2 Learning Collaborative Clinical Staff Survey

Identifying and Testing Strategies for Management of Opioid Use and Misuse in Older Adults in Primary Care Practices

Attachment B_Learning Collaborative Clinical Staff Survey_05-04-2020

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Attachment B: Learning Collaborative Clinical Staff Survey










Opioid Management of Older Adults in Primary Care




Attachment B


Clinical Staff Survey



Version: 3.31.20







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Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.



Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.







Care Provided to Patients with Pain


  1. In the last month, approximately how many patients with chronic pain did you see?

  • 1 patient

  • 2-5 patients

  • 6-10 patients

  • 11-20 patients

  • More than 20 patients


  1. In the last month, approximately how many older adult patients with chronic pain did you see?

  • 1 patient

  • 2-5 patients

  • 6-10 patients

  • 11-20 patients

  • More than 20 patients


  1. Are you licensed to prescribe opioids?

  • Yes

  • No


  1. In the last month, have you prescribed opioids to patients with chronic pain?

  • Yes

  • No



  1. Have you signed up with the state Prescription Drug Monitoring Program (PDMP)?

  • Yes, as a prescriber

  • Yes, as a delegate

  • No

  • Not applicable

  • Don’t know





  1. Are you waivered to prescribe buprenorphine to patients with opioid use disorder (OUD)?

    • Yes

    • No GO TO #8


  1. In the last month, have you prescribed buprenorphine to patients with opioid use disorder (OUD)? Please select all that apply.

    • Yes, including for patients aged 18-64

    • Yes, including for patients aged 65 or older

    • No




  1. When caring for patients aged 65 and older with chronic pain on opioids in the last month, about how often did you or your team conduct these specific aspects of care? Please answer each item thinking specifically about your patients aged 65 and older.

     

    Always

    Often

    Sometimes

    Rarely

    Never

    Discuss risks and benefits of opioid therapy with patients

    Discuss a treatment agreement (pain contract)

    Discuss storage and disposal of opioids

    Engage in shared decision making with patients regarding treatment of chronic pain

    Refer patients to physical therapy for pain

    Refer patients to acupuncture for pain

    Refer patients to other non-pharmacologic therapies for pain

    Check patients’ records in the Prescription Drug Monitoring Program (PDMP)

    Order and/or interpreting urine drug test results

    Assess for constipation

    Assess for fatigue

    Assess for confusion

    Assess for functional status decline

    Assess for depression and/or anxiety

    Assess for decreased cognition

    Assess for drug-drug interactions

    Assess patients’ current and past use of benzodiazepines, other sedatives, and/or controlled substances

    Assess patients’ current and past use of alcohol or illicit drugs

    Assess whether patients are taking more opioids than prescribed

    Assess patients for opioid use disorder

    For patients with opioid use disorder, refer to or treat them with medication assisted treatment (MAT)

    Prescribe or refer patients for naloxone (overdose reversal drug)

  2. Do you conduct any of the above aspects of care differently with patients aged 65 and older (i.e., not with patients younger than 65?

  • No

  • Yes, please describe: _______________________________________________


Confidence and Awareness

        1. Confidence in Caring for Patients with Chronic Pain


  1. On a scale from 1 to 5, how confident are you in your care team’s ability to:


1

(Not at all confident)

2

3

4

5

(Very confident)

Provide care to older adults according to guidelines and regulations for chronic pain and/or on long-term opioid therapy?



