Key elements of such a campaign include executive sponsorship, clear goals and accountability, effective planning and coordination, and data analysis to evaluate progress. In this section we share steps and tools to help health plans effectively organize, execute, and improve an opioid safety initiative. The tools include work plans, slide decks, and infographics that we encourage you to use and customize for your opioid safety initiative.
- Create a sense of urgency: How to rally your organization to address the opioid crisis impacting your members
- Form an internal coalition: How to engage board, executive, and departmental leadership in an opioid safety initiative
- Build your case: How to communicate about your opioid safety initiative and garner support for change
- Remove obstacles: How to proactively identify and address barriers that may impede your opioid safety initiative’s progress and success
- Create quick wins: How to set up your opioid initiative for success by starting with attainable goals, tracking your progress, and celebrating achievements
Create a Sense of Urgency
Do you know how many of your members suffer from opioid use disorder? Do you know the toll it is taking on your community and your health plan network? Raising awareness about the human, societal, and health care toll of the opioid epidemic in your community is an important first step to rallying support for launching an opioid safety initiative. In this section we include a chart pack with national and California data on the impact of the opioid epidemic; you may use these slides in presentations to support the case for an opioid safety initiative. We also share an infographic template for you to customize with information about the epidemic’s impact on your members and community.
How to Do It
- Demonstrate that members are at risk.
- Illustrate how government and communities are mobilizing to address the issue.
- Emphasize the value of leading the change and being seen as part of the solution.
Health Plan Stories
Blue Shield of California
The chief health officer in 2014 recognized the impact of the opioid crisis on Blue Shield of California’s members.
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The chief health officer in 2014 recognized the impact of the opioid crisis on Blue Shield of California’s members. Narcotic analgesics were among the most frequently prescribed drugs. Hydrocodone and its variants topped the list, with three to four times more prescriptions than OxyContin, the second most commonly prescribed opioid. The chief health officer received endorsement for a Narcotic Safety Initiative from Blue Shield of California’s board of directors and asked the director of clinical pharmacy programs to lead the effort, saying, “If we do not act now, it is only going to get worse.” Both Blue Shield of California leaders recognized that health plans have a role in helping to reduce overprescribing and overuse of prescription opioids. As the executive sponsor, the chief health officer drove participation across the organization, while the director developed the program strategies and led their implementation.
Inland Empire Health Plan and the Inland Empire Opioid Crisis Coalition
In 2015, Inland Empire Health Plan (IEHP) joined a coalition of community and health care stakeholders concerned with the opioid crisis.
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In 2015, Inland Empire Health Plan (IEHP) joined a coalition of community and health care stakeholders concerned with the opioid crisis. The coalition is a place for organizations to take ownership of their roles in addressing the opioid crisis, and to act collaboratively with otherwise unlikely partners beyond their individual goals and needs. The coalition developed a toolkit for hospital emergency departments, which it implemented in 2016 and 2017. In 2017, the coalition came back together to assess its progress and discuss next steps. IEHP and other stakeholders agreed that the coalition could have the greatest impact by expanding its efforts to develop community- and provider-facing strategies. The coalition is still in operation today.
Kaiser Permanente Southern California
Kaiser Permanente Southern California (KPSC) saw the opioid crisis emerge through its data.
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Kaiser Permanente Southern California (KPSC) saw the opioid crisis emerge through its data. What the organization first thought was an issue with increased pharmacy volume due to its electronic health record turned out to be increased prescribing of opioids. The combination of internal pharmacy and medical record data uncovered the issue by showing a substantial trend in increased opioid prescribing.
Partnership HealthPlan of California
Partnership HealthPlan of California (PHC) discovered that Vicodin (hydrocodone) was its most frequently prescribed medication.
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Partnership HealthPlan of California (PHC) discovered that Vicodin (hydrocodone) was its most frequently prescribed medication. Opioid use and overdose rates were high throughout the counties in its network. Primary care providers were vocal; they found pain management work to be dissatisfying compared to the rest of primary care. Patients also were frustrated: They remained in pain despite being on high doses of opioids. A triple threat — the high cost of opioids combined with provider and patient dissatisfaction — drove PHC to take action.
