they are is essential for the healthcare system to remain effective.

All these consumerism trends point to patients becoming more engaged in their own healthcare and seeking care at lower costs; which lead to better quality outcomes. A 2017 National Academy of Medicine publication on evidence connected better quality outcomes to engaged patients/consumers; she said it hasn’t yet led to lower costs but she sees that on the horizon.

But with the landscape changing so dramatically – financially and technologically – with programs like Doctor on Demand, do-it-yourself disease management phone apps, artificial intelligence, and personal wearable technology, she said, it’s important to keep healthcare where it needs to be – centered on the patient. It must be accountable to engaged patients, families, and consumers.

Policy Changes

And the landscape is also changing with respect to policy. In 2017, the National Academy of Medicine revised its definition of patient-centered care to read:

“care designed with patient involvement, to ensure timely, convenient, well-coordinated engagement of a person’s health and healthcare needs, preferences, and values: it includes explicit and partnered determination of patient goals and care options; and it requires ongoing assessment of the care match with patient goals…”

In addition, the CMS payment reform initiative on Alternative Payment Models (APM) now includes patient engagement criteria; shared decision-making is a ‘must pass’ criteria for PCMH certification; congress has taken steps to aid family caregivers; a public-private partnership funded by HHS to the tune of $1billion, Partnership for Patients (PfP), is working to improve the quality, safety, and affordability of health care for all Americans; and CMS is awarding funding to continue Hospital Improvement Innovation Networks (HIINs).

Idaho is participating in PfP with 29 hospitals (61%-80% of hospitals) enrolled for the state. The PfP vision for hospitals and other health care providers is to achieve quality and safety goals by:

  • fully engaging patients and their families,
  • determining what matters most to them in every situation,
  • and partnering with them to make improvements to all aspects of care.

Despite these trends, Dr. Frampton asked whether consumer-centric approaches to health care are a capability in the U.S. healthcare system? Her answer was no, not yet. In a recent study, 66% said consumerism is a priority but not a capability (16%). She said resistance to change, lack of urgency, competing priorities, and lack of clear evidence seem to be barriers to action.

Still, consumers want it quick and easy – this is what is means to be an engaged patient – and, she said, you lose business when you don’t deliver. So, the Centers for Medicare and Medicaid Services (CMS) has listed as its strategic goals:

  1. Empowering patients and doctors to make decisions about their health care.
  2. Ushering in a new era of state flexibility and local leadership.
  3. Supporting innovative approaches to improve quality, accessibility, and affordability.
  4. Improving the CMS customer experience.

All of which lead to what Dr. Frampton spoke directly to as the theme of this year’s summit, “Healthcare Solutions the Idaho Way.” Her address focused on policies and practices that align with Idaho’s efforts to transform healthcare and initiatives taking place around the state to keep the patient at the center of care. Her closing urged the audience to ‘Think Globally, and Act Locally,” and suggested:

  • Using technology more effectively to engage patients, families, and consumers.
  • Tying healthcare service quality improvements to consumer preferences and related emerging ‘personalized’ technologies.
  • Striving to meet and exceed patient and consumer expectations around cost, convenience, access, and quality.
  • Supporting patients and their families to play larger roles as members and captains of their own healthcare teams.

…it’s all about continuing the story of patient-centered care in Idaho.

________

Dr. Frampton is the president of Planetree International, a non-profit advocacy organization that works with a growing network of healthcare provider organizations across the continuum to implement comprehensive person-centered models of care. Dr. Frampton, a medical anthropologist, has authored numerous publications, including the three editions of Putting Patients First (Jossey-Bass 2004, 2008, 2013) and served as lead author on the National Academy of Medicine’s Harnessing Evidence and Experience to Change Culture, released in early 2017. In addition to speaking internationally on culture change, quality, safety, and the patient experience, she was honored in 2009, when she was named one of “20 People Who Make Healthcare Better,” by Health Leaders Magazine.

