Leadership program readies new doctors to meet needs of rural Kentucky

By PATRICIA CORRIGAN

Lung cancer. Heart disease. Diabetes. All three, often complicated by obesity, are prevalent in rural northeastern Kentucky. St. Claire HealthCare in Morehead — a town of about 7,000 — draws patients from 13 counties in the region, 12 of which are said to be medically underserved. The hospital is the largest employer in the region, employing nearly 1,000 staff members and more than 100 medical providers.

Dr. Ashley Brown, a physician in the hospital’s emergency department, is one of them. She has been on staff since 2017. A native of Greenup, a town about an hour from Morehead, Brown is a graduate of the Rural Physician Leadership Program.

The program was founded in 2008 by St. Claire, the University of Kentucky College of Medicine and Morehead State University with the mission of educating doctors to practice medicine in small communities that need health care.

“The idea is that doctors who train in Kentucky will stay in Kentucky,” said Brown, who also serves as the program’s director of admissions and outreach. Medical students in the program complete their first two years at the University of Kentucky’s campus in Lexington and then acquire core clinical experience for one year at St. Claire HealthCare. The fourth year consists of elective clinical rotations in different departments in Morehead and the surrounding counties.

Fireproofing against opioid dependence

From page 1 readily available prescription opioids and aggressive, unscrupulous marketing by drugmakers are widely believed to have set off the opioid crisis in the U.S. Some pain patients who became dependent on narcotics switched from pills to less expensive heroin and later to fentanyl, a cheap synthetic street drug that is linked to the catastrophic increase in opioid overdose deaths.

The thrust of PeaceHealth’s effort to reduce opioid use and abuse has been around finding alternatives to prescription opioids in pain management and reducing dosing and duration of opioids to avoid dependency. The system has been providing clinicians with deeper training on evolving federal prescribing guidance and on how to approach conversations with patients who suffer debilitating pain, including chronic pain patients who must be safely tapered off opioids.

PeaceHealth calls the work “fireproofing” because of the focus on addiction prevention, but the initiative also increases the clinical staff’s ability to recognize a patient with opioid use disorder and guide him or her to supportive treatment. At many of its outpatient care sites, PeaceHealth offers medication-assisted therapy to quell opioid cravings.

Mindset change

Dr. Heidi Radlinski is a family and addiction medicine physician at the PeaceHealth Family Medicine Southwest clinic in Vancouver, Washington. She says fireproofing also involves integrating addiction medicine across the continuum of medical care so that no matter where patients impacted by substance abuse enter the PeaceHealth system, there will be resources for them to get help, either within PeaceHealth or through its community partners.

Radlinski anticipates that some of those community partners will be among the many beneficiaries of the $26 billion four drug companies are to disperse to states and communities as part of a settlement of numerous lawsuits claiming drug manufacturers knowingly fueled the opioid crisis.

Around 2016 PeaceHealth convened a multidisciplinary team that included inpatient and outpatient prescribers throughout the system. Dr. Robin Virgin, chief medical officer of PeaceHealth Medical Group in its Oregon Network, says the multidisciplinary team acknowledged that clinicians in general had played a part in the proliferation of opioids and they agreed that much could and should be done to shift the way prescribers approached pain control.

That same year, the Centers for Disease Control and Prevention had issued guidelines for primary care physicians prescribing opioids in outpatient settings.

The CDC says its aim in 2016 was to make sure that clinicians and patients weighed benefits and harms and considered safer, more effective alternatives to opioids in the management of chronic, acute and subacute pain. In updated guidance issued last year, the agency describes pain as a clinically complex condition with physical, psychological and social consequences. Pain also is one of the most common reasons adults seek medical care in the United States.

The guidance, which is not intended to be an inflexible standard of care, underscores that proven treatments including non-pharmacological therapies can improve patient outcomes and reduce the risk of opioid dependency.

With the update, the agency expanded its audience to take in oral health provid-

Opioid

RATE PER 100,000 PERSONS

Washington Oregon Alaska*

Vancouver-based nonprofit Lifeline Connections. That drug treatment and recovery services agency operates in several regions in Washington state. Lifeline has a substance use peer support specialist at Southwest Medical.

Patients usually are referred to peer support by the provider taking care of them or identified as at risk according to their admitting diagnosis. The Lifeline specialist meets with patients who agree to see them, screens those patients for drug use risk and socioeconomic needs, talks with them about their goals and barriers, and then provides a warm handoff to needed services.

