Virtual Launch Meeting

Six Building Blocks
Team Approach to
Improve Opioid
Management in
Primary Care
Site Launch Meeting
May 16, 2019

Agenda
• Welcome and Introductions
• Six Building Blocks Development, Evidence, and
Approach
• Six Building Blocks Clinic Implementation Guide
• Common Challenges and Solutions
• Clinic Story
• Questions and Discussion

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Welcome & Thank You
Welcome
• Sarah Shoemaker-Hunt, PhD, PharmD, Abt
Associates, Project Director
Thank You
• Deborah Perfetto, PharmD, Agency for
Healthcare Research and Quality (AHRQ),
Project Officer

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Study Team
Abt Associates
• Sarah Shoemaker-Hunt,
PhD, PharmD
• Leigh Evans, MPH, PhD
• Holly Swan, PhD
• Jaclyn Rappaport, MPP,
MBA
• Olivia Bacon

University of Washington
• Laura-Mae Baldwin, MD
• Brooke Ike, MPH
Kaiser Permanente
Washington Health
Research Institute
• Michael Parchman, MD,
MPH

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Project Overview
Aim
• AHRQ funded project to study the implementation and
effectiveness of the Six Building Blocks Clinic Implementation
Guide in primary care practices

Implementation (focus of today)
• What is the Clinic Implementation Guide?
– A self-service guide designed to support clinics as they
independently implement effective, guideline-driven care for their
patients with chronic pain and using opioid therapy

• Self-service, but we can answer clarifying questions and we
want to understand what else you needed to improve
– Email: [email protected]
– Quarterly check-in calls
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Project Overview
Evaluation
• Interviews with QI lead and four additional staff
at several time points
• Two brief online surveys for clinical staff in
participating practices
• Reported quality improvement (QI) measures
• Six Building Blocks’ milestone worksheet, selfassessment, and other documents related to
the implementation process
*Note: we will not start collecting data until late fall 2019.

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Participating Practices
• Recruited primary care practices across the U.S.
• 43 practices from 14 health care organizations
• 9 states represented
• Diverse range of types of practices:
– 5 academically-affiliated
– 4 federally-qualified health center (FQHC)
– 4 patient-centered medical homes (PCMH)
– 10 part of a health system or hospital affiliated
– 4 solo/independent practices
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Participating Practices

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Participating Practices
• Harbor Medical Group - WA

• Sheridan Medical Group - NY

• Highland Family Medicine - NY

• St. Claire Health Care - KY

• Huntridge Family Clinic - NV

• Summa Health System, Family
Medicine Center - OH

• Jericho Road Community
Health Center - NY
• Mile Square Health Centers - IL

• University Hospitals Cleveland
Medical Center - OH

• North Buffalo Medical Park NY

• Westminster Medical Clinic CO

• North Country Health Care - AZ

• The Wright Center for
Graduate Medical Education PA

• Peninsula Community Health
Services - WA

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The Six Building Blocks
How-To Guide
A Team-Based Approach to
Improving Opioid
Management in Primary
Care

The Six Building Blocks program has received funding from the Agency for Healthcare Research & Quality (R18HS023750), the Washington State Department of Health
(Subcontract HED23124 of Cooperative U17CE002734, funded by the CDC), and the Washington State’s Olympic Communities of Health. Its contents are solely the
responsibility of the authors and do not necessarily represent the official views of CDC, NIH, the WA State Department of Health, or the Olympic Communities of Health.
The Six Building Blocks Train-the-Trainer program is funded by the National Institute on Drug Abuse (Award UG1DAO13714). This program has not been reviewed by NIDA
and does not necessarily reflect the views of the Institute.

What is the
Six Building Blocks program?
An evidence-based* ‘roadmap’ or
implementation blueprint to guide clinics and
health care organizations in redesigning
opioid management processes to improve
care

*Parchman ML, et al. Ann Fam Med May 13, 2019
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The goal of the
Six Building Blocks program
To support clinics in building their capacity to
help patients with chronic pain maximize
their functional status and quality of life with
a treatment plan that minimizes risk to the
patients and their providers

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The Six Building Blocks derived from approaches taken
among 20 primary care practices across the U.S. that were
identified as having exemplar, team-based clinical
innovations.