ECHO Idaho Launches its First TeleECHO Clinic

ECHO* Idaho opened its virtual doors in March 2018. Through a collaboration between the University of Idaho and WWAMI** Medical Education Program, ECHO Idaho has launched its first learning and guided practice groups. ECHO sessions are led by expert teams that use video conferencing to conduct education and mentoring sessions with remote community providers. In this way, primary care doctors, nurses, and other clinicians acquire the knowledge to provide specialty care to patients right in their own communities. Sessions consist of a brief lecture and a review and discussion of patient cases submitted by clinic participants.

With support from the Idaho Department of Health and Welfare’s Statewide Healthcare Innovation Plan (SHIP), ECHO Idaho’s first virtual teleECHO clinic is focusing on Opioid Addiction and Treatment. The clinic’s goal is to create a network of Idaho providers equipped to enhance patient care, treatment, and management of opioid abuse. During sessions, everyone teaches and everyone learns as community providers learn from specialists and from each other, and specialists learn from providers as best practices emerge. Participants report they, “Love hearing the clinical experience,” and there have been “excellent discussions with lots of ideas about treatment.”

A panel of six specialists (MD Pain Specialist, PharmD, MD Addiction Specialist, MD Physiatrist, LCSW, and NP) use video conferencing to connect with providers from around the state. After just four ECHO sessions, 56 people have participated from 16 communities representing every public health district in the state. Examples of lecture topics include CDC Guidelines, Evaluating the Patient with Chronic Pain, Evidence-Based Screening for Opioid Use Disorder, and Non-Opiate Therapy for Pain.

ECHO Idaho Opioid Addiction and Treatment Clinic sessions are held every other Thursday from 12:15-1:15 p.m. MT. Enrollment is free, open to all healthcare providers, and continuing medical education credits are available to participants at no cost. Even though the clinic has already begun, you can join at any time during the clinic period. To learn more and enroll in the clinic visit: www.uidaho.edu/echo, email: echoidaho@uidaho.edu, or call 208-364-4698.

ECHO Idaho is led by the University of Idaho and WWAMI and is supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.

 

*Extension for Community Healthcare Outcomes

**(Washington, Wyoming, Alaska, Montana, Idaho)

 

To read more posts about virtual PCMH, click here.

To learn more about ECHO Idaho, click here.

Community Health EMS: Cutting Costs at the County Jail

[Guest post by Travis Spencer: Travis is a Paramedic/Community Paramedic with Payette County Paramedics in Payette, Idaho.]  

Three o’clock Saturday morning. Alarms suddenly blare through the station. The dispatcher orders Medic 20 and Fire Rescue to respond to a medical call at the county jail. First responders rush out the door and into the ambulance, responding with lights and sirens screaming. They arrive on scene to find a male subject sitting in the holding cell, alert and oriented, no obvious life threats noted. They obtain a history, and the patient explains that he’s had tooth pain for three days. Tonight, he feels he needs an ambulance to take him to the emergency room for immediate care. EMS secures the patient to the gurney, handcuffs him to the gurney, and loads him into the ambulance. He’s accompanied by a jailer and taken to the local ER for evaluation.

All over the county (and in counties like it all over the state), EMS agencies experience similar incidents.

Current legislation dealing with EMS mandates that all patients get transported to an emergency room when it’s requested. Many times, patients do not require the medical attention of an emergency department and could be better handled in an urgent care or primary care clinic. So why are EMS’s required to use one of the most expensive patient transport vehicles and the most expensive treatment centers to treat minor illnesses or injuries?

When doing a needs assessment within Payette County, we identified that the county jail is one of the highest utilizers of EMS responses. Many of the prisoner requests involve non-life-threatening emergencies that could be handled differently than the prisoner going to the emergency room. The average cost of medical treatment for the local jail in Payette County is around $250,000 a year. This doesn’t include the cost of ambulance personnel, fire personnel, and the additional jailer required to transport the patient.

Payette County Paramedics have been proactively developing a community health EMS system that would address this problem. The program is based on the idea of the Triple Aim: to reduce healthcare costs, provide a good patient experience, and improve population health. We identified the jail as a huge area for improvement and have placed the problem within our five-year plan for the community health EMS program.

