Kimberly Sharp BSN,RN-BC Chronic Pain Nurse Navigator Franciscan St. Francis Health

1. Responsible Pain ManagementImplementing Regulations of Indiana’s Medical Licensing Boardand Best Practices for Patient Care Kimberly Sharp BSN,RN-BC Chronic Pain Nurse Navigator Franciscan St. Francis Health

2. Goals and Objectives Review new Indiana laws for opioid prescribing Outline office implementation of best practices and compliance monitoring

3. “First Do No Harm”Indiana’s Safe Prescribing Recommendations

4. Healthcare Provider Toolbox: http://bitterpill.in.gov/ • A comprehensive “Clinical Resource” to assist you in managing your patients with chronic pain • A starting point for you and your staff

5. Toolkit - Format • Not a dissertation; “designed for the busy doc” • Designed to be easy to read • Provides links to resources/tools • Provides templates for various surveys & forms • Links to websites with more in-depth information for you and your patients • Talking points for difficult conversations

6. A number of topics to choose from to assist you in coming into compliance with recommendations and rules

7. Key Stat To engage Overview Has a bit more depth than the recommendations and includes links to forms, additional info, etc Specific Recommendations Just the facts ma’am

8. Includes “Talking Points” • Conversation starters with patients • In the margins are testimonials and other useful info

9. The NEW Medical Licensing Rules The MLB rules take effect on December 15, 2013 and apply to: • Any patient taking >60 opioid pills per month for ≥ 3 months • Any patient taking a morphine equivalent dose (MED) of >15 mg for ≥ 3 months

10. Physician Shall Do…but it takes a Team to achieve

11. Challenges to Adoption of Opiate Guidelines • Lack of Time • Lack of knowledge • Patient expectations • Decreased patient satisfaction • Strained physician-patient relationship • Beliefs that opioids are safe • Physician belief that this change is not necessary

12. Optimize Workflow • Develop policies and protocols • Educate office staff • Scheduling • All persistent pain patient’s on same day • Allow additional time on first visit to complete screening and agreements • Two visit process in the beginning • Signage • Documentation templates

13. Policies • Prescription Policies • Should be consistent among all providers • Refill policy • After hours • Missed appointments • Pill counts • Things to consider • Will you prescribe on first visit? • How to handle “lost scripts” or stolen medications • How to handle “Benzo’s”

14. Policies • Compliance Testing Policy • Urine Drug Screen • Frequency • Beginning January 2015 at least annually • Circumstances in which you will re-monitor • Consequences • Unable to void • “No show” if called in • Presence of alcohol • Presence of illicit drugs

15. Policies • Compliance Testing Policy • Urine Drug Screen • Process • Referring to lab outside of office • In office • Environment • Identified staff • Better data collection up front leads to less question about results

16. Policies • Inspect • How often • At least initial and annually thereafter • Designated staff to run query • Discharge Policy • Must be consistency among all providers

17. Treatment Agreement • Communication to your patient of your policies • Provides information and education to the patient • Can be presented by your staff in detail but • The physician and patient shall review and sign a “Treatment Agreement”

18. Risk Stratification • 2 Areas required • Mental Health Assessment • Risk for substance abuse • Can be completed by staff or patient and reviewed by physician • Examples in the online toolbox

19. Educate Staff • Overview of the regulations • Office policy and protocols • Scripting on how to introduce Treatment Agreements and policies • Emphasize this is all about keeping your patients safe -- not judging or being critical • Conflict management strategies

20. Educate Patients • Letter • Policy • Signage • Framed around safety to them, their family and their community

22. Documentation • Forms • Informed Consent/Controlled Substance Agreement • Behavioral Health Screening tool (s) • Substance Abuse Screening tool(s) • Treatment Plan Templates for Providers

23. Documentation • Electronic Medical Record • Code or identifier for chronic opioid patient • Code or identifier if “no longer prescribing opioids” • Program prompts • No INSPECT/UDS in 6 months • Trigger if no appointment in 3.8months • Template or checklist format that includes all aspects of MLB rules

24. Toolbox Includes resources for implementation: • Screening tools • Templates • FAQs • Drug Information • Primer on Urine Drug Monitoring

26. Changing the Paradigm • Need to begin educating public about the new rules and recommendations for physicians and the impact on healthcare delivery. • Focus is on functionality as well as pain control. • Resetting expectations of the public – they will need to be more actively engaged in their treatment.

27. Summary • Preserve and emphasize patient safety first and foremost. • Policies and protocols provide structure • Education • Staff • Patients • Public • Team approach makes a difference!

28. It takes preparation and a little time