A:

Morasco:
As clinicians, we might offer care recommendations, but there are barriers to adherence. Having a NCM is something that we think is critical for patients to help navigate the system and access care successfully. Essentially, a care manager is the bridge between patient and provider, serving as a known point of contact who not only speaks the medical language of clinicians, but also can connect one-to-one with the patient. Our hypothesis is that the NCM helps to reduce barriers to people being able to engage in or access services, as well as understand and follow through with care provider recommendations.

Travis Lovejoy:
Veterans are in a unique position that we don’t see as often within the civilian population wherein they have access to numerous types of care and are eligible to get that care in multiple places.  In order to avoid fragmented care from lack of communication among providers, the NCMs not only identify resources but, once patients access those resources, they help to communicate treatment plans and other information among all the providers caring for the patient.  Typically, this will be through an electronic health record system, but sometimes it can be a phone call, an instant message to a VA provider, or other means of communication. When that information is provided in an easily accessible way, we’ve found that clinicians across all systems are open to and enthusiastic about receiving coordinated communications.

A:

Lovejoy:
There are many ways to define rurality. For our project we’ve adopted the definition that the Veterans Health Administration (VHA) uses, which is by RUCA codes (rural-urban commuting area code). These codes range from 1 to 10, where one indicates larger metropolitan areas and ten is highly rural.   The RUCA codes are defined, in part, by the size of the community, but also the distance from major metropolitan areas. The VHA defines rurality as anything on a RUCA of two or greater. Here in Portland, we have some communities that are on the outskirts of Portland, so they barely make a RUCA of two, but they are culturally rural because of some of the challenges they face.  We also will involve rural communities where patients may be more than a four-hour drive away from a major VA facility.

A:

Morasco:
The central issue is that people who live in certain areas of the country don’t have access to resources. As we know from research, ideal pain care is multidisciplinary care that includes nonpharmacologic interventions, which sometimes require more frequent visits to hands-on evidence-based treatments like physical therapy or chiropractic care.  People living in rural areas are less likely to receive those treatments due to limited availability of services within a reasonable driving distance.  When all the options are not available, the result is truncated care.

Even when options are available, patients and their existing care providers often don’t know about them, and or, if a patient does access care from multiple agencies, one provider often doesn’t have access to what another is doing, which inhibits quality. As clinicians, we tend to know about one or two options for managing pain, but it’s a monumental task to know about all the available nonpharmacological options for pain.  Particularly in rural areas, there is a need for a repository of options that are available to a patient, based on whatever limitations that the person is presenting, whether that be insurance, ability to pay, proximity, or other barriers.

Lovejoy:
Those living in rural communities face many other challenges like high-speed Internet access and transportation barriers, as well as a lower number of care facilities that are available to them within a relatively close proximity. Additionally, there aren’t many wraparound services to address other patient needs. You may have a dozen physical therapists and in your rural area there may be one half-time physical therapist that is an hour drive away from you.

There are also barriers to utilization of technology. If we can’t get patients to the care facilities because of geographic barriers, we generally look to care delivered via telehealth; however, Veterans in rural areas still face access challenges if they don’t have internet connections or devices to go online or aren’t comfortable using technology.  We also know that within the VA population, those who live in rural areas tend to be an older population, which tend to have more barriers to accessing telehealth on their own.

Veterans in rural areas are navigating multiple complex healthcare systems to access care and, often, we find that patients are not aware of the opportunities available to them and/or they have difficulty finding care or navigating care systems.  Many rural patients are eligible for community care through the VA MISSION Act, where they can receive care from providers within their community using a referral from the VA and the cost of care is reimbursed by the VA.

The VHA has really tried to promulgate access to technology that allows Veterans to be able to engage in telehealth services through partnerships with other VA offices to provide iPads or exploring potential funding for internet access.  Providing that connectivity is really important in terms of being able to access technology-based services, but outside of that, there are transportation grants and a Veterans Service Officer (VSO) in every county, who is there to help Veterans be able to identify services that they may need both within and external to the VA.

A:

Lovejoy:
As part of the intervention, we do have a pain education class where patients learn about different types of approaches and services that are available to them. Some of these classes will even have guest speakers from different departments.  We might have a nutritionist talk about anti-inflammatory diets that can be helpful in managing some forms of pain.  A physical therapist or an occupational therapist would talk about forms of PT or OT that can help alleviate pain.  A psychologist might talk about behavioral interventions to help lessen the experience of pain. These sessions are really meant to be introductions for patients, and if there are approaches that resonate with them, the nurse will talk about their options and help connect them with those services.

A:

Lovejoy:
Many nonpharmacological pain management approaches can be done via telehealth, but there are some that can’t.   We can’t engage with interventional pain medicine. We can’t virtually give someone a facet injection.  Those services need to be done in-house.  In order to identify when those services are needed, patients need an initial assessment.  The Tele-Pain teams are equipped with the expertise to shepherd those types of services and often they can do the initial evaluations to determine appropriateness for those services.

There are a couple of different ways to provide virtual care. A patient can interface with the clinician from an Internet-enabled device anywhere; they can be in their own home or elsewhere, assuming they have an Internet connection that is sufficient to be able to engage in that encounter. They can also go into a HIPPA-compliant telecom room at a VA facility to engage in a video teleconferencing assessment.  There are some types of assessments that need to happen in those settings because clinical staff need to be on hand for in-person exams.

This can be quite helpful for folks living in rural areas. They can go into a nearby clinic—which may not be nearly as far as the nearest major medical center—have an evaluation via telehealth, and then be able to access clinical support staff in the building as needed. If determined to be appropriate, the patients can receive treatments like physical therapy and be taught home-based exercise programs all virtually with the help of the Tele-Pain team.

A:

Lovejoy:
We’re really excited to be doing this work exclusively in rural locations. There are very few trials that focus on rurality and it is a high-need area, so this work has far-reaching implications.  This is the first time that I’ve been part of a research study that has the level of support that the Pain Management Collaboratory provides. It’s support not just from our peers, but also from a wonderful thinktank of accomplished people who collectively generate some fantastic ideas on how to approach important problems. Having the infrastructure that allows for this amazing network has been extremely beneficial.

We have utilized the Collaboratory for assistance overcoming some regulatory challenges as well as for thinking through defining or operationalizing certain types of measurable variables.  We bring various methodological decisions for our larger scale trial to the different work groups and workshop those. Within the first several months of joining the Collaboratory, we probably did six or seven presentations to the larger PMC group as well as to different Work Groups and received great feedback and that informed some of the modifications that we’ve made as we’ve been in this planning year before launching a larger-scale trial.

Morasco:
We’ve only been doing this for less than a year and we’re already very highly appreciative of the larger Collaboratory. There is a great deal of measurable support, but there is also the immeasurable support as well, such as knowing that there is a group out there that can provide resources, offer guidance on some of the trials and tribulations of navigating certain aspects of these studies that we haven’t encountered before, such as regulatory requirements.  There have been several instances where we’ve sought guidance from investigators in the larger Collaboratory and have been provided with very tangible strategies to address different issues. Additionally, PIs have spontaneously offered up what they learned when planning and implementing their trials. It’s helpful because other investigators may identify something that is  not on our radar.

The in-person Steering Committee meeting in May allowed for us to have informal conversations in a relaxed environment.  Talking with other investigators about their experiences with their trials was helpful, yielding new strategies, opportunities for collaborations, or ways that we can synchronize our data.