*Data available only through 2020 ers, clinicians managing postsurgical pain in outpatient settings and emergency room physicians writing prescriptions at patient discharge.

Virgin says that when many of the doctors practicing today were in medical school, they were trained to use different dosing for narcotics than is called for now.

She says participants in PeaceHealth’s 2016 summit recognized that the dramatic changes that clinicians would need to make in their approach to pain management would require educating providers as well as the patient community.

Virgin and Radlinski say the system is offering education and resources to both its own prescribers and to patients explaining why opioid prescriptions have been curtailed and offering pain management alternatives.

Provider education

The system’s addiction medicine specialists guide the system’s ongoing work to eliminate problematic opioid prescribing in line with evolving guidelines and recommendations from the Oregon Health Authority, the Washington State Department of Health, the Alaska Department of Health and the CDC.

The addiction medicine specialists educate and train frontline prescribers and other clinicians across the continuum of care in the PeaceHealth inpatient and outpatient sites. Radlinski and Virgin say the provider education explains the landscape and guidelines currently in place, which includes decreasing the number of prescriptions, pills taken and length of time taken as compared to past prescribing patterns. They say the goal is to avoid starting opioids if possible. For established patients, the goal is to reassess, minimize, taper or stop opioid treatment.

Radlinski heads a Vancouver-area program that trains providers throughout that region on protocols for prescribing opiates, screening for drug abuse, the administration of medication-assisted therapy in opioid recovery, the availability of alternate pain relief treatments and the incorporation of trauma-informed practices with patients.

She says anywhere patients enter the PeaceHealth system they’ll encounter providers and other staff with at least a basic understanding of how to get addicted people timely and compassionate help.

Colleague collaboration

PeaceHealth addiction medicine specialists also have spurred the creation of databases that make it easy to identify through the medical record patients being prescribed opiates. Designated clinicians in each PeaceHealth location review the registry to determine that patients are receiving the appropriate dosing. They meet with prescribers who are outliers among their peers in terms of the prescribing guidance. Radlinski and Virgin say the first step is to show the data and simply ask, “Do you know you are an outlier? Why do you think you are an outlier?” They say this open, conversational approach can lead to the clinicians changing their prescribing pattern.

PeaceHealth also has ensured that providers across its facilities are educated about the use of the opioid overdose reversal medication Narcan so they can teach patients.

The whole system is set up to quickly identify people in inpatient and outpatient care who are experiencing or at risk of addiction, assess them, provide or refer them to treatments or services and set them on a path to better outcomes and/or recovery from substance dependence, either at PeaceHealth or at partner organizations.

Medication-assisted therapy

PeaceHealth also has strengthened its partnerships in all its regions with nonprofits and other organizations that can help address the many needs with which patients with opioid use disorder may struggle. These include access to drug treatment, mental health care, stable housing, transportation and food aid.

One such partnership is between PeaceHealth’s Southwest Medical Center and the

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Kaylee Collins, Lifeline program director of medication-assisted recovery, says the changes PeaceHealth has been making as part of its fireproofing have resulted in widespread improvement in how PeaceHealth clinicians treat people with opiate use disorder. She says patients are being cared for in a more comprehensive way that gets at the source of the challenges they are facing. When patients are treated as human beings, deserving of compassion, they are more likely to get the care they need, she says.

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Rural physician leaders

From page 1

A strategic value

Is the program working? Bodie Stevens, site administrator at Morehead, reports that it is.

The program has tripled in size since it started, and receives about four times as many applications each year as can be accepted. After graduation next month, a total of about 110 students will have completed the program, with all of them trained at St. Claire. After residency training, about half the program’s graduates have chosen to practice medicine in rural Kentucky.

“The program is a strategic value on several levels,” said Dr. William Melahn, senior vice president of quality and clinical affairs at the hospital. “In the short term, it helps us attract physicians of the caliber that they are able to become faculty at a medical school and teach. In the long term, we demonstrate that top high school and college students who live in eastern Kentucky can have the opportunity to have a highly competitive medical school to apply to in eastern Kentucky. We are teaching them that highquality medicine happens here.”

Connecting to community

While at St. Claire, the medical students routinely become involved with the community, said Dr. Rebecca Todd, associate dean of the program. They work at a free clinic one day a week, they partner with the library to promote public health literacy and they present educational programs for addiction recovery organizations and at a domestic violence shelter.

“In their fourth year, students partner