“Passionate, engaged” VCH front-line staff at the heart of the BOOST Collaborative

The BOOST Collaborative (Best-practices in Oral Opioid agoniSt Therapy) is a pilot project launched in September 2017 and spearheaded by the BC Centre for Excellence in HIV/AIDS and driven by VCH frontline staff to improve treatment outcomes for clients living with opioid use disorder.

Over 70 frontline staff and physicians from approximately 20 teams across primary care, mental health, substance use and outreach services in Vancouver are involved in the Collaborative including staff from Raven Song CHC, Three Bridges CHC, and South Mental Health.

“When it comes to fine tuning how we deliver care to our clients, it makes sense to involve the staff delivering the care,” says Dr. Rolando Barrios, Senior Medical Director, VC. “It also makes sense to follow other successful models of care.” That’s exactly what the BOOST Collaborative is doing by implementing a model of care used originally for HIV/AIDS clients to ensure they were supported to keep to their specific treatment plan, which could mean the difference between life and death. It too was driven by front-line staff.

The successful Vancouver-made HIV/AIDS model of care is being used to support front-line staff to regularly check in on thousands of people in the city on opioid-agonist therapy (methadone, suboxone, and slow release oral morphine) to ensure they don’t miss a day of treatment. “Evidence shows that people with opioid use disorder will reduce illicit use and stay in treatment longer with appropriate therapy, reducing their risk for overdose death,”explains Dr. Barrios. “The current retention rate for people on opioid-agonist therapy is only 30 per cent. We need to increase that rate and in the process literally save lives.”

The BOOST Collaborative is all about thinking big but starting out small. The Collaborative brings together front-line staff and physicians into self-made teams who work together to develop and implement ideas that will help people living with opioid-use disorder access treatment and remain engaged in care and reduce some of the burden of the current opioid crisis.

Dr. Cole Stanley

VCH News sat down with Dr. Cole Stanley, Medical Lead for Quality Improvement (QI) for Vancouver Community, and Family Physician at Raven Song Community Health Centre and the John Ruedy Clinic (HIV Primary Care) at St. Paul’s Hospital, to ask him why he got involved with this program and why he believes this innovative pilot project could help alleviate the opioid crisis.

How did you become involved in the BOOST Collaborative?

When I took on my new role as Medical Lead for QI at the start of 2017, we were well into the opioid crisis, which I had witnessed first-hand in my primary care practices. There appeared to be significant room for improvement when considering engagement of our clients and their retention in appropriate therapies. Dr. Rolando Barrios and the BC-CfE (BC Centre For Excellence in HIV/AIDS) team had successfully used a Collaborative approach to improve HIV viral suppression rates in recent years and saw an opportunity to apply this framework again. He asked me to work as Medical Lead for BOOST, which has frontline team QI work at its core.

Why do you think the BOOST Collaborative is important?

The obvious answer here is that frontline teams want to provide optimal care for our clients and we know the stakes are high. The Collaborative gives us a framework for working towards this goal, using a tried and tested approach that allows us to create a community of learning in which teams collaborate with each other to discuss common issues, share ideas, and spread best practices. Beyond this, we are increasing our teams’ QI expertise so that they can apply the approach to other systemic care challenges as they are identified.

What makes the BOOST Collaborative different from other initiatives?

Two things come to mind here when comparing to other initiatives for change. First, the frontline staff are valued for their expertise and indeed are the drivers for this change. They can design changes instead of simply being told by their bosses to do something differently. Secondly, the changes can happen much more rapidly, so that we are constantly progressing and weeding out ideas that don’t work in the real world. This is different than the “analysis paralysis” that can plague planning meetings, which risks late deployment of overbaked, untested “solutions”.

What are the challenges staff and clinics are facing right now in light of the current opioid emergency? 

There are plenty of challenges, but as QI lead I like to instead think of these as potential areas for improvement. The current opioid crisis has taken an enormous emotional toll on our staff. How can we improve the environment so that we have happier staff who will be better equipped to provide the best possible care? Staff and clients can encounter broader system challenges when trying to get treatment. How can we work within our own system to remove these challenges, and how can we implement change? That’s the opportunity that the BOOST Collaborative provides.

Why do you think VCH staff are up to the challenge of addressing challenges in care for people living with opioid use disorder (OUD)?

It is clear from the staff in my own clinics and from the other BOOST teams that there is no shortage of passionate, engaged folks wanting to do the best they can with the resources they have. When given the time and framework for addressing these challenges, teams have readily taken up the call. There have been significant improvements in clinic processes since we launched this past September and I am confident that we will continue to implement successful initiatives as we move forward.

Are there some positive early outcomes you can share?

Our improvement work hinges on us having a reliable list of who our clients are. Teams have done great work to get accurate lists for their Population of Focus (their clients with opioid use disorder). This involves ensuring this is set up correctly in the EMR (Electronic Medical Record), and people with the standard diagnostic code for opioid use disorder have been listed accurately in the system. Having an accurate Population of Focus is key in our efforts to improve engagement and retention. For instance, when we started out, we had a list of approximately 600 people with Opioid Use Disorder. When we finished implementing our new tracking system, we had about 2800 people. We can’t help get people into treatment and ensure they remain in treatment until we know who they are. Teams also worked hard on having prescribers adopt use of a standardized form for creating prescriptions and tracking a few key items (eg. naloxone training, duration on therapy, etc). We now have over 90 per cent of prescribers using this standardized form. At the individual site level, we see that teams are implementing multiple small steps leading to big improvements, with reports of lower missed doses, missed appointments, etc. So, these changes are starting to work in terms of retaining clients in therapy on their recovery journey.

Written in partnership with the BC Centre for Excellence in HIV/AIDS

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