  1. On a scale from 1 to 5, how confident are you in your ability to conduct each of the following clinical care activities with patients aged 18 to 64 and 65 or older with chronic pain on opioids? [Only for providers]


Patient age group

1

Not at all confident

2

3

4

5

Very confident

Provide care according to regulations and guidelines for patients with chronic pain on opioids

18-64

65+

Develop a taper plan collaboratively with the patient when appropriate

18-64

65+

Engage in difficult conversations with patients (e.g., tapering, urine drug test or prescription drug monitoring program results)

18-64

65+

Diagnose co-occurring behavioral or mental health conditions among patients with chronic pain on opioids

18-64

65+

Identify patients with chronic pain on opioids who are misusing opioids

18-64

65+

Diagnose opioid use disorder (OUD),distinguishing it from physical dependence, among patients with chronic pain on opioids

18-64

65+

Prescribe or refer patients for medication-assisted treatment (MAT) like buprenorphine/naloxone or naltrexone

18-64

65+




Observations of Patients

        1. Observations of Patients with Chronic Pain

  1. When caring for patients with chronic pain on opioids during the last three months, how often have you observed the following with patients aged 18 to 64 and 65 or older?


Patient age group

Always

Often

Sometimes

Rarely

Never

Misuse of opioids1

18-64

65+

Challenges with side-effects related to opioids2

18-64

65+

Patient experiencing confusion

18-64

65+

Patient experiencing fatigue

18-64

65+

Patient is willing to try non-pharmacologic therapy for pain

18-64

65+

1. Misuse of opioids can include taking too much medicine, taking someone else’s medicine, taking it in a different way than you are supposed to, or taking the medicine to get high. Citation: National Library of Medicine (NLM), MedlinePlus. “Opioid Misuse and Addiction.”

2. Side-effects related to opioids can include drowsiness, mental fog, nausea, constipation, and slowed breathing. Citation: National Library of Medicine (NLM), MedlinePlus. “Opioid Misuse and Addiction.



Clinic-Level

        1. Policies and Supports

  1. Does your practice or health care system have policies or guidelines related to providing care for patients with chronic pain on opioids?

  • Yes

  • No GO TO #15

  • Don’t know GO TO #15


  1. Does your practice or health care system have policies or guidelines related to providing care for patients with chronic pain on opioids that are specific to adults aged 65 and older?

  • Yes

  • No

  • Don’t know




  1. Does your practice or health care system have a standardized treatment agreement (pain contract) for patients with chronic pain on opioids?

  • Yes

  • No GO TO #17

  • Don’t know GO TO #17


  1. Does your practice or health care system have a standardized treatment agreement (pain contract) for patients with chronic pain on opioids specific to adults aged 65 and older?

  • Yes

  • No

  • Don’t know


  1. Does your practice or health care system have electronic health record tools (e.g., notes templates, alerts, clinical decision-support tools) to support care for patients with chronic pain on opioids?

  • Yes

  • No

  • Don’t know


  1. Does your practice or health care system use a registry or other tracking system to help care for patients with chronic pain on opioids?

  • Yes

  • No

  • Don’t know


  1. Does your practice or health care system provide financial or administrative support to clinicians to apply for a buprenorphine waiver? Please select all that apply.

  • Yes, financial support

  • Yes, administrative support

  • No

  • Don’t know


        1. Measures and Monitoring

  1. Does your clinic use regular reports to monitor patients on opioids?

    • Yes

    • No

    • I don’t know




  1. What measures are included in the reports? [check all that apply]:

    • Number of patients on long-term opioid therapy

    • Number of patients with chronic pain on long-term opioid therapy

    • Patients’ opioid dosages (e.g., Morphine Equivalent Dose or Morphine Milligram Equivalents)

    • Prescription refills

    • Patient pain and function (e.g., PEG scores)

    • Self-reported quality of life

    • Date of last urine drug test

    • Date of last Prescription Drug Monitoring (PDMP) check

    • Co-prescribing of benzodiazepines

    • Whether treatment/pain agreement is up-to-date

    • Other (please specify): _____________________________________________


  1. Does your practice capture any measures specific to older adults with chronic pain or taking opioids?

    • No

    • Yes. Please describe_____________________________________________





Implementation

The following questions relate to the strategies and tools your practice used to improve care of older adult patients with chronic pain and/or on long-term opioid therapy as part of AHRQ Opioids in Older Adults Learning Collaborative.

