1. Pain Action Consulting Team (PACT): A Mentoring Model for Teaching Responsible Opioid Prescribing Edie Vargo, MD Michael Clark, MD Lauren Whiteman, MPH Maura McGuire, MD Johns Hopkins Community Physicians

2. Chronic Pain in Primary Care 1.Chronic non-cancer pain is a common condition 2.Primary care providers (PCPs) frequently bear the responsibility for managing this pain 3.PCPs may feel inadequately equipped 4.Best practices are often not followed

3. Pressures Experienced by PCPs (Olsen & Daumit, 2004)

4. Pain Action Consulting Team: Meeting the Need An initiative within Johns Hopkins Community Physicians to meet the needs of PCPs –Coordinated with Johns Hopkins Office of Continuing Medical Education and Medscape –Funded by educational grant from Pfizer

5. Project Objectives Identify PCPs’ educational needs related to chronic non-cancer pain and opioid management Increase PCPs’ comfort with existing guidelines as evidenced by adherence to guidelines Increase patient safety by better adherence to opioid prescribing guidelines and documentation

6. Intervention: PACT Timeline Enroll Assess Learn Attend Webinars & Groups: 2/19/14 – 3/25/14 Re- enforce Follow-up Audit of Visits 2/29/14 – 6/30/14 Chart-stimulated Recall of concepts 9/1/14 – 9/30/14 Enroll Enrollment: July 2013 – February 2014 Assess Baseline Chart Audit Visits 2/1/13 – 1/31/14 Attend Webinars & Groups: 2/19/14 – 3/25/14 Follow-up Audit of Visits 2/29/14 – 6/30/14 Chart-stimulated Recall of concepts 9/1/14 – 9/30/14 Learn Reinforce

7. Participants and Baseline Audit Recruiting: 26 PCPs in 8 JHCP practices, 23 completed the entire activity Patient identification: –Selected by PCPs –Aided by EMR report of chronic opioid patients Chart audits of 6-10 patients on opioids for participating PCPs (N=192 patients) –Pain assessments/documented ratings –Presence of Opioid Treatment Agreement in charts –Follow up visit documentation

8. Baseline Chart Audit (Visits 2/2013-2/2014) Avg. Number of Chronic Pain Dx per patient4.6 Opioid Agreement Present40.6% Average # PCP visits3.5 Average % PCP visits documenting severity51.9% Functional activity assessed in last year51.0% Adverse Drug Reaction Screen in last year16.7% Aberrant behaviors assessed in last year8.9% Substance Abuse screen done1.0% Drug monitoring/adherence screening in last year5.2% Urine tox Ordered in last year25.5% * 192 patients, 25 unique PCPs in 8 practices

9. Webinar Topics Webinar 1 –Pain & Risk Assessment Tools Webinar 2 –Pharmacology of Pain Webinar 3 –Monitoring & Risk Mitigation Strategies Webinar 4 –Interdisciplinary Approaches to Management

10. Mentoring Sessions Each Webinar was followed by a 30- minute Mentor-led discussion with 5-6 mentees/group to recap the concepts discussed in Webinar Each Mentee also participated in two 30-minute one-on-one phone discussions with Mentor

11. Systematic Chart Audits: Post-intervention Assessed for changes in documentation after PACT activity Univariate analysis showed significant improvement in documentation of pain score and alleviating factors Multivariate analysis showed mixed results with some providers making few changes while others made significant changes in multiple areas

12. Chart Audits after Intervention Univariate Analysis

13. Chart Audits after Intervention Multivariate Analysis Provider Assess Function al Activity Assess Adverse Events Depression Screening Opioid Agreement Quanitativ e Pain Score Alleviating Factors 2 5.3 (1.3- 20.7) 4.1 (0.9- 18.4) 13.4 (2.9- 62.2) 3 4.7 (1.3- 16.4) 6.6 (1.3- 34.5) 5.1 (0.99- 26.6) 6 14.6 (1.4- 150.4) 11 6.7 (1.6- 28.0) 13 4.5 (1.0- 20.0) 14 13.3 (1.0- 170.8) 15 3.5 (0.9 - 13.7) 8.9 (1.6- 48.0) 13.5 (1.4- 131.1) 16 3.5 (1.0- 11.9) 20.0 (3.3- 120.0) 17 4.7 (1.2- 8.8) 5.6 (1.1- 29.5)

14. Chart-Stimulated Recall (CSR) Interviews Done in September-October 2014 Mentees chose 2-3 charts to review for the CSR interview Reviewed for changes in practice and documentation since the PACT program (e.g. pain scores, opioid treatment agreements, aberrant behavior screens)

15. Chart-Stimulated Recall Selected charts reviewed with mentees by a trained interviewer Increased content validity by bringing in qualitative aspects of interview Helps to understand clinical reasoning Identifies patient and system barriers that may influence medical decisions and practices

16. Chart-Stimulated Recall Asked about specific best practices before and after PACT intervention Centered around the “4 As” of pain management: –Assessment & documentation of Analgesia –Assessment of functional status (ADLs) –Assessment for Adverse Effects –Assessment for Aberrant Behavior

17. Chart-Stimulated Recall: Documentation Improvements

18. Participant Assessment of PACT Activity Overall, PACT was well-rated by participants Webinars were rated as less useful than the mentor meetings and audit review with RN Most indicated that they would make changes in their practices based on the information presented

19. Summary of Findings Audits indicated deviations from best practices A distance-learning curriculum and mentoring relationships were well received by PCPs. There was less than expected improvement in best-practice documentation

20. Summary of Findings, cont’d Few participants employed validated risk assessment tools even after education. Comments suggested a need for enhanced documentation tools and decision support aids in our EMR; these are being developed.

21. Future Directions Use content from webinars to create online module for all JHCP providers –New state requirement for responsible opioid CME Encourage consistent adherence to best practice guidelines Develop tools in the EMR to support this Encourage new local experts in each practice with ongoing mentorship

22. Acknowlegments PACT Collaborators: –Thomas Bogetti, MBA, Mollie Jenckes, RN –Mentors: Michael Clark, MD, Bill McCarburg, MD, Penny Tenzer, MD, Katherine Galluzzi, MD and Zorba Paster, MD. I also gratefully acknowledge Zack Berger, MD, who developed one of the webinars