The plan involves obtaining funding for a community EMS provider to be available daily; changing the response plan to just one responder for non-emergency illnesses/injuries; and being able to direct patients to other treatment centers by either utilizing telehealth medicine with a physician or changing protocols and increasing training of community EMS providers to be allowed to treat and release.

Community health EMS can be an essential program to counties all over the state to help reduce overall healthcare spending. Rural areas can benefit greatly from the programs and can focus on similar issues such as the jail as an example of a cost-saving measure. Payette County hopes to be able to implement such a program to keep unnecessary utilization of the emergency room down and eliminate costs of ambulance and fire personnel. And it will keep patrons of the jail, in the jail, where they can serve their time.

To read more articles about virtual PCMH click here.

EHR Interoperability and Patient-Centered Care

Interoperability is defined by Merriam-Webster as “the ability of a system to work with or use the parts of another system.” It was unheard of in the healthcare field just a few years ago. Today it’s a touchstone in the field, functioning to modernize systems and help foster patient-centered care across the U.S.

In a recent article published by the Center for Healthcare Research & Transformation (CHRT) at the University of Michigan, the authors reported the results of a survey of primary care physicians in Michigan around the value of Electronic Health Record (EHR) interoperability to patient-centered care.

Background

With the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, Electronic Health Records (EHRs) – software systems that create a digital version of a patient’s medical record – came into widespread use among healthcare providers.

An unforeseen difficulty with the use of EHRs was the ability to exchange information among different proprietary EHRs. This exchange of information is known as interoperability. It’s important because it allows patients and providers increased access to their medical records, faster communication, and better quality of care. However, the issue was not considered when the legislation went into effect.

Now, eight years later, according to the authors, EHRs are used by more than 80 percent of providers and physicians who increasingly report that interoperability is important. Data from the CHRT Michigan Physician Survey show primary care physicians (PCPs) consider interoperability an important feature for providing patient-centered care.

Findings

The study showed that over a two-year period – from 2014 to 2016 – there was a significant change in PCPs’ perceptions of the value of EHR interoperability and the role it plays in patient care. The survey asked PCPs how important having an EHR with interoperability was to their ability to deliver patient-centered care.

“Significantly greater proportions of PCPs in 2016 said it was ‘very important’ to have EHRs that are interoperable between hospitals and practices, and practice to practice. There was no significant change in the proportion of physicians who saw just having an EHR in their own practice as ‘very important.’”

“While younger doctors are more likely to say EHRs are important, increasing numbers of doctors of all ages are embracing them. Regardless of how long they have been in practice, there was a substantial change in PCP views on the importance of interoperability from 2014 to 2016.”

Implications

Primary care physicians in Michigan have reported an increase in the value of interoperability over time. The study mirrors what is being seen in Idaho’s SHIP initiative. Almost all SHIP clinics in the state use an EHR. But as in Michigan, incompatibility among EHRs in Idaho is an issue. So too, is the problem of how healthcare data is described and recorded. There are nationwide initiatives underway, and in states like Idaho and Michigan, to improve interoperability. The long-term goal is a reliable tool that leads to coordinated care and delivery of quality, patient-centered healthcare.

To read the entire article, visit http://www.chrt.org/publication/ehr-interoperability-and-patient-centered-care/

A Report on Rural Family Physicians in PCMHs and Their Scopes of Practice

The post below is a summary of a study done by the Rural & Underserved Health Research Center at the University of Kentucky. The purpose of the study was to determine whether rural family physicians who work in PCMH practices have broader scopes of practice than those not in PCMH practices. The study used data from 18,846 family physicians nationally.

Summary:

In general, there are fewer health care services provided in rural America than in urban America. But due to a lack of subspecialty care in rural areas, rural providers frequently deliver a broader range of services than their urban colleagues. The Patient-Centered Medical Home (PCMH) model of care provides a whole person-centered approach that delivers care coordination, improved accessibility, and higher quality care. Rural practices have shown a similar readiness to transform to the PCMH model compared to urban practices, but they frequently lack the financial and human resources to do so.

