When opioid overdoses and deaths reached stunning proportions in 2016 and 2017, and a public health crisis was declared, Dr Cole Stanley recognized that he and his colleagues might be able to better serve their patients with opioid use disorder (OUD).
Having recently completed quality improvement training by the Specialist Services Committee’s Physician Quality Improvement (PQI) initiative, Dr Stanley was enthusiastic to use the new skills to make a difference in the lives of patients.
The BOOST Collaborative
With funding from the BC Centre for Excellence in HIV/AIDS (BCCFE), Dr Stanley led a year-long quality improvement program in Vancouver called the BOOST Collaborative -- BOOST being the acronym for Best-Practices in Oral Opioid agoniST Therapy. The collaborative was intended to improve treatment outcomes for patients with OUD and proved to be quite successful in improving the retention rate of these patients, which was previously a major stumbling block. The number of individuals retained on OAT as a result of the collaborative increased from 30 to 70 per cent.
The Oral Opioid agoniST Therapy (OAT) helps patients by suppressing withdrawal, decreasing illicit opioid and cocaine use, reducing the risk of contracting HCV and HIV, providing better HIV control, decreasing criminal activity and significantly reducing mortality.
According to Dr Stanley, OUD patients often have co-existing mental health conditions and unstable housing, which make it difficult for them to stick to the strict rules of some OAT programs. Meanwhile, the health care system has long been focused on dealing with the patients in busy waiting rooms, with little time spent on thinking about those who do not show up at all.
“It turns out these ‘no-shows’ are often in need of more of our help, but they were falling through the cracks,” he said. The patients who can’t come to their appointments may find it easier to get their drugs from drug dealers rather than jump through the hoops put up by the system, which require them to come into clinics during limited working hours, or to clinics far from where they live, he explained.
To address this problem, BOOST teams started shifting to a proactive approach that included attentive follow-up for each patient. Some of steps that were developed for care providers to help patients remain on OAT, include standardized clinical data entry, regular client feedback surveys, reminder calls for appointments and expiring prescriptions, assertive outreach for clients lost to care, follow-up on missed OAT dose faxes from pharmacies, and work-flow changes to support Suboxone inductions.
“Simple things like reminder calls can push up the numbers for retention,” said Dr Stanley, confirming that when retention rates are higher, more people are kept on OAT, which protects them from overdose compared to not being on it.
BOOST through the province
Building on the success of BOOST, the BCCFE launched the collaborative province-wide in January 2019, with funding from multiple stakeholders, including Health Canada, the Shared Care Committee and Vancouver Coastal.
Currently constituting 31 teams across BC, the care providers, administrators and community members who are part of the collaborative regularly see people with OUD.
As part of the province-wide collaborative, a new standardized form for prescribing OAT was initiated that allows a better tracking system for key items like naloxone training, while decreasing the time necessary to prepare each prescription. Instead of having to look back in the chart to see previous doses and write an entirely new prescription by hand, prescribers can see the recent prescriptions and simply copy it forward or make necessary changes. Over 95 per cent of prescribers in Vancouver BOOST clinics now use this form.
What are the Joint Collaborative Committees doing?
- The Specialist Services Committee’s completed and ongoing work in the area of overdose and substance use includes a total of 14 projects: Eight projects by the Medical Staff Associations under Facility Engagement, five Physician Quality Improvement projects, and one Physician Leadership project. Find out more about these projects in The Exchange, a database of SSC’s quality improvement projects.
- The Shared Care Committee’s current and past initiatives to improve access to care in the area of mental health and substance use, include 35 projects, a provincial CYMHSU Collaborative (completed December 2017), and current support of an Adult Mental Health and Substance Use Network, and physician CYMHSU Community of Practice.
- The Shared Care Committee supports inclusion of private practice physicians and their team members in the Provincial BOOST Collaborative for 2019.
- The General Practice Services Committee is supporting a number of projects to help family doctors in the delivery of mental health care and substance use with incentive fees, education and training, and division-led initiatives. For more information, see Family Practice Incentive Program, Practice Support Program, and Divisions of Family Practice.