Sunrise Community Health: Comprehensive opioid oversight and buprenorphine treatment program

Friday, September 01, 2017 12:01 PM

Sunrise Community Health is a federally qualified health center serving more than 38,000 individuals in Weld and Larimer Counties through robust partnerships with many local agencies, including North Range Behavioral Health and SummitStone Health Partners. Sunrise was an early responder to the nationwide epidemic of prescription drug abuse, especially with regard to opioids. Our medical team noted that there were some patients who were misusing their opioid prescriptions and that our providers needed support to prescribe opioids safely. In direct response to aberrancies in patient behavior and widely varying provider prescribing behaviors, Sunrise established the Opiate Oversight Committee (OOC) in 2008. The purpose was to establish and maintain best practices for opioid prescribing among providers, provide comprehensive review of patients receiving ongoing opioid prescribing, and provide recommendations to providers to improve safe prescribing. Sunrise supported this effort by freeing three physicians to participate in the OOC, hiring an OOC case manager and developing the relevant reporting. Sunrise also incorporated the embedded behavioral health team members supplied by our NRBH and STS partners.

The committee of physicians, case management, behavioral health and pharmacy personnel meets weekly to review all patients receiving ongoing prescriptions for opioid pain medications and those who are identified with high-risk behaviors. As part of the review process, a written document is generated with the assessment and recommendations for the provider. The committee deliberately chose to provide recommendations to providers rather than to establish separate work flows to engage directly with patients. Sunrise felt strongly that it was best to educate providers as a result of the review process and leave the patient-provider relationship intact, thus honoring our philosophy that chronic pain is part of the primary care relationship and should be managed within that structure unless specialty care is required.

A few years after establishing the review process, Sunrise recognized that while provider communication and education had improved, there were some patients who were not receptive to these efforts and continued to exhibit unsafe behaviors. Consequently, frequent outbursts were taking place in the pharmacy and during office visits with patients who did not understand changes in their medication regimen or were confused by new policies. Clearly, Sunrise was not effectively communicating these changes. As a result, the OOC evolved to include twice-weekly group visits for patients who needed a higher level of care. New patients who had been terminated by their previous provider for aberrancies in managing their opioid medications were coming to the Sunrise community, and it was imperative that a therapeutic relationship be maintained even in the face of potentially aberrant behaviors. Firing patients is always a last resort.

The group visit is designed as a higher level of care for patients who exhibited unsafe behaviors with these controlled substances. The visit, which involves a Sunrise OOC provider and a behavioral health consultant, allows clinicians to respond to high-risk behaviors and enhances the practice’s ability to monitor these patients more closely. Hour-long group visits involve regular, mandatory urine drug screens, shared teaching around concepts such as safe medication storage, skills for coping with chronic pain, the role of psychiatric and other chronic medical conditions in chronic pain, and alternatives to opioid medications for pain. Patients are asked to attend weekly group visits for four consecutive weeks.

If the unsafe behavior can be corrected after engagement in group visits, the patient is returned to routine monthly follow-up with their PCP. If the unsafe behavior continues despite this higher level of care, the patient is told that controlled substance prescribing must be discontinued, but that Sunrise can continue to be their medical home and is willing to continue to treat their chronic pain condition(s) with non-opioid medications. Any specialty services from this point forward are made with a specific request for intervention rather than management of additional opioids. Patients can be re-evaluated for reinitiation of opioid medications.

Through this enhanced mechanism for safety, Sunrise has also established training for safe opioid prescribing for all new providers during provider orientation.

Providers have appreciated OOC involvement in patient care and the enhanced education that has been delivered through systematic review of patients. Patients have also expressed increased satisfaction with the management of their opioid prescriptions and the teaching around safety and skills-building delivered through the group visits.

Sunrise began prescribing buprenorphine for opioid use disorder around the same time the OOC was established. The same collaborative programming with North Range and SummitStone is used to initiate and manage patients with opioid addiction, a truly unique practice model. With differing payment structures, practice models, documentation systems and billing practices, there are myriad reasons that partnering between community health centers and community mental health centers should not work.

Strong leadership and creative programming have diminished the impact that these challenges might otherwise have, and the shared programming brings primary care and behavioral/mental health together in service to the most vulnerable populations, enabling this critical service to be offered in a more comprehensive manner than either could individually.