Building Better Interdisciplinary Pain Teams Across Disciplines

背景：慢性疼痛对退伍军人的影响不成比例，通常在退伍军人初级保健中得到控制。 因为慢性疼痛可能会表现出身体、情感、社交和存在的维度，个性化， 跨学科的方法在临床上很重要。各种疼痛团队模型已在 临床环境多样，有些是有效的。然而，为了满足特定患者的复杂需求，疼痛 团队通常受益于动态的成员资格和履行特定角色的不同提供者(例如药剂师 或任务(例如，阿片类药物逐渐减少)。聚集在一名患者周围的提供者可能会也可能不会工作 在其他患者身上定期或以相同的组合使用。事实上，动态团队和受限团队 经常是重叠的。与受限团队相比，动态团队，我在下文中称为“团队”，是一种 更复杂的过程和较小的经验性研究基础。团队是有界的还是动态的(以及 通常两者兼而有之)，他们需要协调/谈判并了解各自的共同角色 有效地为患者服务的角色界限。通过建立脚手架来促进“团队合作”，是一种 围绕共享的患者护理目标组织具有动态成员资格的提供者的策略。 意义/影响：开发“团队”干预措施，以促进围绕众多任务的协作 参与提供良好和安全的疼痛管理特别及时，因为它符合VA Ord临床 优先事项。这项工作将与退伍军人、供应商和来自 国家疼痛计划办公室，以确保与退伍军人病痛和阿片类药物倡议保持一致。 创新：拟议的干预将为以下方面创建团队脚手架和团队促进流程 参与疼痛护理任务的跨学科提供者。组织理论与合作伙伴关系的整合 用于产生和测试团队干预的设计原则和策略代表了一种新的方法 改进退伍军人事务部的疼痛护理流程。 具体目标：这项提案寻求通过三个项目解决科学差距。目标1：确定角色、 参与以初级保健为基础的慢性疼痛管理的跨学科提供者的结构和流程。 目标2：共同设计一项干预措施，以改善与退伍军人管理局提供者和退伍军人的跨学科“合作”。AIM3： 试点测试团队干预的可行性和可接受性，以改善一个地点的疼痛管理。 方法：为了获得关于团队、团队合作和团队以及AIM3试验设计的研究特征的见解，AIM1a 将完成对初级保健环境中慢性疼痛护理的随机对照试验的系统审查。 描述动态组队的概念，并获得有关组队治疗慢性疼痛的见解，1b 将使用半结构化访谈来探索PACT提供者、药剂师、Pain 专家、非药学提供者和主管/领导(n=45)。基于AIM1洞察力和 合作设计的原则和流程，我将建立一个逻辑模型，1)问题和2)所需的变化。 我将与供应商和退伍军人一起进行3)基于理论的设计和4)干预生产，然后5) 利用实用、稳健的执行和可持续发展模式(PRISM)进行实施规划，以及6) 评估规划。患者(n=30)和跨学科PACT团队(n=10)参与“团队合作” 弗吉尼亚州帕洛阿尔托医院的慢性疼痛管理将被招募为干预手臂的飞行员，以告知 随后的随机试验的可行性和可接受性。在这项试点工作之后，我将申请HSR&D IIR进行一项双臂整群随机试验(通常的疼痛过程与“联合”干预)。 实施/下一步：通过这项工作的成功执行，我们将准备提交VA HSR&D优秀奖申请与通常的护理相比，进行全功率的“团队”干预试验。 联合设计过程和由此产生的团队干预将作为制定战略以支持 临床医生在不同的退伍军人管理局设置中合作。

Background: Chronic pain disproportionately affects Veterans and is often managed in VA primary care. Because chronic pain may exhibit physical, emotional, social, and existential dimensions, individualized, interdisciplinary approaches are clinically important. Various pain team models have been implemented in diverse clinical settings, and some are effective. However, to meet the complex needs of specific patients, pain teams often benefit from dynamic membership and different providers (e.g., pharmacist) fulfilling specific roles or tasks (e.g., opioid tapering). The providers who come together around one patient may or may not work together regularly or in the same combinations on other patients. In fact, dynamic teams and bounded teams often overlap. Compared with bounded teams, dynamic teaming, which I refer to hereafter as “teaming”, is a more complex process with a smaller empiric research base. Whether teams are bounded or dynamic (and often they have elements of both), they need to coordinate/negotiate and understand their mutual roles and role boundaries to serve patients effectively. Facilitating “teaming”, through establishing scaffolds, represents a strategy for organizing providers with dynamic membership around shared patient care goals. Significance/Impact: Developing a “teaming” intervention to facilitate collaboration around the numerous tasks involved in providing good and safe pain management is particularly timely as it aligns with the VA ORD clinical priorities. This work will be done in partnership with Veterans, providers, and operational leaders from the national pain program office to ensure alignment with VA pain and opioid initiatives. Innovation: The proposed intervention will create team scaffolds and a teaming facilitation process for interdisciplinary providers that participate in pain care tasks. The integration of organizational theory and co- design principals and strategies to produce and test a teaming intervention represents a novel approach for improving processes of pain care in the VA. Specific Aims: This proposal seeks to address scientific gaps through three projects. AIM1: Identify roles, structures and processes of interdisciplinary providers involved in primary care based chronic pain management. AIM2: Co-design an intervention to improve interdisciplinary “teaming” with VA providers and Veterans. AIM3: Pilot test the feasibility and acceptability of a teaming intervention for improved pain management at one site. Methodology: To yield insights on teams, teamwork and teaming and AIM3 study features for trial design, AIM1a will complete a systematic review of randomized controlled trials of chronic pain care in primary care settings. To characterize the concept of dynamic teaming and garner insights on teaming for chronic pain in PACTs, 1b will use semi-structured interviews to explore experiences and perceptions of PACT providers, pharmacists, pain specialists, non-pharmacologic providers, and supervisors/leadership (n=45). Building on AIM1 insights and principles and processes of co-design, I will build a logic model 1) of the problem and 2) for the desired change. I will conduct 3) theory-based design and 4) intervention production with providers and Veterans, followed by 5) implementation planning with the practical, robust implementation and sustainability Model (PRISM), and 6) evaluation planning. Patients (n=30) and interdisciplinary PACT teams (n=10) involved in “teaming” around chronic pain management at the VA Palo Alto will be recruited for the pilot of an intervention arm to inform feasibility and acceptably of a subsequent randomized trial. Following this pilot work, I will apply for an HSR&D IIR to conduct a two-arm cluster randomized trial (usual pain processes vs. “teaming” intervention). Implementation/Next Steps: Through the successful execution of this work, we will be prepared to submit a VA HSR&D merit award application for a fully powered trial of the “teaming” intervention in comparison to usual care. The co-design process and resultant teaming intervention will serve as a model to develop strategies to support clinicians teaming in a diverse array of VA settings.