        1. Intervention Characteristics: Acceptability, Appropriateness and Feasibility


24. Please rate your agreement with the following statements about the [INSERT INTERVENTION] on a scale from 1 to 5, with 1 being completely disagree to 5 being completely agree.1


Acceptability of Intervention Measure (AIM)

Completely disagree

Disagree

Neither agree nor disagree

Agree

Completely agree

1. (INSERT INTERVENTION) meets my approval.

2. (INSERT INTERVENTION) is appealing to me.

3. I like (INSERT INTERVENTION).

4. I welcome (INSERT INTERVENTION).



Intervention Appropriateness Measure (AIM)

Completely disagree

Disagree

Neither agree nor disagree

Agree

Completely agree

1. (INSERT INTERVENTION) seems fitting for care of older adults with chronic pain and/or on long-term opioid therapy (LTOT).

2. (INSERT INTERVENTION) seems suitable for care of older adults with chronic pain and/or on LTOT.

3. (INSERT INTERVENTION) seems applicable for care of older adults with chronic pain and/or on LTOT.

4. (INSERT INTERVENTION) seems like a good match for care of older adults with chronic pain and/or on LTOT.



Feasibility of Intervention Measure (FIM)

Completely disagree

Disagree

Neither agree nor disagree

Agree

Completely agree

1. (INSERT INTERVENTION) seems implementable.

2. (INSERT INTERVENTION) seems possible.

3. (INSERT INTERVENTION) seems doable.

4. (INSERT INTERVENTION) seems easy to use.



        1. Improvement Effort [Post only]


  1. In the last 12-15 months, have the strategies/intervention your practice has used for opioid misuse, abuse and overdose among older adults impacted your day-to-day work with older adult patients with chronic pain or on long-term opioid therapy?

    • Yes

    • No GO TO #XX

    • I don’t know GO TO #XX



  1. How have these changes impacted your day-to-day work with patients with chronic pain on long-term opioid therapy?

    • Positively

    • Somewhat positively

    • Neither positively or negatively

    • Somewhat negatively

    • Negatively





        1. Challenges [Post only]



  1. In the last 6 months, which of the following made it difficult for you to provide care aligned with current guidelines and regulations for older adult patients with chronic pain or for those on long-term opioid therapy? Please check all that apply.

      • Insufficient time in office with patients with chronic pain

      • Patient resistance to considering changes to opioid prescriptions

      • Poor or limited tools within the electronic health record (EHR)

      • Limited access to non-opioid or non-pharmacological therapies

      • Poor or no coverage of non-pharmacologic therapies by insurance

      • Limited access to medication-assisted treatment (MAT) for opioid use disorder

      • Other providers abandoning patients on long-term opioids

      • Working with new patients already on opioids long-term

      • Limited confidence/experience in having difficult conversations with patients

      • Patients turning to illicit opioids

      • Not knowing if and/or when a patient overdosed on opioids

      • Social determinants of health factors (such as poverty, food insecurity, homelessness) affecting patients

      • Too many other initiatives taking place that compete for time and/or resources

      • Not enough resources to change my practice

      • Other (please specify): ___________________________





  1. Is there anything else that would be helpful to understand about your experience providing care to older adults patients with chronic pain generally, or for those on long-term opioid therapy?

_________________________________________________________________



Clinic Environment

        1. Practice Capacity

The following questions ask about the working environment in your clinic, how your clinic addresses change, and burnout or stress from work.


  1. Please indicate how strongly you agree or disagree with the following statements regarding your clinic:2



Strongly agree

Agree

Disagree

Strongly disagree

Unsure

Mistakes have led to positive changes here.

I have many opportunities to grow in my work.

People in our practice actively seek new ways to improve how we do things.

People at all levels of this office openly talk about what is and isn't working.

Leadership strongly supports practice change efforts.

After trying something new, we take time to think about how it worked.

