Redesigning Chronic Pain Management in Primary Care: Improving Coordination, Outcomes, and Experience

At the Palo Alto Medical Foundation (PAMF), a multi-specialty integrated ambulatory-care delivery network of Sutter Health in Northern California, we are changing the culture around what it means to take care of patients with non-cancer chronic pain (CP). Through a CP Management Redesign (CPMR) program, we are shifting from an outdated model that promotes procedures and medicines as a means to alleviate symptoms to a care-coordinated approach that empowers patient autonomy in guided self-management. Our CPMR targets primary-care providers, appropriate specialists, community-dwelling CP patients, and their families/caregivers.

The primary objectives of the CPMR are to: (i) Educate providers on evidence-based management of CP; (ii) Develop Electronic Health Record (EHR) tools, Shared Medical Appointments, and web-based content to facilitate CP management; (iii) Evaluate the implementation and impact of the CPMR program; and (iv) Disseminate findings, share best practices, and implement the program throughout Sutter Health.

We will evaluate the implementation process using the RE-AIM framework. We will use data from the PAMF EHR, administrative databases, and patient and provider surveys to assess program impact. Using a combination of methods, including interrupted time-series analysis and a matched-control comparison with patients across four Sutter Health ambulatory-care regional divisions, we will measure: (i) medication (opioid) prescribing patterns; (ii) patient-reported pain and functional outcomes; (iii) care coordination; (iv) provider  engagement/satisfaction; patient engagement/satisfaction; and (v) healthcare costs.

We hypothesize that the CPMR program will reduce and make opioid use safer; improve care coordination, patient outcomes, and patient and provider experience; and reduce costs.