QUERI – Quality Enhancement Research Initiative

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Improving Pain-Related Outcomes for Veterans (IMPROVE)

VA Connecticut Healthcare System and VA Palo Alto Health Care System

Program Leadership
Principal Investigators: William Becker, MD (West Haven VA), Alicia Heapy, PhD (West Haven VA), and Amanda Midboe, PhD (VA Palo Alto).
Program Manager: Leonore Okwara (Leonore.Okwara@va.gov).

Principal Operational Partners: VHA Pain Management, Primary Care Services, and Pharmacy Benefits Management (PBM).

Executive Summary:

Among Veterans treated in the VA healthcare system, chronic non-cancer pain is highly prevalent (up to 50% of patients) and a major contributor to poor health-related quality of life. VA primary care teams - responsible for most of chronic pain care - report feeling overburdened, under-resourced, and generally ill-equipped to meet the needs of Veterans with chronic pain. In some cases, this results in low-quality pain care that is unsatisfactory for patients and providers, and is sometimes unsafe. Consistent with recommendations from the Institute of Medicine (IOM) and the U.S. Department of Health and Human Services (HHS), the primary goal of this Program is to improve safe and effective pain management through partnered implementation of personalized, proactive, patient-centered interventions that optimize access to care.

Program MyVA Goals: Improving Veterans' access to and experience with VA healthcare. The MyVA initiative will reorient VA around Veterans' needs and empower employees to assist them in delivering excellent customer service to improve their experience with VA healthcare.

Program Objectives:

To improve function and quality of life and also decrease morbidity and mortality among patients with chronic pain, a growing body of research and expert consensus support multi-modal pain care. In this type of care, evidence-based non-pharmacologic treatment modalities are incorporated alongside pharmacologic treatment and reduction in high-dose opioid therapy and avoidance of opioid-benzodiazepine combination therapy. Although efficacious non-pharmacologic interventions exist, determining which patients might be best served by which interventions is a challenge for primary care; moreover, referral to specialty programs often is overly complex, time-consuming or even unavailable. To address needs for specific strategies and tools, this QUERI program has assembled an expert team of implementation scientists, clinical researchers with extensive expertise in pain management - and has partnered with clinical leadership to create a consortium of inter-related and complementary projects that address cross-cutting quality gaps in pain care. Specific project objectives include developing and refining implementation tools and strategies that facilitate uptake and increase access to evidence-based, multi-modal pain management services.

Program Methods:

Develop an informatics tool that will support the proactive identification of patients through automated case finding. Optimize the implementation strategy through formative work, guided by the Consolidated Framework for Implementation Research (CFIR), to identify factors that facilitate or hinder uptake of the interventions. Investigators also will evaluate the effectiveness of the implementation strategies on the uptake of evidence-based, multi-modal pain management services, with an emphasis on unburdening patient-aligned care teams (PACTs) and conserving local resources. Investigators will work with their operational partners (see below) to refine, evaluate, and disseminate these programs and policy initiatives to promote safe, effective, and patient-centered care for Veterans with chronic pain.

Project Summaries:

Project 1: Reach Veterans who currently do not have access to pain management resources by helping patients use cognitive behavioral therapy to manage their pain through an automated Interactive Voice Response system called "Cooperative Pain Education and Self-management." (PIs: Heapy & Piette)

Project 2: Utilize Primary Care-integrated Pain Support - a care management strategy - to decrease the number of Veterans using opioid-benzodiazepine combination therapy by having pharmacists follow up with Veterans who agree to taper opioids and use more non-pharmacologic treatment modalities. (PI: Becker)

Project 3 (Quality Improvement): Interview academic detailers and providers from VISN 21 to evaluate the Pharmacy Benefit Management Services' opioid-prescribing practices, and determine which sites could benefit from local operational partners' support. (PI: Midboe)