Most of the people who work in our practice seem to enjoy their work.

It is hard to get things to change in our practice.

This practice is a place of joy and hope.

This practice learns from its mistakes.

Practice leadership promotes an environment that is an enjoyable place to work.

People in this practice operate as a real team.

When we experience a problem in the practice we make a serious effort to figure out what's really going on.

Leadership in this practice creates an environment where things can be accomplished.



        1. Major Disruptions

  1. Have there been any of the following major changes in your practice in the last 12 months?3


No major disruption

One major disruption

More than one major disruption

New electronic health record (EHR) system

Moved to new location

Lost one or more clinicians

Lost one or more office managers or head nurses

Been purchased by or affiliated with a larger organization

New billing system

COVID-19 pandemic had significant impact on our practice. Please describe________________________

_______________________________

_______________________________

Other





Respondent

        1. Burnout

  1. Overall, based on your definition of burnout, how would you rate your level of burnout? Please select one.

    • I enjoy my work. I have no symptoms of burnout.

    • Occasionally I am under stress, and I don’t feel I always have as much energy as I once did, but I don’t feel burned out.

    • I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion.

    • The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot.

    • I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help.



        1. Stress

  1. In the last month, how much did caring for older adult patients with chronic pain who are on long-term opioid therapy or for whom you are considering initiating opioid therapy contribute to your overall level of stress at work? (please select one):

    • Not at all

    • Very little

    • Somewhat

    • Moderately

    • Extremely





        1. Respondent Characteristics

  1. What is your primary role in this clinic (select ONE answer)?

  • Primary care provider (MD, DO, NP, PA)

  • Registered nurse (RN)

  • Licensed practical nurse (LPN or LVN)

  • Medical assistant (MA)

  • Pharmacist

  • Behavioral health provider (e.g., psychologist, psychiatrist, mental health counselor)

  • Social worker (Licensed Clinical Social Worker)

  • Community health worker or patient navigator

  • Administrative or clinical support staff (e.g., front desk staff)

  • Clinic administrator (e.g., practice manager)

  • Physical therapist

  • Occupational therapist

  • Other, please specify ________________________________________


  1. How long have you worked in your current position?

  • Less than one year

  • 1-5 years

  • More than 5 years


  1. Do you have a specialty in or are you credentialed in geriatrics?

  • Yes

  • No


  1. When caring for patients aged 65 or older, are you able to consult in-person or by phone, as needed, with the following staff working at your practice? Please select all that apply.

  • Geriatrician or geriatric nurse practitioner (NP)

  • Clinical pharmacist

  • Pain management specialist

  • Addiction specialist

  • Mental health clinicians (e.g., therapists, psychologists, psychiatrists)



END OF SURVEY

Thank you for completing this survey! Your input is greatly appreciated!!

1 These are validated items for evaluating implementation outcomes. Weiner, B. J., Lewis, C. C., Stanick, C., Powell, B. J., Dorsey, C. N., Clary, A. S., ... & Halko, H. (2017). Psychometric assessment of three newly developed implementation outcome measures. Implementation Science, 12(1), 108. Note: these measures were adapted, specifically the AIM measure.

2 Adaptive reserve instrument to measure practice capacity. See: Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaén CR. Primary care practice development: a relationship-centered approach. Ann Fam Med. 2010;8 Suppl 1:S68-79; S92.

3 This item was used in AHRQ’s EvidenceNOW initiative, although the COVID-19 item was added. See: Balasubramanian BA, Marino M, Cohen DJ, Ward RL, Preston A, Springer RJ, Lindner SR, Edwards S, McConnell KJ, Crabtree BF, Miller WL. Use of quality improvement strategies among small to medium-size US primary care practices. The Annals of Family Medicine. 2018 Apr 1;16(Suppl 1):S35-43.

Abt Associates 19 Attachment B: Learning Collaborative

Clinical Staff Survey

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