Building Better Interdisciplinary Pain Teams Across Disciplines

背景：慢性疼痛不成比例地影响退伍军人，通常在VA初级保健中进行管理。 因为慢性疼痛可能表现出身体，情感，社会和存在的维度，个性化， 跨学科方法在临床上很重要。各种疼痛团队模型已经在 不同的临床环境，有些是有效的。然而，为了满足特定患者的复杂需求， 团队通常受益于动态成员资格和不同的提供者（例如，药剂师）履行特定职责 或任务（例如，阿片样物质逐渐减少）。围绕一个病人的提供者可能会工作，也可能不会工作。 定期或以相同的组合在其他患者身上。事实上，动态团队和有限团队 经常重叠。与有限团队相比，动态团队，我在下文中称之为“团队”， 更复杂的过程，更小的经验研究基础。团队是有界的还是动态的（以及 他们往往两者都有），他们需要协调/谈判和了解他们的相互作用， 角色界限，有效地为患者服务。通过建立脚手架来促进“团队合作”代表了一种 围绕共同的病人护理目标，组织具有动态会员资格的提供者的战略。 意义/影响：制定“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是特别及时的，因为它符合VA ORD临床 优先事项这项工作将与退伍军人、医疗服务提供者和来自 国家疼痛计划办公室，以确保与VA疼痛和阿片类药物倡议保持一致。 创新：拟议的干预措施将创建团队支架和团队促进过程， 参与疼痛护理任务的跨学科提供者。组织理论与协同管理的整合， 设计原则和策略来产生和测试团队干预代表了一种新的方法， 改善退伍军人事务部的疼痛护理流程。 具体目标：该提案旨在通过三个项目解决科学差距。目标1：确定角色， 结构和过程的跨学科提供者参与初级保健为基础的慢性疼痛管理。 目标2：共同设计一项干预措施，以改善与VA提供者和退伍军人的跨学科“团队合作”。目标3： 试点测试的可行性和可接受性的团队干预，以改善疼痛管理在一个网站。 方法学：为了深入了解团队、团队合作和团队协作以及试验设计的AIM 3研究特征，AIM 1a 将完成一个系统的审查随机对照试验的慢性疼痛护理在初级保健设置。 为了描述动态团队合作的概念，并获得对PACTs中慢性疼痛团队合作的见解，1b 将使用半结构化访谈来探索PACT提供者，药剂师，疼痛 专家、非药物提供者和主管/领导（n=45）。基于AIM 1见解和 原则和过程的协同设计，我将建立一个逻辑模型1）的问题和2）所需的变化。 我将进行3）基于理论的设计和4）干预生产与供应商和退伍军人，其次是5） 采用实用、稳健的实施和可持续性模型（PRISM）进行实施规划，以及6） 评价规划。患者（n=30）和跨学科PACT团队（n=10）参与“团队合作”， VA帕洛阿尔托的慢性疼痛管理将被招募为干预组的试点， 后续随机试验的可行性和可接受性。在这个试点工作之后，我将申请HSR&D IIR进行一项两组随机分组试验（通常的疼痛过程与“团队”干预）。 实施/后续步骤：通过成功执行这项工作，我们将准备提交VA 与常规护理相比，HSR&D优秀奖申请用于“团队”干预的全功率试验。 共同设计过程和由此产生的团队干预将作为制定战略的模式，以支持 临床医生在各种VA环境中合作。

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.