Primary Health Care

Opioid Response Initiative

PCN Strategic Leads Forum February 24, 2018

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Overview ● Opioid Crisis in Alberta

● The Primary Health Care Opioid Response Initiative

● Tools and Resources to Support Capacity Building

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The Opioid Crisis in Alberta Overview of the Issue and Alberta’s Response

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Number of apparent accidental fentanyl toxicity deaths, by Zone (based on place of death) and quarter. Jan. 1, 2016 to Sept. 30, 2017

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Opioid Deaths

Of those that died of an opioid–related poisoning since 2016, within the year before their overdose: • 46% were known to have a mental health issue (including anxiety,

depression, etc.) • 16% were diagnosed with an opioid use disorder (opioid addiction) • 76% of deaths were illicit opioid poisoning from fentanyl or a non-

fentanyl opioid not dispensed from pharmacy

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Opioid Deaths

• 14% in Fort McMurray, Grande Prairie, Lethbridge, Medicine Hat, Red Deer

• 21% occurred outside an urban centre

• 70% of all opioid-related deaths within Edmonton and Calgary occurred outside of centralized urban core of the cities, whereas the highest rates of opioid-related deaths occurred within the centralized urban core of those cities.

Scope of problem is much bigger

https://www.cdc.gov/drugoverdose/pdf/PolicyImpact-PrescriptionPainkillerOD-a.pdf

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Minister’s Opioid Emergency Response Commission

Inception: May 31, 2017

Mandate: to develop recommendations for, and facilitate implementation of, urgent coordinated actions to effectively address the crisis.

As of November 2017, the Commission has made 12 publicly posted recommendations.

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What is the Issue?

This is an issue in Primary Care – opioid use affects people in all walks of life

Primary Care requires additional resources to support them in treating patients in what has been historically been considered a specialty service

We need Primary Care involvement in order to increase access to treatment

We need to increase understanding and acceptance across the health system for a harm reduction approach to patients

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MOERC Recommendation The Commission recommends the Minister support the proposal and funding request from Primary Care Networks and their partners to increase and accelerate the participation of primary care in the urgent opioid response in the following areas:

Urgent Treatment Optimization of existing Primary Care Networks Programming Opioid related population based health service planning and

integration Education and knowledge translation targeted to primary care

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Why the Primary Care Initiative Matters

Ability to reach more Albertans than any other Commission recommended initiative

Will improve access to Overdose Response (Take Home Naloxone) kits, expand and improve Opioid Agonist Therapy and related primary care services, and better equip physicians to be able to treat patients with Opioid Use Disorder, using a harm reduction approach

Plays an important supporting role to other response activities

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Key Opportunities

Opioid Response Initiative can act as a test case for the Zone Service Planning approach; there are resources to enable, engage, and involve

Opportunity to impact key priority areas for action

Builds on foundational work underway to strengthen the primary health care system in Alberta

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PCN Objectives

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Catalyst for Patient’s Medical Home

Accessible Continuous Care Patient and Family

Centered Comprehensive Team-

Based Community and

Population Focused

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The Primary Health Care Opioid Response Initiative Overview of the Initiative

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PHC Opioid Response Initiative Grant

$9.5 million in one-time funding, focused on three key priority areas for action:

Urgent Opioid Response

Enhanced Opioid Related Service Delivery through PCN Zone Committee Engagement, Planning and Implementation

Enhanced Provider Decision Support, Knowledge Translation & Education in Primary Health Care

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Provincial Response and Support

Multi-partner initiative focused on supporting coordination and integration of activities across primary care.

Zone PCN Committee Support Teams

Alberta College of Family Physicians

AMA Integrated Programs (TOP, PMP, PCN PMO)

Alberta Health Services

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Goal 1: Improve access, continuity and care delivery within primary care settings for individuals using opioids. Objectives 1.1 Albertans using opioids have access to a primary care provider and team that they know and trust

1.2 Patients with complex health needs including Opioid Use Disorder are engaged to develop a plan of care with their primary care provider and team

1.3 Expand and improve the capacity within PCNs to support member practices to implement practice changes related to opioid prescribing, monitoring of opioid use, pain management, patient self-management support, and Opioid Agonist Therapy (OAT)

1.4 AHS zone services and PCNs support primary care clinics to increase access to and distribution of Overdose Response Kits (THN) and OAT

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Goal 2: Implement relevant and practical evidence informed decision supports and knowledge translation tools, including mentorship to better equip and educate primary care providers and teams, including clinics and PCNs; to support patients using opioids and/or with Opioid Use Disorder.

