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

• Published in: Pain medicine (Malden, Mass.) Vol. 19; no. suppl_1; pp. S30 - S37
• Main Authors: Edmond, Sara N, Moore, Brent A, Dorflinger, Lindsey M, Goulet, Joseph L, Becker, William C, Heapy, Alicia A, Sellinger, John J, Lee, Allison W, Levin, Forrest L, Ruser, Christopher B, Kerns, Robert D
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01-09-2018
• Subjects: Aged; Analgesics; Analgesics, Opioid - administration & dosage; Anti-Inflammatory Agents, Non-Steroidal - administration & dosage; Cohort Studies; Delivery of Health Care, Integrated - methods; Delivery of Health Care, Integrated - trends; Electronic medical records; Female; Health services utilization; Humans; Male; Middle Aged; Narcotics; Opioids; Pain; Pain - diagnosis; Pain - drug therapy; Pain - epidemiology; Pain management; Pain Management - methods; Pain Management - trends; Patient-centered care; Primary care; United States - epidemiology; United States Department of Veterans Affairs - trends; Veterans; Veterans Health - trends; United States; Primary Care; Pain Management; Stepped Care Model of Pain Management
• ISSN: 1526-2375; 1526-4637
• DOI: 10.1093/pm/pny094

Abstract
Objective
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.
Design
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.
Subjects
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).
Methods
We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data.
Results
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.
Conclusions
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.