Tools
Download a customizable infographic (ZIP) and slide deck (ZIP), both with instructions. These tools provide an easy and compelling way to visually tell the story of the opioid epidemic in your California county or region.
See also the Zero Suicide Toolkit site, which hosts a wide variety of tools that can be easily adapted to opioid safety work.
Resources
- Centers for Medicare & Medicaid Services: CMS Roadmap to Address the Opioid Epidemic (PDF)
Form an Internal Coalition
Broad engagement across the health plan is essential to the success of your opioid safety initiative. We recommend building a coalition of key stakeholders, including board members, executive leadership, and departmental leadership. In this section we provide a motivational interviewing guide that can help you assess their readiness to lead a change effort.
How to Do It
- Enlist board members around issues of member safety and the need to manage reputational and other risks associated with the epidemic.
- Enlist executive leadership around the business case for action.
- Bring together departmental leaders around the need for workable policies that minimize unintended consequences.
- Begin with a “coalition of the willing” and expand over time.
Health Plan Stories
Blue Shield of California
Blue Shield of California recognized that addressing the opioid crisis would not be just a pharmacy initiative.
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Blue Shield of California recognized that addressing the opioid crisis would not be just a pharmacy initiative. It engaged key players across the organization who understood the key levers that needed to be used to drive change — medical policy, formulary management, benefits, programs supporting members and providers, provider credentialing, analytics, etc. Together, this cross-functional leadership team leveraged existing approaches and launched new ones to reduce the number of members on chronic opioids for chronic noncancer pain, prevent the progression from acute to chronic use, and provide appropriate treatment for chronic pain and addiction.
The team developed pharmacomedical analytics with a data-driven dashboard to look at the key medical and pharmacy metrics, assess the impact of interventions, and evaluate progress over time. Analytic support and expertise were key elements of the initiative; data-driven insights helped guide and inform the leadership team. For example, the analytic model to identify and exclude members from interventions and reporting (e.g., those with cancer, in hospice or palliative care, etc.) based on information available to the health plan required refinement over time because it was not as straightforward as originally thought.
An internal governance structure provides accountability for the initiative. A steering committee and workgroups meet routinely to develop and monitor activities, and results of the initiative are reported through Blue Shield of California’s quality committee structure. An unplanned result of this enterprise approach is the ability for the plan to address new national quality measures on opioid use (see more at www.ncqa.org).
Inland Empire Health Plan and the Inland Empire Opioid Crisis Coalition
Inland Empire Health Plan (IEHP) assumed organizational and administrative responsibility for the coalition in mid-2017.
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Inland Empire Health Plan (IEHP) assumed organizational and administrative responsibility for the coalition in mid-2017. It formed six workgroups: (1) access to treatment, (2) overdose/access to naloxone, (3) education and engagement, (4) emergency department toolkit, (5) reporting/outcomes, and (6) reducing prescriptions. Data from the California Department of Public Health (CDPH), which was disseminated by the California Health Care Foundation, helped define the issues each workgroup would tackle, along with baseline metrics against which the workgroups would measure their progress. These workgroups are still in operation today. A steering committee comprised of coalition leadership oversees the workgroups, while all participants on the coalition are expected to take part in at least one workgroup.
Kaiser Permanente of Southern California
Recognizing that the opioid crisis touched the entire organization, Kaiser Permanente Souther Calfornia (KPSC) formed a multidisciplinary steering committee. It had representation from all major departments, including pharmacy, pain management, adult primary care, surgery, emergency room / urgent care, addiction treatment, and hospitalists, among others.
Partnership HealthPlan of California
Using a quality-improvement methodology, Partnership HealthPlan of California (PHC) developed a driver diagram, identifying the levers it could use to drive change internally.
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Using a quality-improvement methodology, Partnership HealthPlan of California (PHC) developed a driver diagram, identifying the levers it could use to drive change internally. The driver diagram helped identify who needed to be involved and their respective roles. A steering committee was created with leadership from every department. Workgroups were formed on pharmacy, member services, provider relations, and other key topics, and engaged network providers in planning efforts to ensure that new policies were helpful and not harmful to providers and patients.