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Objectives 2.1 Within a harm reduction, approach develop and support implementation of provider and

patient education, decision support tools, knowledge translation strategies, practice change

tools and resources

2.2 Engage primary care providers to participate in the PACT initiative (Care Planning

initiative) to facilitate the identification of patients using opioids and proactively reach out to

those patients identified to develop a person centred care plan

2.3 Develop and implement a capacity building plan and approach to support distribution and

uptake of decision supports, tools, resources and education in zones, PCNs and primary care

practices

2.4 Develop and coordinate a mentorship collaborative network(s) within each zone related

to opioid use

Goal 3: Enhance coordination of care between primary care practices and other service delivery partners for patients using opioids including those with Opioid Use Disorder.

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Objectives 3.2 Primary, specialty care and community teams work together to identify opportunities for

improved coordination and continuity of care across or within service areas; such as primary care

clinics, Primary Care Networks, specialists, AHS specialty care programs, hospitals, acute care

services, community services, social services, and other community supports.

3.2 Primary care teams work together to develop comprehensive and accessible care pathways

exist, for patients using opioids, including Opioid Use Disorder, between primary care, specialty

programs, specialists and hospital in each zone

3.3 Utilizing a harm reduction approach, interdisciplinary teams of providers within primary care

settings work collaboratively with patients and their families to develop and implement

successful care planning processes

3.4 Patients using opioids are collaboratively supported to transition between primary and

specialty care as needed

Goal 4: Use a population health based approach to develop and implement a service plan for the integrated delivery of opioid related care.

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Objectives 4.1 Based on identified population and community needs, PCN Zone Committees

develop and implement a service plan focusing on opioid related care

4.2 PCN Zone Committees are able to gain experience and apply learnings from

opioid service planning in identifying and responding to other health needs of a

population

4.3 PCN Zone Committees prioritize the development of comprehensive and

accessible care pathways across the continuum

Populations of Focus

Sub-populations of relevance in optimizing care for patients using opioids: Non-medical - often referred to as ‘recreational’ use or the well at risk

Pain management – individuals with acute, sub-acute and chronic pain; implications include prescribing practices for opioids and non-pharmacological treatments of pain

Substance misuse and addiction – individuals whose day to day functioning has been negatively and substantially impacted by opioid use, including individuals with Opioid Use Disorder; often unattached (do not have a family physician or medical home)

** Mental Health – individuals with complex health issues frequently have underlying mental health needs

Proposal Development Flexibility to identify and address particular zone service level gaps and priorities

Identified actions must align with the parameters of the Opioid Response Initiative as outlined by MOERC

Approval process for proposals will be an iterative Opportunity for feedback and discussion to ensure

alignment

The patient’s journey through the health system is central in system level health service planning.

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Funding Allocation

Funding distribution across zones is guided by the following principals:

Each zone will be eligible for up to $500,000 to support planning, operational components, education, support project planning, operations, education, support for practice change, and the delivery of their opioid response service plan

Each zone is eligible for additional population-response based funding

Funding Allocation Sample distribution of zonal Opioid Response funds.

Zone Project Planning, Operations Design, Delivery, Education and Evaluation

Population Response

Total*

South 500,000 280,000 780,000* Calgary 500,000 830,000 1,330,000* Central 500,000 280,000 780,000* Edmonton 500,000 830,000 1,330,000* North 500,000 280,000 780,000* 2,500,000 2,500,000 5,000,000

*Totals in table are estimates based on equal distribution. These totals may be different based on specific requests and in response to cross-zonal partnerships

• This allocation of funds by zone is designed to recognize the different contexts of each zone.

• Shared approaches and allocations may be negotiated between the Zone PCN

Committee dyads based on existing care corridors, options for telehealth/alternative visits, mentorship and other innovative and sustainable solutions.

Proposal Submission and Timelines

A Letter of Intent (LOI) must be submitted by the Zone PCN Committee Dyads by March 15, 2018

Complete Proposals including Application for Funding, High level Budget, and Letter of Endorsement must be received by either intake date and time specified below:

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Intake Proposal Submission Date Target Award Date

1 May 17, 2018 at 12 noon MST May 30, 2018

2 June 21, 2018 at 12 noon MST June 28, 2018

Proposal Toolkit

An Opioid Response Toolkit has been developed to support planning efforts, and includes:

Population health data specific to the zone Key messages and communication related to the

primary care opioid response Information on other opioid related grants Contact list Glossary of terms and acronyms

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How Do Physicians Answer Questions and Keep Up to Date?

