Opioids for chronic pain: Getting to a safe place

By Natasha Marchand, IT Project Coordinator, Coulee Medical Center I’ve been at Coulee Medical Center (CMC) in Grand Coulee, Washington for about six years in various positions.  Several years ago I went to school for my medical assistant certificate and worked in the clinical setting for three years before stepping into a newly created position: IT Project coordinator.  The position was created to address the challenges the practice was facing with opioid prescribing. Developing documented care plans When I first came on board at CMC as Clinic Coordinator, we created a pain management committee whose first task was a thorough review of our organization’s pain management policy.  Using guidance from the Agency Medical Director’s Group and with the help of the IT Department, I helped create a custom set of pain management forms fine-tuned for our EMR.  Using the data generated by the new forms and other chart information, we created a report to keep track of the patients participating in the program while having the capability to focus on individual providers. We also created a contract for patients to sign, along with a clear contract procedure for providers and staff. This helped in multiple ways:  providing patient education, while establishing the seriousness of participation in our pain program. I also developed another set of policies and procedures that cover chart documentation for the nursing staff and additional reporting for me. Stratifying risk All of our pain management patients complete an initial intake annually, which puts them in a risk category.  We have low, moderate, and high risk categories.  Our low-risk patients are seen every three months:  They submit a urine drug screen at least once a year, and we print out prescription monitoring at least once a year.  Moderate-risk patients have more flexibility:  They can be seen every one to three months for follow-up visits.  We leave the frequency up to the provider because they know their patients (for example, they know a patient is at moderate risk because of a history of depression or other family risk factors).  The moderate-risk patients complete urine drug screens at least twice a year.  High-risk patients are seen monthly by their primary care provider, with a urine drug screen schedule of at least three times per year. Using limited resources wisely My advice for practices that are starting to focus on improving their opioid program would be to identify all patients who are receiving prescriptions for narcotics. Pull all your data and cross-reference it with your goals to identify the areas that need improvement. We were also seeking to identify patients on the highest opioid doses when we first gathered these data.  This was so that we could put the most effort into helping the heaviest users.  We’re in a small community, and we don’t have a lot of resources we can refer patients to for additional help managing their pain.  Shifting to a population approach makes the way forward much clearer. A tool for clinical staff I serve as a tool.  That might sound strange, to think of myself like that, but nursing staff and providers come to me with questions about patients and what to do.  I meet with our nurses and providers monthly to review our pain management patient list and ensure that providers and nursing staff are working according to our organizational policy and state guidelines and regulations.  I help nursing staff by answering their questions or resolving issues with the EMR and making sure correct data gets captured. Having support like this prevents mistakes and makes the program safer for the staff and the patients. My work may be in the background. But my focus is very patient centered, and I firmly believe that the patients are why we’re here. I think a lot of folks in facilities like ours have jobs with multiple responsibilities.  Pain management is often combined with a number of other duties, even though the work is time consuming. It’s an ongoing process to make sure that everything’s done correctly, in accordance with our organizational policies and state guidelines. But all the hard work on this project results in better care for our patients and saves time and energy for the staff in the long run. Seeing results When we were working on redesigning the way our clinic addresses pain management, our focus was to get patients and providers to a safe place.  Once the program got off the ground, we’ve been able to decrease our population of patients on chronic opioid therapy.  That’s really great to watch. Although I’m behind the scenes, the work I do helps patients actually start feeling better.  We’re making a difference in their lives, although they may not see it at first.  Our providers and nursing staff are telling me that they’re hearing from patients that they feel better.  At the end of the day, this is really what matters most. Learn more about how other primary care practices have implemented care plans and risk stratification for opioid prescribing. Natasha Marchand is a medical assistant and IT project coordinator at Coulee Medical Center (CMC).  CMC is a 25-bed Trauma Level IV Critical Access Hospital near the famous Grand Coulee Dam that provides professional medical services to the residents and visitors of the greater Grand Coulee area, the five surrounding counties, and the nearby Confederated Tribes of the Colville Reservation.   

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