Case Example: Collaborative Care for Chronic Pain in Primary Care (PPACT)

Collaborative Care for Chronic Pain in Primary Care (PPACT) is a trial targeting patients with chronic pain receiving long term opioid treatment and is designed to help patients adopt self-management skills for chronic pain, limit use of opioid medications, and identify factors amenable to treatment in the primary care setting (Debar et al. 2012, Debar et al. 2018). The trial is being carried out in the regions of Kaiser Permanente (KP) Georgia, Hawaii, and the Northwest (Oregon/Southwest Washington) and relies on an interdisciplinary team (nurse case managers, behavioral specialists, physical therapists, and pharmacists) to carry out the intervention and support the primary care providers in working with their patients enrolled in the intervention. By design, PPACT interventionists continue ongoing frontline clinical work in participating healthcare systems in addition to their work implementing PPACT. While this helps to ensure that the intervention is as closely integrated into the health care delivery system as possible, it has also meant that the study is vulnerable to many forces within the health care systems that affect staffing in the requisite areas. This has influenced availability of clinicians for the study and staff turn-over across the studies. For example, the simultaneous integration of behavioral health specialists into primary care in the KP Hawaii and Northwest regions has led to a dearth of adequately trained clinicians and led to the use of health coaches at KP Hawaii rather than behavioral health specialists, as well as the need to rehire and train for the behavioral health role multiple times at KP Northwest. At KP Georgia the consolidation of nurses in primary care clinics has led to many cohorts of the intervention being conducted without the involvement of a nurse case manager. Further, physical therapy is carved out of the integrated health plan at KP Georgia leading to the need to organize communications and hand offs between interdisciplinary team members differently in that region. Across all performance sites we have streamlined intervention training and customized it depending on the experience and professional scope of work of those from different disciplines.