The Six Building Blocks© were developed as part of a research project on Team Based Opioid Management in rural clinics. The three-year research study is a collaboration between 20 rural and rural-serving clinics in Washington and Idaho. Funding is provided by the U.S. DHHS AHRQ grant # R18HS023750. For further information, contact Dr. Michael Parchman, Director, MacColl Center for Innovation, Kaiser Permanente Washington Health Research Institute.

The Six Building Blocks have been adapted for the Oregon State Prescription Drug Overdose (PDO) project. This project is broader in scope and scale, involving eight regions in Oregon and their respective local healthcare communities and agencies. The target organizations vary from sole practitioners to larger health care systems. For information about the PDO project, contact Lisa Shields, PDO project manager, Oregon Health Authority. For information about the PDO Six Building Blocks, contact Mark Stephens, PDO project consultant.

CDC Guidelines Alignment: The CDC Guideline for Prescribing Opioids for Chronic Pain has 12 recommended policies for prescribers. All the CDC recommendations are incorporated in Building Block #2. We cross-reference the CDC recommendations.

Overview of the Six Building Blocks

Building Block #1: Leadership, goals, and assigned responsibilities

The organization’s leadership sets the goals for treatment of pain, both acute and chronic, and the safe use of opioids where appropriate. The goals are measurable and progress towards the goals is reviewed by leadership at least quarterly. Individuals are assigned with the responsibility of working on these goals and tracking progress and resources committed. To achieve buy-in, leadership engages all providers and clinical teams in understanding the importance of the goals and the plans for meeting them. The organization collaborates with other health care organizations and agencies in the local community to ensure good communication between all parties participating in the health and safety of patients and families in the community.

Building Block #2: Produce policies, workflows, treatment agreements, patient education materials

The organization’s goals need to be supported by corresponding policies (“What”) and associated workflows (“How”). Patient education is an essential component that explains how these clinic policies ensure patient safety and promote improved quality of life. The treatment agreement is a key part of patient education.

Building Block #3: Identify the patient population and develop ways to track progress

The patient population includes all patients receiving opioids. As the goals include pain management, both acute and chronic, organizations will consider whether to include, for example, chronic pain patients who may not be receiving opioids, but who would benefit by being included in the process improvement initiative. It may be helpful to identify high risk, complex patients within this population for more urgent action and more frequent monitoring. Each organization will determine the most efficient way to monitor this population given the tools and staff skills available.

Building Block #4: Planned, patient-centered visits

Through planned visits, conduct pro-active population management before, during, and between clinic visits of all patients on chronic opioid therapy to ensure that care is safe and appropriate. Support patient-centered, empathic communication for patient care.

Building Block #5: Caring for complex patients

Develop policies, screening tools, and resources to identify patients who are high risk, complex pain patients. This includes determining opioid dependence, addiction, substance use disorder. These patients often require diagnosis expertise and treatment options that cannot be provided with the clinics in-house resources and need to be referred to specialists. When this is indicated, the clinic has coordinated with the resources and specialists in the community and have referral agreements in place.

Building Block #6: Measuring success

The goals and clinical measures defined in building block #1 are monitored and reported on monthly or quarterly by the individual responsible in regularly scheduled (monthly/quarterly) meetings with the leadership and other providers. The leadership shares and discusses results with the clinical team and encourages suggestions for improvement. Leadership decides if any changes or adjustments to the process improvement project is needed. Changes are implemented as a high priority for the clinic/organization.

Instructions for using the Six Building Blocks and completing the Self-Assessment Questionnaire

The Six Building Blocks provides a framework for improving the treatment of patients with pain, including the use of opioids. As a starting point, we recommend that organizations do a self-assessment to evaluate their current policies and practice using a level 1 to 4 self-assessment system. We highly recommend that this initial self-assessment is done in conjunction with a consultant or practice coach with expertise in the six building blocks who has worked with other organizations. This initial self-assessment accomplishes two things. First, it clearly identifies strengths, weaknesses and gaps in how pain is treated and how safely and effectively opioids are used as compared to the CDC Guideline for Prescribing Opioids for Chronic Pain. Second, it helps the organization decide on overall goals, and identify and prioritize specific practice changes they want to make.

A common reaction to the self-assessment is that the magnitude of possible areas to address is overwhelming. However, we do not recommend that organizations take on more than they have resources or capacity to undertake. We suggest you select some high payoff areas, especially where patient safety is at risk. It is important that your clinical teams are part of the decision making process and the goals are strongly supported by everyone on the team. One component though is essential, that you have a robust system to first identify the patients and providers involved, and to track progress regularly where both leadership and the clinical teams review results and make continuously improvements.

Six Building Block Authors and Contributors

Initial version for research project on Team Based Opioid Management: Michael Parchman, Michael Von Korff, Mark Stephens, David Tauben, Laura-Mae Baldwin, Brooke Ike

Revised and expanded version for Oregon State Prescription Drug Overdose project: Above authors and Laura Heesacker, David Labby, Roger Chou, Lisa Shields, Mark Sullivan, Jim Shames, Paul Coelho, Safina Koreishi