Learning from Effective Ambulatory Practices (LEAP) study

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Learnings from these practices were organized into the Six
Building Blocks for Improved Opioid Management and
published in the Journal of American Board of Family
Medicine in February 2017

http://www.jabfm.org/content/30/1/44.full#abstract-1
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The Six Building Blocks

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The Six Building Blocks

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The Six Building Blocks program has been
tested in primary care
A research project in 20 rural and rural-serving clinics in
Eastern Washington and Central Idaho
Provided coached support for 15 months to implement the
Six Building Blocks:
o Creation of an opioid quality improvement team at each site
o Team-building Kickoff Event where clinic providers and staff completed a
self-assessment of the Six Building Blocks
o Coaching from an external practice coach on implementing best practices
for opioid prescribing – quarterly action planning
o Monthly Shared Learning Calls with other participating clinics
o Monthly UW TelePain participation

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Outcomes from the Six Building Blocks
Program
The number of patients using long term opioid therapy and the proportion
on high dose opioids decreased after implementing the Six Building Blocks
Total COT Count
2100

Percent MED ≥ 100
14%
13%

2000

12%
1900

11%
10%

1800

9%

1700

8%
7%

1600

6%

1500
-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Month

-3 -2 -1 0 1 2 3 4 5 6 7 8 9 101112131415

Month

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What one clinician said about how he felt after his
clinic implemented improvements to opioid
management using the Six Building Blocks:
"Having a defined care pathway for an emotionally
charged and complex area of care - to walk in with a
plan. It's like walking into the ER and someone having a
cardiac arrest. Not the most stressful thing I do because
we have a clear plan. Now I have the same kind of
pathway for opioids. Having what we are going to do
defined.”

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What clinic staff and providers have said about
working in the clinic after implementing the Six
Building Blocks:
“Everybody that works in
this clinic says to me, ‘do you
remember how much
turmoil there was around it?
Wow, we don’t have any of
that anymore.”
Medical Director
“The teamwork, there’s
been a lot of teamwork
regarding it. I wouldn’t
say that was a surprise,
but it’s been nice.”
Nurse

“Hopefully there’s no going
back. It works. I don’t think
any one of us wants to go
back.”
Medical Assistant
“I saw one of the high MED
patients that I inherited… we
got him down to 80... just for
him to say, ‘You know, I’m
more functional — my pain is
not different, might be
better.”
Physician

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After implementing the Six Building
Blocks, clinical teams have reported:
 Increased confidence and comfort in clinical practice
 Improved relationships with patients using long
term opioid therapy
 Increased collaboration and teamwork
 Improved ability to respond to external
administrative requests (e.g., from insurers,
governmental agencies)

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With these successes, we are ready to
scale up and spread the Six Building
Blocks program!
 We have brought the best practices and
learnings from clinics that have implemented the
Six Building Blocks into a self-service guide
 With an effective self-service guide, any clinic
has the opportunity to implement the Six Building
Blocks.

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Questions?

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The Six Building Blocks:
A guide to making
improvements to opioid
management

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Stages of Six Building Blocks Implementation

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Stage 1: Prepare & Launch
Purpose

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Stage 1: Prepare & Launch
Organization of Guide

For the preparatory work we outline:

For each meeting we outline:

 What’s going on in this step?

 Time

 How to do it

 Objectives

 Helpful resources

 Who should attend

 Milestone aims

 Helpful resources
 Agenda outline and details
 Milestone aims
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Stage 1: Prepare & Launch
Tips
 Opioid improvement team
 Self-assessment
 Data
 Kickoff

Don’t forget the hyperlinked resources!
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Stage 1: Prepare & Launch

Questions?

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Stage 2: Design & Implement
Purpose

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Stage 2: Design & Implement
Organization of the guide
 Overview
 First Action Plan meeting guide
 Future opioid improvement team meetings guide
 Tips on how to achieve milestones and overcome common obstacles
 Action plan templates and an example

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Overview

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First action plan meeting
Objectives
Reflect on what you learned
Decide on measures of success
Identify milestones
Develop an action plan

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First action plan meeting
Objectives
Reflect on what you learned
Decide on measures of success
Identify milestones
Develop an action plan
Types of measures
Reduce the number of patients with an MED
of 50/90 or higher by XX% by DATE.
Identify and label all patients on long-term-opioid
therapy with the same ICD-10 code by DATE.
Experience of front desk staff using an iPad to give patients
annual pain visit forms over the course of one week.
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First action plan meeting
Objectives
Reflect on what you learned
Decide on measures of success
Identify milestones
Develop an action plan

