Care Model For Pain Management Research Articles

Stepped Care Models for Chronic Pain


 CADTH included 6 reports describing the potential clinical benefits of 5 stepped care models for chronic pain in this review.
 
 The randomized controlled trial of the stepped care model for patients who are overweight or obese with chronic pain due medial tibiofemoral osteoarthritis described the impact on pain remission, pain intensity, and function.
 The before-after and retrospective cohort study of the Stepped Care Model of Pain Management described the effects on pain, quality of chronic pain care, pharmacotherapy use, and health care utilization in US veterans.
 The before-after study of the biopsychosocial stepped care model for non-cardiac chest pain described the potential benefits on chest pain, depression, anxiety, quality of life, and health care use.
 The prospective cohort study of the Stepped Care Strategy compared a cohort of patients who received stepped care strategy-consistent care for hip or knee pain due to osteoarthritis with a cohort who received stepped care strategy-inconsistent care and described the results on pain physical function, self-efficacy, active pain coping, and health care use.
 The Evaluation of Stepped Care for Chronic Pain randomized controlled trial described the effects on pain, disability, and pharmacotherapy use in US veterans.
 
 
 CADTH included 1 cost-effectiveness analysis that described the cost implications of a stepped care pathway for treating sciatica pain.
 While all included models used a stepped care approach to chronic pain management, the models were customized, and the evaluation methods were heterogeneous.

Tools, Time, Training, and Team-Military Primary Care Providers' Perspectives on Improving Chronic Pain Assessment and Management.

Primary care providers are on the front lines of chronic pain management, with many reporting frustration, low confidence, and dissatisfaction in handling the complex issues associated with chronic pain care. Given the importance of their role and reported inadequacies and dissatisfaction in managing this challenging population, it is important to understand the perspectives of primary care providers when considering approaches to chronic pain management. This qualitative descriptive study aimed to comprehensively summarize the provider challenges and suggestions to improve chronic pain care in military primary care settings. Semi-structured interviews with 12 military primary care providers were conducted in a single U.S. Army medical center. All interviews were audio-recorded and lasted between 30 and 60 minutes. Interview transcripts were analyzed using ATLAS 9.0 software. Narratives were analyzed using a general inductive approach to content analysis. The Framework Method was used to organize the codes and emergent categories. All study procedures were approved by the Institutional Review Board of the University of Washington. Four categories captured providers' challenges and suggestions for improving chronic pain care: (1) tools for comprehensive pain assessment and patient education, (2) time available for each chronic pain appointment, (3) provider training and education, and (4) team-based approach to chronic pain management. Providers suggested use of the Pain Assessment Screening Tool and Outcomes Registry, more time per visit, incorporation of chronic pain care in health sciences curriculum, consistent provider training across the board, insurance coverage for complementary and integrative therapies, patient education, and improved access to interdisciplinary chronic pain care. Lack of standardized multifaceted tools, time constraints on chronic pain appointments, inadequate provider education, and limited access to complementary and integrative health therapies are significant provider challenges. Insurance coverage for complementary and integrative health therapies needs to be expanded. The Stepped Care Model of Pain Management is a positive and definite stride toward addressing many of these challenges. Future studies should examine the extent of improvement in guidelines-concordant chronic pain care, patient outcomes, and provider satisfaction following the implementation of the Stepped Care Model of Pain Management in military health settings.

Collaborative Care Management for Community-Dwelling Older Adults Prescribed Opioids: A Summary of Pilot Program Findings

