Evaluating the National Implementation of Virtual Interdisciplinary Pain Care Teams - TelePain

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Project: Chronic pain is a leading cause of disability and a major contributor to the opioid epidemic and suicide. Providing evidence-based pain care to Veterans is vital, yet nearly 1 in 3 VA facilities lacks an interdisciplinary, multimodal pain management program. Interdisciplinary, multimodal pain treatment (IMPT) has been recognized as the standard of care for high-impact chronic pain; however, outside of VA, community pain clinics primarily offer unimodal treatment focused on high-reimbursement medical procedures instead of IMPT. Pain management is one of VA’s highest-cost community care expenditures, yet VA facilities that lack an IMPT team rely heavily on community care for pain management. To address the lack of pain specialists at smaller VA facilities and the gaps in community pain care, the National Pain Management and Opioid Safety Program (PMOP) is rolling out a telehealth model of virtual specialty pain teams, TelePain, to deliver evidence- based IMPT to under-resourced regions. Our operational partners are building on VISN 20’s success to scale up TelePain nationwide, starting with 3 VISNs per year in June 2021. PMOP needs rigorous evaluation support to assess the impact of this high-priority TelePain initiative. Given its national scope and range of implementation settings, the rollout of TelePain presents a unique opportunity to evaluate the implementation of this program in the VA, with the goal of yielding actionable findings to inform not only the current effort but also future implementation efforts to spread similar programs across the VA. The purpose of the proposed Partnered Evaluation Initiative is to use systematic evaluation methods to continually improve TelePain implementation and monitor the impact of TelePain on patient outcomes and costs at 9 VA facilities. Project objectives: To assess the impact of the TelePain initiative, the Specific aims of this project include: 1.) To assess the acceptability, feasibility, adoption, fidelity, reach, and costs of TelePain implementation at each new VISN, 2.) To prospectively evaluate patient-reported clinical outcomes, comparing TelePain to referral to community care or no specialty pain care (usual care control groups), to ensure that TelePain is benefitting Veterans relative to usual care, 3.) To compare use of low-value pain care (e.g., injections, unnecessary imaging, spinal fusion surgery) among patients referred to TelePain relative to control groups. Project Methods: The proposed activities will be conducted as quality improvement. We will conduct a mixed methods, quasi-experimental multisite evaluation to examine implementation outcomes and costs (Aim 1), clinical outcomes, including both patient-reported outcomes and administrative data (Aim 2), and economic impact of TelePain (Aim 3). Data sources for this project include administrative and electronic health record data from VA’s Corporate Data Warehouse (CDW), Pharmacy Benefits Management Services, the Suicide Prevention Applications Network, the National Death Index, the Managerial Cost Accounting Office, the Fee Basis files in the Program Integrity Tool, patient surveys administered electronically via Qualtrics or paper- based via postal mail, and semi-structured interviews with patients and providers. A novel aspect of the proposal is the prospective cohort patient survey (Aim 2). For this, we will identify potentially eligible patients across three comparison groups (TelePain, matched 1:1 to TelePain but referred to community pain care, matched 1:1 to TelePain but without referral to specialty pain care) on a weekly basis and enroll them in a 6- month longitudinal survey with 3 times points. The prospective, multisite design will provide a rigorous evaluation of TelePain using patient-centered outcomes that are of key importance to our operations partners. Project Impact: The results from this evaluation will inform and enhance our operational partners’ ongoing national implementation of TelePain. Our findings will provide evidence regarding the clinical outcomes of TelePain and its impact on pain care costs, both of which are needed to support a business case for the long- term sustainment of TelePain.