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First action plan meeting
Objectives
Reflect on what you learned
Decide on measures of success
Identify milestones
Develop an action plan

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Future opioid improvement team
meetings guide
Time: 1 hour
Frequency: depends on team structure, but at least monthly as working group
Purpose: these meetings are the engines of the work
Resources: www.improvingopioidcare.org
Agenda
1. Review work accomplished
2. Review data
3. Brainstorm plans and resources to handle challenges
4. Develop next action plan
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Tips on how to achieve milestones
and overcome common obstacles
For each Building Block:
An overview of the work, milestones, relevant resources, and common
challenges
Tips for accomplishing each milestone
Suggested approaches for overcoming common challenges

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Stage 2: Design & Implement
Tips
 Include staff in education
 Make it a standing meeting item
 Three legs of the stool
 Incorporate the people doing the work

Don’t forget the hyperlinked resources!

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Stage 2: Design & Implement
Tips
 Include staff in education
 Make it a standing
meeting item
 Three legs of the stool
 Incorporate the people
doing the work

“People don't start out [as] addicts, it evolves
into that. And that's what I learned from
attending the webinars, from talking to people,
from listening to the providers and their
insight. So, it was a huge learning experience
for me, and I hear the medical assistants and
the LPNs say the same thing. It's like my gosh,
these are people – these are people with
problems, you know, and they're not the
enemy. So, I think it has changed the way we
look at that population.” – Staff member

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Stage 2: Design & Implement
Tips
 Include staff in education
 Make it a standing meeting item
 Three legs of the stool
 Incorporate the people doing the
work

“And we continue to tell patient
stories as well, look at our data
and the data is important and
helpful, but also just telling good
patient stories, because that's
what sticks to physicians is that
vignette, that experience that
you're able to navigate a really
successful transition for
somebody or you're able to avoid
a new start, or whatever the case
may be.” – Provider

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Stage 2: Design & Implement
Tips
 Include staff in education
 Make it a standing meeting item

Consistent
care

 Incorporate the people doing the
work

Agreement

 Three legs of the stool

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Stage 2: Design & Implement
Tips
 Include staff in education
 Make it a standing meeting item
 Three legs of the stool
 Incorporate the people doing the
work

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Overall hints for using these
guides
 Confused by an acronym? Check the acronym list at the beginning of each guide.
 Use the “navigation pane” and search feature to find what you’re looking for
 There are additional resources hyperlinked to throughout the guides. Follow
these links and also just explore www.improvingopioidcare.org
 The callout boxes give tips from clinics like yours who have done this work.

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Stage 2: Design & Implement

Questions?

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Common challenges & solutions
• Patient Stories of Harm: intrinsic motivator
• Data: stages of grief and good v. perfect
• Patient agreements as risk communication
• Let Medical Assistants re-design workflows
• Don’t abandon patients
• Find resources or train for MH/BH co-morbidities
• Look for opioid use disorder: diagnose and treat

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Clinic Story

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St. Mary's & Clearwater Valley
HOSPITAL SYSTEM

• Frontier Area
• Loggers & Farmers
• 2 hospitals, 2 emergency rooms, 8 clinics served
by 2 medical staffs
• Began our journey in 2015

First Steps
• Defining what chronic opioid
therapy is
• Know which patients are COT
• Develop a practice philosophy
• Policy-offer clinical discretion

Clinic Philosophy
Consistency & Support

Nursing-Your Advocate

Define Your Goal
• It’s about safer prescribing-- not getting to 0
• Let clinicians decide who to taper
• Stick to your methodology for reporting

Challenges

Walk This Road Together

Operationalizing the Measures

Measures
• Balance your pace
• Baselines may challenge you
• PDSA

Christine Packer M.Ed, Chief Strategy Officer
Clearwater Valley & St. Mary’s Hospitals & Clinics
[email protected]
208-850-7245

Questions

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Next Steps and Wrap Up
• Please look out for information regarding
scheduling the first check-in call
• Stage 3: Monitor and Sustain Guide will be
provided in the coming months

For questions or comments, please contact us at:
[email protected]

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