• Primary care physicians spend on average < 2 minutes answering clinical questions1,2

• To read top medical journals relevant to primary care would take ~ 627.5 hours/month, or 21 hours a day3

1) JAMA Intern Med. 2014;174(5):710-718 2) BMJ 1999; 319: 358-61. 3) Alper et al. J Med Libr Assoc 2004;902(4):429-37 4) Can Fam Physician. 2015 Jan;61(1):52-8. 5) J Contin Educ Health Prof. 2009 Winter;29(1):63-7.

A Primary Care Day:

Chronic Disease

10.6 hours

Preventive Services

7.4 hours

Acute Issues

3.7 hours

Miscellaneous

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6

12

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Ann Fam Med. 2005;3:209-14. Am J Public Health. 2003;93:635-41. Ann Fam Med 2012;10:396-400.

If we follow Clinical Practice Guidelines: 18 hours every day for prevention & chronic disease

The Trouble with Normal is,… It Always Gets Worse

JAMA. 2009;301:831-41. Ann Fam Med. 2014;12(3):202-3.

The Trouble with Normal is,…

0 1000 2000 3000

It Always Gets Worse Cardiology Guideline Recommendations

Original

Revision

JAMA. 2009;301:831-41. Ann Fam Med. 2014;12(3):202-3.

The Trouble with Normal is,…

0 2000 4000 6000 80000 1000 2000 3000

It Always Gets Worse Cardiology Guideline Recommendations

Original

Revision

1990

2012

Mentions of Guidelines On Pubmed

JAMA. 2009;301:831-41. Ann Fam Med. 2014;12(3):202-3.

Family doctors provide

~70% of all the nation’s healthcare

Can Fam Physician 2015;61:449-53

An increase of 1 primary care physician per 10,000 persons was associated with a reduction of 3.5 deaths per 10,000.

Background

• Only 17% of Continuing Professional Development designed for primary care is presented by primary care5

• Family Physicians make up only 17% guideline authors, majority are specialists4

1) JAMA Intern Med. 2014;174(5):710-718 2) BMJ 1999; 319: 358-61. 3) Alper et al. J Med Libr Assoc 2004;902(4):429-37 4) Can Fam Physician. 2015 Jan;61(1):52-8. 5) J Contin Educ Health Prof. 2009 Winter;29(1):63-7.

Podcast ≥30,000 month

TFP: Written brief updates >31,000 clinicians: most Canadian FP Every 2 weeks.

Academic Detailing Pharmacists visit ~500+ docs in clinics

Local Conferences 30 events, 17 different communities in ~6 yrs

Annual Pricing Update Improving Cost Awareness

Large Edmonton Event Sold out every yr, >450, now added webcast!

Opioid Tools and Resources Develop 2 Guidance Documents • Infographic tools • On-line learning modules • On-line apps • Educational pamphlets 3-6 Tools for Practice Two podcast series (2-3 each) Foundation of Medical Practice Education (McMaster) module

Deliver talks at largest conferences in primary care Develop workshop Academic detailing, audit & feedback Roadshow presentations

PEER

Toward Optimized

Practice

Patients Alberta College of

Family Physicians

Physician Learning Program

Primary Care

Networks

LifeLong Learning (U of A)

Continuing Medical

Education (U of C)

College of Family

Physicians of Canada

National KT (FMPE, CADTH,

Choosing Wisely, RxFiles, etc)

Simplified Guidelines

Simplified Tools

Timelines

• First Guidance Document: Identification and Management of Opioid Use Disorder in Primary Care

• Ready for dissemination early 2019 – including associated tools, academic detailing, roadshows, workshops

Questions and Panel Discussion

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Presenter Contact Information Shannon Berg: shannon.berg@gov.ab.ca Bill Hnydyk: bill.hnydyk@albertadoctors.org Dr. Christina Korownyk: cpoag@ualberta.ca Grant Oversight Terri Potter: terri.potter@acfp.ca Grant Letters of Intent and Proposal Submissions Cora-Lee Polansky: cora-lee.polansky@acfp.ca For assistance, contact any member of your PCN Zone Support Team.