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Six Building Blocks

Six Building Blocks is an evidence-based quality improvement roadmap that helps primary care teams implement effective, guideline-driven care for their chronic pain and long-term opioid therapy patients.

The program focuses on six key areas:

  • Leadership and consensus
  • Policies, patient agreements and workflows
  • Tracking and monitoring patient care
  • Planned, patient-centered visits
  • Caring for patients with complex needs
  • Measuring success

Six Building Blocks can help anyone who is interested in improving the care of patients using long-term opioid therapy, such as:

  • Quality improvement personnel
  • Clinicians and staff
  • Clinic administrators
  • Practice facilitators

We Can Help

Comagine Health provides technical assistance to sites implementing the Six Building Blocks program. If you would like assistance or have questions, please send us an email at

Learn More About Each of the Six Building Blocks

Leadership and Consensus

Demonstrate leadership support and build organization wide consensus to prioritize more selective and cautious opioid prescribing.

Leadership plays an important role by:

  • Prioritizing the work
  • Creating opportunities for conversations among providers and staff to reach a shared understanding of how patients on chronic opioid therapy are managed.
  • Taking part in setting clinicwide performance goals
  • Helping providers and staff understand their roles and responsibilities with patients on long-term opioid therapy
Policies, Patient Agreements and Workflows

Revise, align and implement clinic policies, patient agreements and workflows for health care team members to improve opioid prescribing and care of patients with chronic pain.

  • Clinic policies about opioid prescribing for chronic pain create a shared understanding and agreed upon standards for managing patients on long-term opioid therapy.
  • It is important to align patient agreements with clinic policies, and many clinics find it helpful to view signed patient agreements as a type of informed consent that is used to communicate risks to patients.
  • Measures to track quality improvement efforts should be informed by the content of clinic policies and patient agreements.
Tracking and Monitoring Patient Care

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

It is important to identify who is on long-term opioid therapy for their chronic pain.

  • This is an “at-risk” population. Identifying who they are provides an opportunity to risk-stratify them as well as produce reports about them so that they are not overlooked in a busy primary care clinic.
  • A population tracking system can be used to identify care gaps between scheduled visits and to conduct follow-up with those patients.
  • Population tracking provides an opportunity to track effectiveness of efforts to improve care.
Planned, Patient-Centered Visits

Prepare and plan for the clinic visits of all patients on long-term opioid therapy. Support patient-centered, empathic communication for care of patients on long-term opioid therapy.

This is where the team can make a big impact!

  • Care gaps can be identified by “scrubbing charts” the day before or during the morning huddle, and tasks that close those gaps can be delegated to team members.
  • Clinicians and staff can briefly rehearse how to have difficult conversations with those few patients who have demonstrated aberrant behaviors, such as early prescription refill requests or an abnormal urine drug test.
Caring for Patients With Complex Needs

Develop policies and resources to ensure that patients who develop opioid use disorder and/or who need mental/behavioral health resources are identified and provided with appropriate care, either in the primary care setting or by outside referral.

Chronic pain can be complicated by other conditions, namely mental/behavioral health conditions, opioid use disorder (OUD), and/or other substance use disorders.

  • Insufficiently addressed mental/behavioral health conditions can interfere with successful pain management.
  • For patients with opioid use disorder, the full agonist opioids used to treat pain (e.g., oxycodone, hydrocodone) are rarely the best choice and often the wrong medication for their pain.
  • Medications such as buprenorphine, naltrexone and methadone are needed for patients with opioid use disorder in addition to treatment for their chronic pain.

Identifying additional, appropriate resources for these patients and creating systems to connect patients to these resources is essential for an effective chronic pain management plan.

Measuring Success

Continuously monitor progress and improve with experience.

Teams need to see that the changes they have been asked to implement are having the desired effect. Selecting a set of one or more measures to track over time and providing that information to the entire clinic team at the local level is crucial to improving and sustaining the work.

Measures might be process-related, like proportion of patients with a signed updated patient agreement, or more outcome-based, such as proportion of patients on high-dose opioids. Set a goal for improvement over a reasonable time period and give frequent progress updates to clinicians and staff.


The Six Building Blocks program was developed by the University of Washington Department of Family Medicine and Kaiser Permanente Washington Research Institute.

This project was originally supported by a grant from the Agency for Healthcare Research and Quality (R18HS0237850). Additional funding was provided by Washington State Department of Health, National Institute on Drug Abuse and the Washington State’s Olympic Communities of Health. Additional support was provided by the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality, CDC or WA DOH.