Cracking the Code: How Clinics Can Improve Opioid Management
"A Resident Clinic's Journey to Better Quality of Care and Resource Efficiency."
Chronic pain management and responsible opioid prescribing are critical issues in primary care, particularly within teaching environments. Resident clinics often face unique hurdles due to trainee schedules, varying levels of experience, and the need for consistent education on best practices. Ensuring patient safety and quality care in these settings requires innovative solutions.
The opioid epidemic continues to be a major public health concern, with significant economic and social costs. Guidelines from organizations like the CDC emphasize the importance of careful opioid prescribing practices, including risk assessment, toxicology screening, and patient agreements. Primary care providers play a vital role in managing chronic pain and preventing opioid misuse, making it essential to equip them with the necessary tools and support.
This article explores how one internal medicine residency clinic addressed these challenges through a quality improvement project. By implementing strategies focused on standardization, team-based care, and the utilization of mid-level providers, the clinic aimed to improve adherence to quality metrics, optimize resource utilization, and ultimately enhance the care provided to patients on chronic opioid therapy.
Standardizing Care: The Power of EHR Templates and Workflow Redesign
The first phase of the clinic's quality improvement initiative focused on standardizing documentation and streamlining the opioid prescription renewal process. They introduced electronic health record (EHR) templates designed to capture essential information related to chronic pain management, including pain assessment, treatment history, functional status, opioid risk tool results, toxicology screening, opioid agreements, and treatment goals.
- Increased annual toxicology screening from 53% to 81% (P<0.0015).
- Increased the use of opioid risk assessment tools from 0% to 75.9% (P<0.0001).
- Increased annual opioid agreements from 13.8% to 53.5% (P<0.0001).
- Decreased average daily morphine milligram equivalents (MME) from 96.6 mg to 67.6 mg (P = 0.0008).
- Decreased the average number of annual office visits from 11.1 to 8.9 (P=0.0004).
Sustaining Improvements: The Role of Previsit Planning and Huddles
In the second phase of the project, the clinic implemented previsit planning and daily huddles to further enhance quality of care. Before each patient visit, the RN reviewed patient charts to identify any missing quality measures or outstanding issues. During daily huddles, the RN provided verbal reminders to resident physicians to address these issues, review pain-related specialty follow-up, and make any necessary prescription adjustments.
While this intervention did not result in significant incremental increases in adherence to quality measures (likely because adherence was already high after the first phase), it did contribute to improved clinic visit utilization and served as a valuable tool for reinforcing policies and sustaining the gains achieved in the first phase. The huddles provided a platform for continuous education and ensured that residents remained focused on providing high-quality care.
This study highlights the importance of a multi-faceted approach to improving opioid management in resident clinics. By combining EHR templates, workflow redesign, and team-based care, clinics can create a sustainable system of care that promotes patient safety, optimizes resource utilization, and provides valuable training opportunities for future physicians. The role of the RN as a point of contact for patients and a moderator for quality control is particularly crucial in these settings.