Building Better Interdisciplinary Pain Teams Across Disciplines

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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.