Patient Education

Most patients are acutely aware of the national opioid epidemic – whether being personally affected by an opioid-related tragedy or just seeing the chilling statistics on the news. This heightened awareness has made patient education more important than ever, though. There is now an expectation from patients and family members that hospitals will not only proactively provide education about opioids, but also will be able to address specific concerns and questions. The sheer amount of news coverage also means that some patients may have misconceptions about opioids – and pain management – that need to be dispelled. Technology increasingly plays a more prominent role in efforts to educate and engage patients about opioids, but it is still early – and IT-centric approaches are still evolving.

“Patients and family caregivers should receive real-time education at the time of initial prescription, prescription fulfillment, and on an ongoing basis. Patients and family caregivers also should be engaged in setting realistic pain management goals based on expectations for safe and effective pain relief and functional outcomes. Patients should know how to use opioids safely once they have left the healthcare setting, and thus the healthcare team must teach techniques for safe drug use, storage, and disposal, as well as signs of drug overdose, diversion, and opioid use disorder (OUD).”

– NQF “Playbook” on Opioid Stewardship (March 2018)

Patient Education with Joint Decision Making and Treatment Agreements

Prescribers should engage patients in a conversation about their expectation for pain and options for management. This requires patient education. Education should include considerations that address biopsychosocial factors with pain care:

• Defining and understanding contributing factors associated with pain
• Education on types of pain and factors that can influence or impact pain
• Differentiation of pain management strategies for acute and persistent or chronic pain
• Education on treatment options including non-pharmacological alternative methods for reducing and managing pain

It is important for care team members to direct patients to credible sources of health information, as an uninformed patient can be easily misdirected by divergent and sometimes false information. (See the “Resources” section for a list of credible sources.)

Shared decision making and use of treatment agreements will assist providers to review realistic benefits, risks and side effects (both common and serious), as well as alterative treatment options with the patient (see Table 1). Health systems and hospitals must fully support providers in helping connect patients to resources, appropriate treatment, social support and the help they need.

Patient engagement and shared decision making requires:

• Discussing benefits, risks and side effects of opioid use, and providing clear and easy-to-understand educational materials
• Offering alternative pain management options
• Assisting patients to focus on managing acute pain during healing and improve functionality
• Discussing safe storage of opioid medications, including keeping out of reach of others
• Encouraging questions and providing follow-up opportunities

The Role of Technology in Patient Education

IT has proven to be an effective means for accurately identifying patients at risk for opioid misuse (see “Real World Examples” below). Technology is even increasingly playing a role in treating opioid use disorder (OUD); in fact, the first prescription digital therapeutic for patients with OUD was approved by the FDA in December 2018. When it comes to educating patients about the risks of opioids, though, approaches at most hospitals and health systems to date have been fairly “low tech” – focused primarily on paper handouts, printed discharge instructions and general content pushed to the patient portal.

However, technology is starting to play a more prominent role in efforts to educate and engage patients about opioids, especially as leading hospitals and health systems are beginning to approach chronic opioid use the same way they approach other chronic conditions. For example, organizations like Ochsner Health System have built and implemented a custom registry of chronic opioid patients to serve as the foundation for their targeted education and outreach efforts (see details in “Real World Example” below). Tools from enterprise EHR vendors are also maturing.

Moving forward, technology will play an even bigger role in helping to provide patients with personalized, easy to understand, clinically effective educational content about opioids at appropriate points in the patient journey (through multiple mediums and platforms).

For example:

• Using chronic disease outreach tools in novel ways to address opioid education
• Electronic alerts embedded in clinical workflows at defined points of care reminding clinicians to provide patients with educational materials about opioids and/or direct the patient to appropriate resources or services
• Automated point-of-care recommendations and suggestions to providers about specific educational content, resources and/or services based on a patient’s unique circumstances and risk level for opioid misuse
• Automatically pushing customized, patient-specific educational content about opioids and pain management to patients’ mobile devices
• Real-time integration of new types of interactive digital education into existing patient-facing apps and tools
• Tracking/monitoring which patients have received opioid education (including when, what type of content, etc.)
• Quantifying/measuring which types of educational content and engagement initiatives are most effective (or most valued by patients)

Ochsner’s (Southeast Louisiana) opioid stewardship efforts began in 2015. According to Todd Burstain, MD, the CMIO at Ochsner Health System, “Our approach to patient education and outreach started with some posters about narcotic use in our emergency department and clinics. Those didn’t really move the needle, though. We realized that effective outreach and education required a solid foundation of analytics and reporting.

Two of our top priorities were to 1) accurately separate chronic opioid users from acute opioid users, and 2) identify which chronic patients might be at risk for opioid misuse.”

Ochsner built a chronic opioid registry and implemented a customized Opioid Risk Tool.  Chronic opioid patients were categorized as either “high” risk, “medium” risk, or “low” risk, based on factors such as frequent early refill requests, recent dose escalations, as well as factors related to social and family history.

Burstain points out, “Knowing our chronic opioid patients’ level of risk was critical, but we also wanted to take the next step and actually monitor – and engage – those patients.”

After sitting down with a team of experts, Ochsner established specific requirements for chronic opioid patients depending on their risk level, managed through the Health Maintenance section in Epic (see rules below). Importantly, these tasks were also pushed to the patient portal. Per Burstain: “So when one of our chronic opioid patients logs into Epic MyChart, they might see they are overdue for a mammography or colonoscopy, and right there alongside that information is a reminder that we would like them to sign a pain contract, or an alert that they need to refill their Naloxone prescription.”

