Adapting and Implementing a Nurse Care Management Model to Care for Rural Patients with Chronic Pain

项目总结 慢性疼痛影响了超过20%的美国成年人口，并经常对质量产生削弱作用 生命以及身体和精神功能的变化。生活在农村社区的个人经历了更高的 慢性疼痛以及因疼痛而导致的较差的健康结果。生活在农村的4600万美国人 这些地区往往缺乏以证据为基础的非药物治疗慢性疼痛的机会。因此，一个 迫切需要实施有效的、全面的疼痛管理计划，其中包括 药物治疗的选择。护士护理管理(NCM)已成功地用于加强 护理患有其他慢性病或并发症风险较高的个人。 使用类型2混合有效性实施设计，我们建议调整、试行和实施 NCM模式，包括护理协调、认知行为疗法(CBT)和远程转诊 为农村慢性疼痛患者提供锻炼计划。每个卫生系统都将确定适当的 卫生保健专业人员将接受培训，成为护理经理。对于CBT组件，护理经理将是 接受培训，让患者参与远程CBT计划。作为练习，我们将提供远程交付 增强健身，这是一个以证据为基础的16周计划，包括有氧和力量训练 锻炼身体。在UG3阶段，我们将聘请来自两个医疗系统的患者、临床医生和护理经理 为农村患者服务的学习型协作试点NCM模式。此外，我们还将调整基础设施 和工作流程，以实施干预计划并让合作伙伴卫生系统参与制定 与社区合作伙伴的关系以及确定护理经理。在UH3阶段，我们将进行一项 农村慢性病患者改良型NCM模式与常规护理的随机对照试验 疼痛。我们从两个以实践为基础的研究网络中招募了6个卫生系统，WWAMI(华盛顿州， 怀俄明州、阿拉斯加州、蒙大拿州和爱达荷州)地区实践和研究网络和梅克伦堡地区 北卡罗来纳州农村初级保健研究伙伴关系。我们的主要结果是疼痛干扰，因为 通过疼痛、生活乐趣和一般活动(PEG)量表进行衡量。我们的次要成果包括 身体功能、睡眠、疼痛、抑郁、焦虑、治疗满意度、物质使用 精神障碍、止痛药的使用/剂量，包括阿片类药物，以及医疗保健利用。我们将探索差异是否 通过按年龄、性别、种族/民族分组分析检查治疗效果的异质性， 和医疗保险。我们将使用RE-AIM框架来评估实施成果和质量 对部分患者进行访谈，以评估干预经验。如果成功，这将是 这项研究将对农村地区的慢性疼痛管理产生革命性影响，扩大获得 通过创新的NCM模式进行循证、非药物治疗。

PROJECT SUMMARY Chronic pain affects over 20% of the U.S. adult population and frequently has debilitating effects on quality of life and physical and mental functioning. Individuals living in rural communities experience higher rates of chronic pain as well as poorer health outcomes because of pain. The 46 million Americans who live in rural areas frequently lack access to evidence-based, non-pharmacologic treatments for chronic pain. As such, a critical need exists to implement effective, comprehensive programs for pain management that include non- pharmacologic treatment options. Nurse care management (NCM) has been successfully used to enhance care for individuals with other chronic conditions or at high risk of complications. Using a type 2 hybrid effectiveness-implementation design, we propose to adapt, pilot, and implement a NCM model that includes care coordination, cognitive behavioral therapy (CBT), and referrals to a remotely delivered exercise program for rural patients with chronic pain. Each health system will identify appropriate health care professionals to be trained as care managers. For the CBT component, care managers will be trained to engage patients in a remotely delivered CBT program. For exercise, we will offer remotely delivered Enhance Fitness, which is an evidence-based, 16-week program that includes aerobic and strength training exercise. In the UG3 phase, we will engage patients, clinicians, and care managers from 2 health systems serving rural patients in a learning collaborative to pilot the NCM model. In addition, we will adapt infrastructure and workflows to implement the intervention program and engage the partnering health systems in developing relationships with community partners and identifying care managers. In the UH3 phase, we will conduct a randomized controlled trial of the adapted NCM model versus usual care in rural dwelling patients with chronic pain. We have recruited 6 health systems from 2 practice-based research networks, the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region Practice and Research Network and the Mecklenburg Area Partnership for Primary Care Research in rural North Carolina. Our primary outcome is pain interference as measured by the Pain, Enjoyment of Life and General Activity (PEG) scale. Our secondary outcomes include physical function, sleep, pain catastrophizing, depression, anxiety, treatment satisfaction, substance use disorder, pain medication use/dosage including opioids, and health care utilization. We will explore if disparities exist by examining heterogeneity in treatment effects via subgroup analyses by age, gender, race/ethnicity, and health insurance. We will use the RE-AIM framework to assess implementation outcomes and qualitative interviews conducted with a subset of patients to evaluate experiences with the intervention. If successful, this study will have a transformative effect on chronic pain management in rural areas by expanding access to evidence-based, non-pharmacologic treatments through an innovative NCM model.