Tracking & monitoring patient care

Implement proactive population management before, during, and between clinic visits of all patients on long-term 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.

XYZ Medical Center has chronic pain management team, comprised of a nurse, pharmacist, and prescriber, 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 long-term opioid therapy
  • Identify data and measures needed for pre-visit planning and monitoring success

Self-Assessment Questions Resources