After the registry was created, Ochsner also crafted a letter to all of their chronic opioid patients (see sample below). The letter included background on the opioid epidemic, outlined the patient’s specific care plan and risk level – and most importantly, emphasized that Ochsner’s top priority was to provide them with the safest care possible. According to Burstain, “We found that our patients were extremely grateful for our outreach efforts. One of the most common responses we heard was ‘thank you – I had no idea that I was even at risk.’”

In terms of outreach and education to a broader patient population, Ochsner worked with local experts to create a do/don’t list for opioids. Any time an Ochsner patient is prescribed an opioid, that educational sheet is automatically included in the after-visit summary (both post-hospital discharge or after an outpatient visit). Additionally, any Ochsner patient with pain in his or her problem list is given access to related digital content through the patient portal.

Keys to Success:

• The right message. According to Burstain, “Patients need to know you are doing this because you care. It isn’t about some law or regulation – it is about their safety.”
• Help patients understand the risks. Even though most patients may be aware of the opioid crisis, they may not know the specific risks; how opioids may interact with other medications, the dangers of mixing opioids with alcohol, or the importance of storing their medications in a safe place.
• Explain the options. “There are a lot of alternatives to opioids that patients may not know about,” says Burstain. “For example, we are using virtual reality to help distract patients from the pain of certain procedures and minimize their initial exposure to opioids. It is critical that patients understand all of the options.”

When CoxHealth (Southwest Missouri) established a multidisciplinary team in January 2018 to respond to the opioid crisis, a subgroup under the committee was created specifically to lead the organization’s patient education efforts. The Education Task Force decided to focus on the highest utilizers of opioids in the health system – CoxHealth surgical patients.

A list of specific education topics – not just about opioids, but pain management as well – was developed by the task force (see below). CoxHealth deliberately decided to provide education to surgical patients through multiple mechanisms: pamphlets, videos and discharge instructions.  According to Tina Tarter-Hamlet, RN, patient education coordinator at CoxHealth, “Not every patient learns the exact same way, so we felt a combination of educational approaches was important. Communicating information in different ways can also help reinforce key messages.”

Payers are in a unique position to respond to opioid addiction, with access to many more and different levers than traditional provider organizations typically have (e.g., the ability to waive naloxone co-pays, eliminate pre-authorization for certain treatments, etc.). When it comes to patient education and outreach, though, both payers and providers offer common keys to success.

One excellent example is Aetna’s “Guardian Angel” program, which is part of the company’s holistic three-pillar strategy implemented in 2016 to improve OUD prevention, intervention and support.

Launched in March 2018, the Guardian Angel program looks at claims data to identify members who have had an opioid overdose that resulted in an emergency room visit. From there, specially trained Aetna nurses and social workers reach out to the member with a phone call to offer support –including answering questions, providing education about naloxone or scheduling appointments with local in-network providers for follow-up care.

The program’s high level of engagement with members is one of its greatest successes.  According to Dan Knecht, MD, vice president of health strategy and innovation at Aetna, between 40-50 percent of calls result in a “meaningful conversation” that aims to understand and address the member’s unique needs. “Unfortunately, these folks are trapped in the cycle of addiction. They need and want help, but they often do not have a good sense of how to navigate the healthcare system after they are discharged from the hospital,” Knecht notes.

Knecht cites four key factors behind the Guardian Angel program’s success to date:

1. Actionable data insights. Aetna focused on a known gap in care (i.e., follow-up post-discharge after an opioid overdose) and leveraged analytics to specifically target at-risk members.
2. Understanding unique circumstances. “Some members just need education, or a few questions answered, but others need specific services,” Knecht says. “It is important to be able to account for those differences and adapt to each unique situation.”
3. The right people doing the right thing. According to Knecht, “The clinicians making the outbound calls need to be extremely knowledgeable; you can’t have someone who isn’t an expert doing this kind of outreach.”

Intervening at the right time. “This program works because we are reaching out and offering support at a key moment in these people’s lives,” Knecht says.

Key Takeaways

• Patients are beginning to expect – and appreciate – outreach related to opioids, just like they expect someone to explain their treatment plan.
• Don’t just focus on education about opioids, but also pain and pain management.
• Look at leveraging existing education and outreach tools from your core EHR vendor – even those originally designed for a different chronic condition.
• Create the right foundation (like a registry) to enable targeted opioid education and outreach to a defined population of patients.
• Don’t be afraid to repeat the same information. Multiple types of education across multiple mediums can help reinforce key messages and points.
• In addition to patient-specific education, include a message on all discharge summaries about opioid risks and proper disposal, as it might apply to the patient or family.
• Learn from others’ experience. This includes:
  • Proactive communication with your EHR vendor to see how other clients are leveraging built-in capabilities to address opioid education and patient outreach.
  • Seek out presentations, webinars, etc., from other provider organizations – especially those that are using the same core EHR vendor(s) that you are.
  • Be active in vendor user group conferences, websites, etc.

Resources

Listed here are examples of credible sources of reliable patient educational content:

• National Center of Biotechnology Information
• Turning the Tide: For Patients – a website with education material for patients by former U.S .Surgeon General Vivek Murthy, MD
• The S. Food and Drug Administration website provides information on opioids. a consumer’s Guide to Safe Use of Pain Medication, as well as a List of Questions patients should ask their provider. Safe disposal instructions can also be found on the website.
• Lock Your Meds Campaign is an opioid safety campaign including educational focus on adult awareness prescription medications storage and safety.
• What Patients Should Ask Prescribers Before Taking Opioids is a good educational tool for patients.
• The FDA has guidance on Disposal of Unused Medications including Drug Enforcement Administration-Authorized Take Back Programs, and how to dispose of medication.