<h3>Introduction</h3> Pain is highly comorbid with mental health problems, and can lead to significant disability and loss of function. Pain is common among older adults, with approximately half of older adults nationwide reporting experiencing bothersome pain in the preceding month. The treatment of pain in later life is complicated by a variety of factors, and there are significant safety risks associated with the use of analgesics, especially opioids. Multimodal strategies and collaborative care models that employ both non-pharmacological and pharmacological methods of pain care management may be especially promising in treating pain and improving outcomes. The objective of this project was to explore preliminary results from a pilot study of a telephone-delivered collaborative care service designed for community-dwelling older adults with chronic pain receiving prescriptions for high doses of opioids. Specifically, we were interested in examining program feasibility and acceptability, the extent to which engaged patients and their prescribers achieved opioid dose reduction, and changes in patient-level symptoms (e.g., pain severity and interference, depressive symptoms). <h3>Methods</h3> Eligible participants included 82 older adults referred by the Pennsylvania Department of Aging's pharmaceutical assistance program for low-income seniors (PACE/PACENET) to the University of Pennsylvania/PACE Behavioral Health Laboratory program. Referred patients were identified as receiving chronic opioid prescriptions for > 120 mg morphine-equivalent dose (MED) per day. Upon enrollment, patients first completed a comprehensive baseline clinical assessment. Clinical data on mental health, cognition, pain and functional status, as well as self-reported daily opioid dose and biopsychosocial needs, were collected over the phone and entered into the program's informatics tool. Patients next engaged in a series of telephone sessions during which care managers offered individualized treatment planning. Program goals included opioid dose reduction to safer levels and improved pain and psychosocial outcomes. Treatment modalities offered included: (1) behavioral pain management, (2) general medication education, (3) reinforcing positive health behaviors, (4) addressing barriers to change, (5) scheduling positive activities, and (6) relaxation techniques. Following each session, summary reports were sent to prescribers with recommendations for pain care management and opioid dose reduction. <h3>Results</h3> Enrolled patients were on average 73.5 (+/-6.1) years old, and the majority were non-Hispanic white (91%) and female (70%). Seventy-seven percent of the sample met criteria for clinically significant anxiety or depressive symptomatology. Of the 82 patients completing the baseline assessment, 53 (65%) engaged in the program. Patients were considered engaged in the program if they completed the baseline assessment and two or more additional follow-up contacts with a care manager. Those who engaged in the program did not differ on sociodemographic or clinical characteristics or baseline reports of pain when compared to those who did not engage. Pre-post intervention comparisons suggest a significant reduction in medication dose at the last contact relative to baseline. Further, at their last clinical contact, 66% of engaged patients achieved dose reductions of >20%. While there were no significant changes in pain interference or pain-related self-efficacy, engaged patients did report reductions in pain severity (p=0.05) and depressive symptoms (p=0.003) at the last contact relative to baseline. Preliminary findings also suggest that patients who achieved dose reductions of >20%, compared to those who did not, showed greater reductions in depressive symptoms and pain interference at the last contact relative to baseline. Pharmacy record data comparing those who engaged versus those who did not engage in the program were also collected for analysis. <h3>Conclusions</h3> In conclusion, the findings provide preliminary support for the feasibility of a community-based, collaborative care model for pain management and suggest the potential for positive treatment outcomes. The results also support further development and evaluation of collaborative care models that aim to address opioid use in later life. <h3>Funding</h3> Pennsylvania Department of Aging, PACE/PACENET program

Evaluation of a Collaborative Care Management Program for Community-Dwelling Older Adults on High-Dose Opiates

Treating pain in later life is complex, and there are significant safety risks associated with the use of analgesics, particularly opioids. This study examined preliminary results from a pilot study of a telephone-delivered collaborative care service designed for community-dwelling older adults with chronic pain receiving prescriptions for high doses of opioids (i.e., >120 mg morphine-equivalent dose). Eighty-two older adults referred by the Pennsylvania Department of Aging’s pharmaceutical assistance program for low-income seniors (PACE/PACENET) were eligible and enrolled in the program (i.e., the University of Pennsylvania/PACE Behavioral Health Laboratory). Patients were on average 73.5 (+/-6.1) years old, and the majority were white (91%) and female (70%). Patients completed a comprehensive baseline clinical assessment capturing their mental health, cognition, pain and functional status, as well as self-reported daily opioid dose and biopsychosocial needs. Patients were considered engaged in the program if they completed 2+ additional follow-up contacts with a care manager. During these contacts, care managers offered individualized treatment planning, with the goal of opioid dose reduction to safer levels. Of the 82 patients completing the baseline, 53 (65%) engaged in the program. At their last clinical contact, 91% of engaged patients achieved dose reductions (with 66% achieving dose reductions of >20% and 30% reporting doses <120 mg morphine-equivalent dose). Engaged patients also reported significant reductions in pain severity (p=0.05) and depressive symptoms (p=0.003) at the last contact relative to baseline. Findings support the feasibility of a community-based, collaborative care model for pain management and suggest the potential for positive treatment outcomes.

