An interview with Nadejda Razi-Robertson, PhD, LCSW, Managing Director, Synergy Health Consulting and Andrew Suchocki , MD, MPH, Medical Director, Clackamas Health Centers
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Anna: Thank you Nadejda and Andrew for spending time with us today to discuss the impressive work being done in your leadership roles around practice transformation at Synergy Health Consulting. Can you tell us a little bit about Synergy and its impact on opioid safety-related care improvement?
Nadejda: Our team works with health systems across the state of Oregon. Our first phase of work started several years ago when we were largely focused on helping systems implement the CDC guidelines around opioid safety. Our work has since evolved, and we’re now focused on helping clinicians develop medication-assisted treatment programs, integrate behavioral health into primary care, and address the opioid epidemic at the community level.
We often use academic detailing as one of the many tools in our toolbox when we work with different health systems on opioid safety. We take the basic concepts, such as conducting a needs assessment and identifying clinician barriers, from the traditional model of a detailing visit, and implement them on a larger scale.
Andrew: Many members of our team are practicing healthcare professionals in the field, which roots a lot of our work at Synergy. I take what I’m seeing on the ground as both an administrator and a provider at a busy clinical practice and incorporate those experiences into my work at Synergy.
Anna: It’s so important to build teams where members have varied expertise and professional training when working together on practice transformation. How have you incorporated academic detailing strategies into the work being done at Synergy, and how has it been received?
Andrew: Some of the academic detailing work I’ve done has been with providers who need extra support from a peer, or from someone else working in the field. When it comes to opioids, chronic pain, and addictions in primary care, there’s a tremendous amount of stigma and information that was accurate at one time, but as we’ve shifted as a society, many primary care providers are yet to catch up.
Stigma isn’t something that folks are actively choosing, it’s more of what they’ve been taught. Changing that culture of practice is much more difficult compared to asking prescribers to prescribe cholesterol-lowering therapy. There’s very little societal baggage when it comes to improving cholesterol than there is when it comes to destigmatizing addictions or chronic pain.
Nadejda: We use the same fundamental approach when working with systems, clinics, or individuals. We start with a needs assessment, provide a group training based on those needs, and follow that up with 1:1 academic detailing visits to address barriers, provide materials, and explore personal bias that may be getting in the way of providing treatment.
I’m currently working to schedule a training for several providers in a rural county in Oregon. A number of those providers are X waivered (allowing them to prescribe medication therapy for patients with opioid use disorder), but they aren’t using their X waivers to prescribe buprenorphine. A needs assessment will provide me with a better understanding of what the challenges and barriers are, what is working well, and where there may be bias, stigma, or gaps in knowledge. We also use the needs assessment as a “listening session” that creates a sense of safety, fosters an experience that participants are being heard, and serves to “normalize” experiences across settings and practitioners. This process is also strategic in that it helps us understand where to focus our educational outreach and academic detailing efforts.
The more we are doing this work, the more we are finding that this approach is effective in getting care teams, medical providers, and service providers across many sectors into increased “philosophical alignment” which is critical to effectively foster culture change around issues of pain, addiction, and trauma.
Anna: Bias, stigma, and gaps in knowledge around chronic pain and addiction are common, especially in primary care. We’ve found that many detailers have been successful in helping providers “catch up” to society and overcome personal bias through their detailing visits. Speaking of detailing visits, face-to-face visits have clearly been impacted by COVID-19. Can you tell us more about other ways that COVID-19 has impacted the work at Synergy?
Nadejda: Again, we’ve gone back to the wisdom of the original academic detailing model. The needs of each setting have changed significantly, and we’ve been pivoting our work to meet those needs. Providers want to know how to best support their patients who are dealing with pain during this time. One thing we were able to provide early in the pandemic was a list of recommendations and resources around pain management for both providers and patients.
Andrew: We saw the need to adapt to massive changes related to COVID-19, and to do so essentially overnight. We’ve had questions about conducting urine drug screenings, initiating treatment over the phone, and maintaining the patient-clinician relationship.
There’s also a shared vulnerability among providers and patients when visits are conducted virtually. Our patients have had requests for increased medication use, which is understandable because they’re not able to do activities that they’ve typically been able to do to keep themselves resilient. That conversation is a difficult one - in some ways it is easier because you don’t have to see someone in person, but it also makes for a very ineffective conversation because you’re not able to demonstrate your humanity through body language. Our team is struggling to wrap our head around this as we try to provide leadership and guide clinicians who are looking to us, or our state, for collective ideas around this field and how we practice.
