This is the closing out stage in which the Practice Facilitator helps prepare the site to continue the work of improving opioid management independently. During this stage, the Practice Facilitator uses the Monitor and Sustain Workbook to lead the Opioid Improvement Team in reviewing baseline goals, celebrating successes, and making plans to move forward independently and sustain the work. After close-out meetings with the Practice Facilitator, 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 ongoing work after the facilitation support ends, which you can adapt to your needs.

Building Block Activities
Leadership & consensus

  • Continue to protect time for improvement team to meet and work
  • Continue to engage leadership, staff, and clinicians by regularly sharing data and stories
  • Assess adequacy of resources needed to support opioid management processes and identify additional resources if needed
  • Obtain feedback from staff and clinicians and adjust as necessary
  • Identify reluctant clinicians and staff and identify strategies to improve engagement
  • Stay up to date with guidelines (Medicaid, CDC, state, 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
Planned, patient-centered visits

  • Offer educational opportunities in opioid management, empathic communication, and patient involvement
  • Integrate opioid management processes into standard trainings, including onboarding new employees
  • When workflows need development or updating, involve those who will do the work and do small cycle tests of change before implementing changes across the organization
Caring for patients with complex needs

  • Ensure clear referral pathways for OUD and mental/behavioral health patient resources and close the loop on referrals
  • If not already in place, consider providing opioid use disorder treatment within the clinic
Measuring success

  • Produce provider-specific reports on performance measures and discuss during medical staff meetings
  • Regularly review performance measure data 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