Project STEP: Implementing the Veterans Health Administration's Stepped Care Model of Pain Management.

The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services. An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care. Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013). We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data. We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology. Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.

Improving pain care through implementation of the Stepped Care Model at a multisite community health center.

PurposeTreating pain in primary care is challenging. Primary care providers (PCPs) receive limited training in pain care and express low confidence in their knowledge and ability to manage pain effectively. Models to improve pain outcomes have been developed, but not formally implemented in safety net practices where pain is particularly common. This study evaluated the impact of implementing the Stepped Care Model for Pain Management (SCM-PM) at a large, multisite Federally Qualified Health Center.MethodsThe Promoting Action on Research Implementation in Health Services framework guided the implementation of the SCM-PM. The multicomponent intervention included: education on pain care, new protocols for pain assessment and management, implementation of an opioid management dashboard, telehealth consultations, and enhanced onsite specialty resources. Participants included 25 PCPs and their patients with chronic pain (3,357 preintervention and 4,385 postintervention) cared for at Community Health Center, Inc. Data were collected from the electronic health record and supplemented by chart reviews. Surveys were administered to PCPs to assess knowledge, attitudes, and confidence.ResultsProviders’ pain knowledge scores increased to an average of 11% from baseline; self-rated confidence in ability to manage pain also increased. Use of opioid treatment agreements and urine drug screens increased significantly by 27.3% and 22.6%, respectively. Significant improvements were also noted in documentation of pain, pain treatment, and pain follow-up. Referrals to behavioral health providers for patients with pain increased by 5.96% (P=0.009). There was no significant change in opioid prescribing.ConclusionImplementation of the SCM-PM resulted in clinically significant improvements in several quality of pain care outcomes. These findings, if sustained, may translate into improved patient outcomes.

Stepped care model of pain management and quality of pain care in long-term opioid therapy.

Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.

Improving the management of chronic non-cancer pain in primary care: Results of a multifaceted quality improvement initiative

How the research advances dissemination and implementation research: The management of chronic pain poses a significant challenge for primary care practices, particularly those caring for medically underserved patient populations. Experience in the Veterans Health Administration (VHA) has demonstrated that implementation of a Stepped Care Model for Pain Management (SCM-PM) can improve outcomes for patients with chronic pain. In this project, we advance the dissemination and implementation research by describing the use of the Promoting Action on Research Implementation in Health Services (PARIHS) Framework to guide the adaptation, implementation, and dissemination of the SCM-PM to a non-VHA setting-a large, statewide Federally Qualified Health Center.

A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management.

Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined. Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period. As part of a comprehensive implementation evaluation of performance improvements, the current evaluation reports performance improvement outcomes related to pain management and OT over a four-year period. We studied Veterans receiving long-term (90+ consecutive days) OT through primary care. We engaged an interdisciplinary clinical-research team to develop and implement a multifaceted performance improvement approach that included interactive educational strategies and other organizational initiatives. We measured the proportion of patients receiving long-term OT; use of opioid risk mitigation strategies; referrals to pain-related specialty services; and use of non-opioid analgesics. The proportion of patients receiving high-dose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased. We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project's design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.

(449) Opioid prescribing and the Stepped Care Model of Pain Management in the Veteran's Health Administration

(449) Opioid prescribing and the Stepped Care Model of Pain Management in the Veteran's Health Administration

Implementation of the veterans health administration national pain management strategy.

Since its introduction in 1998, the VHA National Pain Management Strategy has introduced and implemented a series of plans for promoting systems improvements in pain care. We present the milestones of VHA efforts in pain management as reflected by the work of the Strategy. This includes the development of the Strategy and its current structure as well as a review of important initiatives such as "pain as the fifth vital sign" and the stepped care model of pain management.