Anna: COVID-19 has certainly impacted the way we think about responding to changing needs for those who are trying to manage their pain. Can you tell us about some of the other major changes you’ve seen in pain management over the past few years?
Andrew: The biggest thing I’ve seen is insurance expansion. We’ve known for years what you need to have effective pain management and how important it is to shift the idea of living with pain and accepting pain versus eliminating pain. We’ve seen Medicaid expansion and expansion of benefits, especially in the Northwest, that has given patients access to modalities that are effective for safer pain management.
Historically, things we knew that worked like, gym memberships, physical therapy, occupational therapy, mindfulness, and chronic pain groups, were never paid for or weren’t available. As society has changed how it believes pain should be managed, we’ve started to see the insurance side supporting these modalities more. There’s also been heavy reporting on the opioid crisis in the media that has led patients to understand that opioids have risks.
Nadejda: We’ve continued to grow and learn as a team over the past several years. Our entry point into communication around chronic pain and pain management has continued to be centered around assessing if patients and their care teams have an understanding about how pain works. We want to make sure that clinicians have the proper training and are up-to-date on evidence and resources.
Andrew: We’ve known some of this information about pain management and how pain works for a while, but it takes many years to take what we know from as a research perspective and translate it into practice. One of our roles at Synergy is to accelerate that. We’re seeing our evolution as a group mimic and reflect the experience we’re having as a culture as we start to dial in to the most effective ways to manage pain.
Anna: As Synergy continues to respond to changing societal needs around pain management, what insights can you share about the impact of academic detailing to date?
Andrew: One thing I’ve learned about academic detailing is that it’s only as effective as your intervention across an entire system. I’ve realized that any work that I’m doing is irrelevant unless I’m addressing the entire system and the culture. If the front desk staff isn’t on board, if the medical assistant isn’t a believer, if the nurse doesn’t understand addiction, if the CEO doesn’t understand that the health system is already treating these patients, there will be challenges that will be harder to overcome.
Nadejda: Because academic detailing has been an arm of a larger change approach we’re using, it’s hard to measure its effects. We don’t have data to show that only detailing has moved the needle around these topics in these ways. Sometimes I see academic detailing as the “cherry on top” after there’s a lot of work that’s been done in prepping a system. I’ve recently been doing practice facilitation work with providers and clinics just to understand the barriers in a system—there’s an art to the change process in the pain management space. Academic detailing comes in after you’ve truly understood what the barriers are. After you understand the barriers, you can bring in nuggets of evidence and information in a way that the system is ready to receive.
Nadejda Razi-Robertson is the Managing Director of Synergy Health Consulting, as well as Synergy’s project lead for the Oregon Health Authority’s Prescription Drug Overdose Prevention Project. Nadejda is a practice facilitator within health systems around the State of Oregon and provides technical assistance to clinics that are focusing QI efforts around safe opiate prescribing, MAT program development, and behavioral health integration. Over the past twelve years, she has worked in private practice with a specialty in trauma treatment, as a behavioral health provider in two Federally Qualified Health Centers (FQHCs), and as a consultant with Oregon’s Coordinated Care Organizations (CCOs) and the Oregon Health Authority supporting efforts in addressing the opioid epidemic throughout the state of Oregon.
Dr. Andrew Suchocki is a family physician with additional training in Preventive Medicine. He has worked in underserved medicine with a focus on chronic pain and addiction for ten years, and has been a medical director at an FQHC in the Portland, Oregon region for the past five. Andrew provides educational outreach and consultation in the areas of system change in primary care around opiate prescribing, MAT system design and capacity growth, coordinated specialty care, and reducing risk. Dr. Suchocki is an Oregon Opioid Prescribing Guidelines Task Force member and Oregon Medical Board consultant. He provides technical support and academic detailing for the Oregon Psychiatric Assistance Line (OPAL) which provides immediate referral sources for primary care. Dr. Suchocki also provides strategic planning, creation of innovative clinical decision support tools, physician mentoring, and health system process mapping for Yamhill County Health and Human Services, Community Corrections and Specialty Behavioral Health. He is a regular presenter at national and international pain related conferences.
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