2 Learning Collaborative Clinical Staff Survey

OMB

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment B: Learning Collaborative Clinical Staff Survey

Opioid Management of Older Adults in Primary Care

Attachment B

Clinical Staff Survey

Version: 3.31.20

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

2. 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

3. Are you licensed to prescribe opioids?

• Yes

• No

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

• Yes

• No

5. 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

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

• Yes

• No  GO TO #8

7. 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

8. 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)	⚪	⚪	⚪	⚪	⚪

9. 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

10. 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?	⚪	⚪	⚪	⚪	⚪

11. 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

2. Observations of Patients with Chronic Pain

12. 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

3. Policies and Supports

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

4. Measures and Monitoring

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

• Yes

• No

• I don’t know

21. 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): _____________________________________________

22. 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.

5. 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.					

6. Improvement Effort [Post only]

23. 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

24. 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

7. Challenges [Post only]

25. 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): ___________________________

26. 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

8. Practice Capacity

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

27. 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.	⚪	⚪	⚪	⚪	⚪

9. Major Disruptions

28. 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

10. Burnout

29. 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.

11. Stress

30. 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

12. Respondent Characteristics

31. 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 ________________________________________

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

• Less than one year

• 1-5 years

• More than 5 years

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

• Yes

• No

34. 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