Chronic pain/ opioid management

New Opioid Initiation 

Ensure that appropriate diagnostic workup and consideration of non-opioid therapies was completed. Provider to determine if patient is an appropriate candidate to initiate chronic opioid therapy by completing Opioid Risk Tool Flowsheet in navigator. For patients in high risk category, strongly consider not starting patient on chronic opiate therapy.

Follow standard office visit workflow for review of vitals, allergies, problem list, etc. Review and update Problem List.

In Problem List and Diagnosis navigators ensure diagnosis Z79.891 (Chronic Prescription Opiate Use) is added to or present on Problems List, and mark primary visit Diagnosis.

In “Overview” of Z79.891, add dot phrase .bfmchronicopioidproblemlist and complete required fields

If diagnosis added to Problem List at current visit, exit and reopen chart to initiate PADT

Under “Quality” activity, open PADT form. Document the appropriate information in PADT form at every opioid medication refill.

Open blank note in NoteWriter. Left click the drop down menu next to “Create Note in Notewriter”. Use the dot phrase .bfmchronicopioidnote for complete visit documentation.

Review, initial all sections and sign Opioid Agreement with patient. Give one copy to the patient, the other copy to be scanned into chart. A new Opioid Agreement needs to be done with every PCP change.

Order opioid medications for patient after the urine sample is collected, if appropriate. Review/change/re-order meds (in 28 day increments, no more than three 28 day increments at a time) with appropriate future fill dates. 

Order labs/tests/referrals.

Vaccines/POCT tests/medications to be administered in clinic.

Verify pharmacy is correct and update as needed.

Associate and Sign all orders in Meds and Orders navigator.

Go to LOS and FU navigator and insert E/M code.

Indicate need for f/u appt in Follow-up section for 28-84 days , reason for visit “opioid refill” and change Billing Provider to your attending if needed.

Determine if Behavioral Health/Case Management is needed

If you need behavioral health/CM:

1. Provider consults with behavioral health/case manager and gives a warm hand off, letting the case manager know that the provider portion of the patient visit is complete. (UNLESS PROVIDER RETURNING TO ROOM)

2. Provider turns off their assigned lights. Case Manager turns on their lights.

3. Behavioral Health/Case Manager addresses needs and finishes the case manager portion of the visit and turns off their lights (UNLESS PROVIDER RETURNING TO ROOM).

4. Behavioral Health/Case Manager to Secure EHR (Do not close EHR or log out of chart).

5. Behavioral Health/Case Manager turns Provider lights on, and discusses any needed information with Provider.

If you do not need behavioral health/CM:

Instruct patient that the MA will return to the room for patient instructions and make f/u appointment. Secure EHR (Do not close EHR or log out of chart).

Continuation of Chronic Opioid Therapy

Follow standard office visit workflow for review of vitals, allergies, problem list, etc.

Follow BPA guidance regarding frequency of UDS and PDMP checks and order these as needed.

Review and update Problem List.

In Problem List and Diagnosis navigators ensure diagnosis Z79.891 (Chronic Prescription Opiate Use) is added to or present on Problems List, and mark primary visit Diagnosis.

In “Overview” of Z79.891, add dot phrase .bfmchronicopioidproblemlist and complete/update required fields

If diagnosis added to Problem List at current visit, exit and reopen chart to initiate PADT. 

Under “Quality” activity, open PADT form. Document the appropriate information in PADT form at every opioid medication refill.

Open blank note in NoteWriter. Left click the drop down menu next to “Create Note in Notewriter”. Use the dot phrase .bfmchronicopioidnote for complete visit documentation.

Review, initial all sections and sign Opioid Agreement with patient.

Give one copy to the patient, the other copy to be scanned into chart.

A new Opioid Agreement needs to be done with every PCP change.

Order opioid medications for patient after the urine sample is collected, if appropriate. Review/change/re-order meds (in 28 day increments, no more than three 28 day increments at a time) with appropriate future fill dates. Order medication, sign and print, then reorder medication, sign and print any subsequent prescriptions with appropriate fill date.

Order labs/tests/referrals.

Vaccines/POCT tests/medications to be administered in clinic.

Verify pharmacy is correct and update as needed.

Associate and Sign all orders in Meds and Orders navigator.

Go to LOS and FU navigator and insert E/M code.

Indicate need for f/u appt in Follow-up section for 28-84 days, reason for visit “opioid refill” and change Billing Provider to your attending if needed

Determine if Behavioral Health/Case Management is needed.

If Yes:

1. Provider consults with behavioral health/case manager and gives a warm hand

off, letting the case manager know that the provider portion of the patient visit

is complete. (UNLESS PROVIDER RETURNING TO ROOM)

2. Provider turns off their assigned lights. Case Manager turns on their lights.

3. Behavioral Health/Case Manager addresses needs and finishes the case

manager portion of the visit and turns off their lights (UNLESS PROVIDER

RETURNING TO ROOM).

4. Behavioral Health/Case Manager to Secure EHR (Do not close EHR or log out of

chart).

5. Behavioral Health/Case Manager turns Provider lights on, and discusses any

needed information with Provider.

If No:

Instruct patient that the MA will return to the room for patient instructions and make f/u appointment.

Termination of Chronic Opioid Therapy

Provider changes diagnosis from Z79.891 (Chronic Prescription Opiate Use) to Z91.19 (Pain Management Contract Broken)

Indicate that patient is not appropriate for opioid therapy under this diagnosis in problem list.

Open care coordination note:

1. Go to Problem List in patient chart

2. Click on “Create Patient Care Coordination Note” at top of page.

3. Indicate reason for termination

4. This will show up at the top of the Snapshot going forward