Tracking & monitoring patient care

Implement proactive population management before, during, and between clinic visits of all patients on chronic opioid therapy.

Why is this important?

Identifying who is on long-term opioid therapy for their chronic pain is important for three reasons: 1) this is an “at-risk” population so identifying who they are provides both an opportunity to risk-stratify them and also produce reports about them so that they don’t “fall between the cracks” of a busy primary care clinic; 2) a population tracking system can be used to identify care gaps between scheduled visits and conduct follow-up with those patients; and 3) population tracking provides an opportunity to track if efforts to improve care are successful.

Raven Medical Center has a nurse, pharmacist, prescriber chronic pain patient review team that identifies and monitors patients on high opioid doses and offered specific recommendations to help providers decide how to make changes.

Example activities

  • Produce a report of current patients on chronic opioid therapy
  • Identify data and measures needed for pre-visit planning and monitoring success

Implement pro-active population management before, during, and between clinic visits of all patients on chronic opioid therapy.

8. Tracking & monitoring of patients prescribed chronic opioids 123 456 789 101112
Use of a system to proactively track & monitor patients prescribed chronic opioids to ensure their safety… …has not been explored or is not possible with existing data systems. …is technically possible, but systems to get useful reports are not yet in place. …is possible and systems are in place to produce basic reports on a regular basis. …is possible, systems are in place, and reports are produced that allow for tracking of patient care and monitoring of clinician practices.
9. Tracking & monitoring data collection workflows established 123 456 789 101112
Workflows to enter data into the tracking & monitoring system… …have not been developed. …are in development, but not established. …are established, but aren’t consistently implemented. …are established and consistently implemented. Responsibilities are assigned and protected time is available to complete assigned responsibilities.
10. Tracking & monitoring data use workflows established 123 456 789 101112
Workflows to use data to track patient care and monitor clinician practices… …have not been developed. …are in development, but not established. …are established, but aren’t consistently implemented. …are established and consistently implemented. Responsibilities are assigned and protected time is available to complete assigned responsibilities.

Tracking & Monitoring Patient Care resources

Morphine Equivalent Dose (MED) calculator

Approaches to identifying patients on chronic opioids: Suggested approaches to try when first attempting to identify your patients on chronic opioid therapy.

Purposes of tracking & monitoring: An outline of the key uses of data in tracking & monitoring patients on chronic opioid therapy to use when planning your approach.

Data to consider tracking: A list of variables to consider tracking and monitoring for care planning and measuring success.

Tracking & Monitoring example spreadsheet: An Excel spreadsheet a clinic can adapt to track and monitor key measures overall and by provider if they are unable to easily pull reports from their EMR.

List of opioid names: A list of opioids to use in identifying patients on chronic opioid therapy.

List of sedative names: A list of sedatives to use in identifying patients on concurrent sedatives and opioids.