The purpose of the study was to determine whether rural family physicians already working in PCMH practices have a broader scope of practice than those not working in PCMH practices.

Scope of practice was defined as a family physician providing each of 21 clinical services, e.g., home visits, inpatient care, obstetrics, etc.; and scope of procedural services was defined as providing each of 18 procedural services, e.g., prenatal ultrasound, endoscopy, office skin procedures.

Rural practices were defined as follows:

Large rural           20,000-250,000

Small rural           2,500-19,999

Frontier                Less than 2,500

Overview

Using data from 18,846 family physicians nationally and an analytical sample of 3,121 rural family physicians, the study found that rural family physicians not only frequently have a broader scope of practice* than urban family physicians, it also found that rural family physicians working in PCMH practices “generally provide a wider scope of clinical and procedural services than those not working in PCMH practices.”

*defined as the range of clinical and procedural services they provide.

Within large and small rural areas, practicing in a PCMH was associated with delivering a wider scope of clinical services than non-PCMH practices. The study cited an example of 93.6% of physicians in PCMH practices and 86.7% of physicians in non-PCMH practices in large rural areas providing pediatric care (a statistically significant difference). In frontier areas, there were no significant differences in services provided except for chronic disease management and preventive services.

Differences in the percentages of physicians providing each clinical service between those practicing in PCMH and non-PCMH practices showed that the “largest differences were generally in large and small rural areas.” Services associated with preventive care (chronic disease management, preventive care), women’s health, newborn care, and coordination of care with surgeons (pre- and post-op care) were more commonly provided by family physicians in all rural PCMH practices than those in rural non-PCMH practices.

Policy and Healthcare Delivery Implications

The findings of the study suggest that the PCMH model is, for the most part, meeting the goals of providing more accessible, comprehensive, and coordinated health care in rural practices. It found that the model is associated with rural practitioners providing a higher number of clinical services and procedures than non-PCMH practices.

As the PCMH model seems to be “associated with an increased scope of health care services available to rural patients,” its policy implications suggest that:

  • Programs that support rural practice transformation to the PCMH model “may need to be investigated.”
  • “Financial payments that encourage family physicians to provide a broader scope of practice within a PCMH may be beneficial.”

This study reinforces the practice transformation being undertaken by the SHIP initiative. With many areas of Idaho being rural and frontier with serious provider shortages, the patient centered medical home model can increase the access patients have through their medical homes. The addition of virtualizing care through the use of Community Health Workers, Community Health EMS teams, and the use of Telehealth are additional aspects of the SHIP currently being evaluated by the Boise State University State Evaluation Team.

 

For more information or to read the entire article, please visit https://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1005&context=ruhrc_reports

To read more articles about PCMH transformation, click here.

Thinking Globally, Executing Locally: St. Luke’s Plans the Patient-Centered ‘Medical Neighborhood’

Chereen Langrill is the Communications Coordinator at St. Luke’s Regional Medical Center in Boise, Idaho. This article was posted on the St. Luke’s blog March 6th, 2018.

A team-based care approach introduced in McCall and some other rural St. Luke’s locations is serving as a springboard to launch similar efforts at other St. Luke’s clinics.

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Community Health Worker In-Person Training Spring 2018

Community Health Worker In-Person Training Spring 2018

April 6, 13, 20, 27

8:00 am – 5:00 pm
Idaho State University – Meridian Campus

Idaho State University, in collaboration with the Idaho Statewide Healthcare Innovation Plan (SHIP) project, is offering an in-person training for Treasure Valley Idaho residents interested in becoming community health workers. This opportunity is also open to students who are currently enrolled in a college or university. The community health worker serves as a bridge between the community and health care, governmental, and social service systems. This training will occur over four consecutive Fridays from 8:00 am – 5:00 pm at ISU – Meridian.

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Children’s Dental Health Month

February is National Children’s Dental Health Month, so it’s a good time to remind everyone – adults and children alike – that your oral health is important to your overall health. Practicing good oral health habits such as daily brushing and flossing and regular dental visits are easy steps toward keeping teeth and gums healthy at every age.

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