This is the closing out stage in which the Practice Coach helps prepare the site to continue the work of improving chronic opioid management independently. During this stage, the Practice Coach leads the Opioid Improvement Team in reviewing accomplishments and making a plan to overcome current challenges and move forward independently. After a close-out visit, the practice continues the work not yet accomplished and continues to monitor and improve.

Download Monitor & Sustain Stage Activities Checklist

This is a starting list of activities for this stage, which you can adapt to your needs.

Building Block Activities
Leadership & consensus

  • Continue to protect time for improvement team to meet
  • Emphasize project importance with updates at weekly & monthly staff meetings
  • Assess adequacy of resources needed for tracking and monitoring and identify additional resources if needed
  • Identify specific clinicians/patients with successes and share stories
  • Obtain feedback from staff and clinicians and adjust as necessary
  • Identify reluctant providers and identify strategies to improve engagement
  • Stay up to date with guidelines (Medicaid, AMDG, CDC, etc.)
Policies, patient agreements, & workflows

  • Revisit and revise policies, patient agreements, and workflows, as needed based on experiences and new evidence
Tracking & monitoring patient care

  • Adjust and iterate best possible tracking & monitoring approaches for pre-visit planning & monitoring success
Planned, patient-centered visits

  • Offer training opportunities for empathic communication and patient involvement
  • Adjust and iterate workflows to risk-stratify patients, identify COT patients, review their charts for care gaps, and prepare for visits
Caring for complex patients

  • Ensure clear referral pathways for complex patient resources and close the loop on referrals
  • Implement and iterate workflows to screen for and identify complex patients
Measuring success

  • Produce provider-specific reports on COT performance measures and discuss during medical staff meetings
  • Regularly review performance measure data (run charts) at the level of the clinic during all staff meetings and other opportunities
  • Identify additional opportunities for improvement and implement small cycle tests of change