Tools
Motivational interviewing is a tool to assess and promote organizational alignment. Through interviews or surveys, you can gather information about stakeholders’ views on the opioid crisis, the role of your organization, potential benefits of an initiative, as well as potential objections or challenges.
The guide below outlines an approach to conversations with stakeholders, such as your department leaders (e.g., pharmacy director, member services director) and board members, that is grounded in listening and collaborative planning to achieve mutually beneficial goals. You can document your assessment of each stakeholder in the Stakeholder Readiness Assessment Tool (ZIP) to produce a heat map of the organization to show where you have pockets of support or resistance.
Download this tool: Motivational Interviewing Guide (PDF)
Build Your Case
Once there is support for an opioid safety initiative, it is critical to describe the steps you will take to effect change, the anticipated impact of those steps, and the resources required. As with any organizational decision, you must weigh the benefits against the costs and determine the potential impact on members. To inform this process, we provide a cost-benefit calculator to assess the trade-offs between the costs and benefits of implementing medication-assisted treatment (MAT). We also list some of the common objections you may encounter when developing an opioid safety initiative, and effective responses to them.
How to Do It
- State simply the change you seek (e.g., no deaths from overdoses).
- Outline clearly how you will make the change (e.g., safer pain management, more medication-assisted therapy).
- Describe the benefits that will come from the change and incorporate available evidence (e.g., fewer deaths from overdoses, fewer emergency department visits and hospitalizations due to complications of addiction).
- Address possible objections to the change (e.g., moral hazard for naloxone, concerns about harm reduction, conflicts between medication-assisted treatment and abstinence methods).
- Estimate costs.
- Establish channels to regularly communicate and reinforce the case.
Health Plan Stories
Blue Shield of California
Part of Blue Shield of California’s strategy is to work with the broader health plan community in local and state coalitions under the belief that opioid safety should be a plan-agnostic endeavor — all stakeholders must work together to drive significant change.
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Part of Blue Shield of California’s strategy is to work with the broader health plan community in local and state coalitions under the belief that opioid safety should be a plan-agnostic endeavor — all stakeholders must work together to drive significant change. For example, it participates in Safe Med LA, a broad, cross-sector coalition of stakeholders addressing the opioid epidemic in Los Angeles County. Safe Med LA has helped reduce the prescribing of opioids in county emergency departments through targeted communications and education. Blue Shield of California is also active in state and federal legislative efforts to fight the opioid epidemic.
Inland Empire Health Plan and the Inland Empire Opioid Crisis Coalition
The coalition publishes a monthly newsletter communicating strategies and progress, and regularly looks to California Department of Public Health data to back up its strategies. It uses these data in its communications with stakeholders. Communicating a compelling case has not been difficult in the Inland Empire. Clinicians know people affected by the epidemic, and many feel personally responsible because of their field’s actions.
Kaiser Permanente Southern California
As a first step, the steering committee quickly developed a plan to target medications at risk for misuse by teenagers.
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As a first step, the steering committee quickly developed a plan to target medications at risk for misuse by teenagers, such as OxyContin, Opana, and Soma. Kaiser Permanente Southern California (KPSC) focused its efforts on reducing prescribing of these medications and saw an almost immediate 98% reduction in prescribing of brand-name opioids. KPSC simultaneously undertook an education campaign to communicate and spread its goals of reducing the prescribing of medications at risk for misuse among teenagers and of curbing the leakage of opioids into schools.
Partnership HealthPlan of California
Partnership HealthPlan of California (PHC) created a call to action around the high death rates in its counties, enlisting local opioid safety coalitions and clinic leaders in the need for change.
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Partnership HealthPlan of California (PHC) created a call to action around the high death rates in its counties, enlisting local opioid safety coalitions and clinic leaders in the need for change. Any major policy rollout allowed time for ample provider feedback, and the pace was adjusted to balance patient safety (e.g., the risk of overdose death with high opioid doses) with the need to avoid harm. For example, PHC began requiring prior authorizations for high-dose opioids, but exempted patients from tapering if they had medical or psychiatric instability, or if the regimen was deemed appropriate by a local peer review committee.
