Caring for complex patients

Develop policies and resources to ensure that patients who develop opioid use disorder and/or who need mental/behavioral health resources are identified and provided with appropriate care, either in the care setting or by outside referral.

Why is this important?

Some patients require more support because their chronic pain is complicated by other conditions, such as mental/behavioral health challenges. Others have developed opioid use disorder or an addiction. Identifying additional resources for these patients and creating systems to connect patients to these resources is essential for an effective chronic pain management plan. Some of these resources might be developed or brought “in-house” within the primary care clinic setting, others will need to be identified in the local community and linkages established to them.

Katsura Medical Center integrated behavioral health services so that the counselors come on site to the clinic to learn more from providers and give feedback as needed.

Example activities

  • Select tools and how to use them for identifying complex patients
  • Ensure clear referral pathways for complex patients and a system for closing the loop on referrals

Develop policies and resources to ensure that patients who develop opioid use disorder and/or who need mental/behavioral health resources are identified and provided with appropriate care, either in the care setting or by outside referral.

16. Identifying complex patients 123 456 789 101112
Policies, clinic-selected screening tools, and workflows to identify opioid misuse, diversion, addiction, and to recognize mental/behavioral health needs… …do not exist. …partially exist. …exist, but are only partially implemented. …exist and are consistently implemented.
17. Behavioral health resources 123 456 789 101112
Mental/behavioral health services… …are difficult to obtain reliably. …are available from behavioral health specialists but aren’t timely or convenient. …are available from behavioral health specialists and are usually timely and convenient. …are readily available from behavioral health specialists who are onsite or who work in an organization that has a referral protocol or agreement with our practice setting.

Caring for Complex Patients resources

Tips for managing legacy patients: Suggestions for how to approach patients you have inherited from another clinician.

Intensity & frequency of monitoring by risk example: How one clinic handled setting monitoring approaches by risk level.

Buprenorphine information from SAHMSA: Buprenorphine is used in medication-assisted treatment (MAT) to help people reduce or quit their use of heroin or other opiates, such as pain relievers like morphine.

Naloxone information from SAHMSA: Naloxone is a medication used in medication-assisted treatment (MAT) to counter opioid overdose.