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.

Identifying High Risk, Complex Patients 1234 Describe briefly what your clinic is currently doing.
The clinic has policies, screening tools, and work flows to identify opioid misuse, diversion, abuse, addiction and for recognizing complex opioid dependence. Recommended screening tools are PHQ-4, PC-PTSD, FSQ, PCS, and PEG. Clinic consistently uses agreed screening tools.
Care Plans for High Risk, Complex Patients 1234 Describe briefly what your clinic is currently doing.
Each patient has a specific care plan addressing the identified risks.  This may involve tapering, conversion to buprenorphine, behavioral health consultation if available in the clinic and/or referral to specialists in pain, addiction, behavioral health.  Patients are monitored monthly by clinic leadership.
Behavioral Health (Mental Health Care and Addiction Treatment) 1234 Describe briefly what your clinic is currently doing.
The clinic has behavioral health (mental health and chemical dependency) services readily available from behavioral health specialists who are onsite or who work in an organization that has a referral agreement.  Process are in place to ensure timely treatment.