Tools
A List of Common Objections and Potential Responses
While there is generally broad support for health plan actions addressing the opioid crisis, you may encounter objections from internal and external stakeholders when launching a new opioid safety initiative. Below are common objections and evidence-based responses you can use when faced with such objections. As discussed in the Motivational Interviewing Guide (PDF), it is important to give weight to everyone’s opinions and listen to ensure you understand their points of view.
Download the tool: List of Common Objections and Potential Responses (PDF).
Health Plan Vision and Mission Statements
As health plans developed opioid safety initiatives, many created vision and/or mission statements to drive their work toward common goals. The statements below were developed by health plans as they embarked on the opioid safety initiatives described in the health plan stories. Health plans can review and consider these statements as they develop their own statements summarizing the goals of their opioid safety initiatives.
Download the tool: Health Plan Vision and Mission Statements for Opioid Safety Initiatives (PDF).
Remove Obstacles
When launching an opioid safety initiative, you may encounter technology challenges, resistance from colleagues, or regulatory and legal constraints. It is important to identify these barriers as soon as possible and work with your team to resolve them. In this section we provide both an assessment tool to determine your organization’s readiness to implement an opioid safety initiative, and resources to help you think about potential regulatory and legal barriers to sharing potentially sensitive information.
How to Do It
- Assess stakeholder readiness at each level of the organization (board, executive leadership, departmental leadership, etc.).
- Identify where process or technology/data issues will complicate implementation.
- Understand how regulatory and legal issues may act as constraints.
- Develop pragmatic strategies to address these obstacles.
Health Plan Stories
Blue Shield of California
At the start of the initiative, Blue Shield of California stakeholders were skeptical that anything could be done to address the opioid crisis.
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At the start of the initiative, Blue Shield of California stakeholders were skeptical that anything could be done to address the opioid crisis. Medical standards of practice and physician training led to the aggressive treatment of pain, and opioid medications were commonly prescribed as a first choice. Blue Shield of California leadership met frequently with provider organizations and individual prescribers, sharing data and convincing stakeholders of both the problem and the strategy that would steer prescribing and opioid use to lower levels. Leadership asked providers to guide policy changes and then adapted interventions based on feedback. The increasing public awareness of the opioid epidemic and the publication of new national prescribing guidelines from the Centers for Disease Control and Prevention also helped to improve acceptance of Blue Shield of California’s Narcotic Safety Initiative.
Inland Empire Health Plan and the Inland Empire Opioid Crisis Coalition
The coalition hosts quarterly meetings to provide an opportunity for all workgroups to meet, celebrate successes, share information, and remove obstacles to goal achievement.
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The coalition hosts quarterly meetings to provide an opportunity for all workgroups to meet, celebrate successes, share information, and remove obstacles to goal achievement. The “access to treatment” workgroup partners with 8–10 primary care providers and Federally Qualified Health Centers to integrate behavioral health and multidisciplinary medication-assisted treatment (MAT). The workgroup learned that Arrowhead Regional Medical Center, a county hospital system, had been awarded a grant to improve transitions of care. As a result, the workgroup expanded its scope to include bridging county emergency departments and primary care offices.
Maintaining a successful and meaningful coalition requires resources and leadership, which are both difficult to maintain. The coalition is constantly looking for new funding sources to support its work. The workgroups that have made the most progress include committed industry and community leaders who, in addition to their day jobs, invest their time and energy into the coalition and its efforts.
Kaiser Permanente Southern California
Some physicians were resistant to change.
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Some physicians were resistant to change. Kaiser Permanente Southern California (KPSC) made a concerted effort to reeducate physicians on the impact of opioids and on appropriate prescribing practices. Today, all physicians are expected to prescribe appropriately; if outlier prescribers are identified, KPSC intervenes and provides individualized education and monitoring.
Physicians were worried that their patient satisfaction scores would drop if they refused to prescribe opioids. In response, KPSC adjusted its survey practices so physicians no longer had to worry that safer prescribing practices would impact patient satisfaction scores.
Partnership HealthPlan of California
Partnership HealthPlan of California recognized that its physician network could not change its prescribing habits overnight.
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Partnership HealthPlan of California (PHC) recognized that its physician network could not change its prescribing habits overnight. PHC spent hundreds of hours in meetings with physicians, communicating why PHC was making changes in prescribing practices, what those changes were, and the impact it expected to achieve. PHC also heavily invested in provider training and in offering consultation support to providers for complex pain management patients. Finally, PHC rolled out changes slowly and incrementally, with substantial advance communication.
Tools
Stakeholder Readiness Assessment Tool
Download the Stakeholder Readiness Assessment Tool (ZIP) — it offers a detailed and structured way to gauge how prepared your team is for change.
Understanding Legal and Regulatory Guardrails
Sharing potentially sensitive information is key to delivering and coordinating care that patients need. However, complex federal and state laws leave plans and providers unsure about what information can be safely shared.
Use these resources to learn more about how information may be safely shared to deliver services and coordinate care.
Download this tool: Resources for Understanding Legal and Regulatory Guardrails (PDF).
Create Quick Wins
There are many strategies a health plan may consider when launching an opioid safety initiative. We recommend starting with the strategies that are easy to implement and will have the most impact. Once you start to see positive change, you can use the momentum to advance the initiative and implement more complex strategies. To help guide your effort, we provide tools to assess potential initiatives for their feasibility and impact, a sample work plan to help you sequence activities, and a project management checklist.
How to Do It
- Assemble a portfolio of potential initiatives.
- Rank them according to their impact and ease of implementation.
- Create a change program that begins with the high-impact, easy-to-implement initiatives.
- Celebrate the early victories.
- Lay the foundation for high-impact, longer-term change.
Health Plan Stories
Blue Shield of California
The development of a meaningful dashboard to report and monitor prescribing practices among Blue Shield of California’s network of providers was a critical first step.
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The development of a meaningful dashboard to report and monitor prescribing practices among Blue Shield of California’s network of providers was a critical first step. Pharmaco-medical analytics remain central to Blue Shield of California’s efforts today and have helped the organization identify its wins. Its partnership with CHCF enabled it to build momentum in its efforts. CHCF recognized health plans’ roles in combating the opioid epidemic and endorsed Blue Shield of California’s internal efforts through publication of a white paper and case studies (PDF) in 2016.
Inland Empire Health Plan and the Inland Empire Opioid Crisis Coalition
The coalition’s ED toolkit was a success and was celebrated as a win. This quick win was a catalyst for increased focus on partnerships between EDs and outpatient primary care providers. The coalition created momentum and secured the organizational relationships necessary to implement a broad strategy to fight the opioid epidemic.
Kaiser Permanente Southern California
Following on the heels of its first initiative, Kaiser Permanente Southern California quickly moved to target members on high doses of opioids who were at risk of overdose or death (e.g., starting with doses over 500 morphine milligram equivalents and then moving on to lower doses).
Partnership HealthPlan of California
Partnership HealthPlan of California (PHC) recognized that its physician network could not change its prescribing habits overnight. Vicodin dropped from the first to the fourth most-prescribed drug among PHC prescribers. PHC continues to meet with and communicate regularly with prescribers about appropriate prescribing practices and to intervene with individual prescribers as needed.
Tools
Initiative Ranking Tool
Use the Initiative Ranking Tool (ZIP) to help your leadership teams prioritize initiatives within their opioid safety strategy.
Project Management Checklist
As you plan for your initiative and develop your work plan, use the checklist below to ensure you have a plan you can control and manage. The checklist will help ensure your initiative is aligned with the organization’s goals.
Download the tool: Project Management Checklist (PDF).
Work Plan Template
A work plan is an essential tool for managing a project and tracking progress. This template (ZIP) tracks to the toolkit’s five chapters and the key steps within each. You should download and modify this template to reflect the scope of your opioid initiative and the steps you will take to achieve the initiative’s goals. Please refer to the Project Management Checklist as you develop your work plan.