Improving pain care through implementation of the Stepped Care Model at a multisite community health center

Figures & data

Figure 1 Modified Stepped Care Model for Pain Management at CHCI.

Abbreviations: CHCI, Community Health Center, Inc.; ECHO, Extension for Community Health Outcomes.

Figure 2 Timeline for Project STEP-ing Out.

Abbreviations: CME, continuing medical education; ECHO, Extension for Community Health Outcomes; EHR, electronic health record.

Table 1 Demographic information of participating providers’ patients with chronic pain

		Baseline (March 2010–February 2011) N (%)	Postintervention (March 2013–February 2014) N (%)
	Total patients	3,357	4,385
	Female	2,109 (63)	2,789 (64)
Age (years)	18–29	339 (10)	370 (8)
	30–39	571 (17)	746 (17)
	40–49	1,019 (31)	1,105 (25)
	50–59	878 (26)	1,351 (31)
	60–69	372 (11)	576 (13)
	70+	151 (5)	237 (5)
Race/ethnicity	White	1,399 (42)	1,822 (42)
	Black	451 (14)	577 (13)
	Hispanic	1,398 (42)	1,819 (42)
	Other	66 (2)	124 (3)
Insurance	Medicaid	2,210 (66)	2,796 (64)
	Medicare	635 (19)	845 (19)
	Private insurance	241 (7)	446 (10)
	Uninsured	241 (7)	286 (7)

Table 2 Primary care provider (N=25) characteristics

Characteristic		n (%)
Sex	Male	11 (44)
	Female	14 (56)
Race	White	19 (76)
	Black	2 (8)
	Other	4 (16)
Professional degree	MD/DO	17 (68)
	APRN	8 (32)

Abbreviations: APRN, Advanced Practice Nurse Practitioner; MD/DO, Medical Doctor/Doctor of Osteopathic Medicine.

Table 3 Pain care documentation data elements

Chronic Pain Care Documentation Element	Baseline (March 2010–February 2011) N=108 (%)	Evaluation (March 2013–February 2014) N=213 (%)	P-values
Documentation of pain	69 (64)	174 (81)	<0.001
Source or cause of pain	67 (62)	158 (74)	0.025
Functional assessment	5 (5)	42 (19)	<0.001
Review of diagnostic tests	6 (6)	37 (17)	<0.003
Treatment plan	99 (92)	209 (98)	0.006
Pain medication ordered	102 (94)	182 (85)	0.017
Pain consult ordered	7 (7)	60 (28.2)	<0.001
Patient education	16 (15)	47 (22)	0.121
Diagnostic imaging ordered	25 (23)	59 (28)	0.379
Assessment of treatment effectiveness	18 (17)	83 (39)	<0.001

Table 4 Pain care treatment data from the EHR for patients with chronic pain cared for by the 25 providers present for intervention

Chronic Pain Care Data Element		Baseline (March 2010–February 2011)	Postintervention (March 2013–February 2015)	P-values
	Total patients	3,330	4,385	N/A
	Average number of visits (±SD)	7.30±14.37	6.83±14.37	0.094
Pain scores	Pain >8, n (%)	2,504 (75.2)	3,245 (74.0)	0.351*
Opioids	Any opioid prescribed, n (%)	1,615 (48.5)	1,943 (44.3)	0.117
	Chronic opioid therapy, n (%)	763 (22.9)	921 (21.0)	0.486
Behavioral health	Patients with a behavioral visit, n (%)	809 (24.3)	1,276 (29.1)	0.009
Pain referrals	Chiropractic, n (%)	3 (0.1)	48 (1.1)	0.008
	Physical therapy, n (%)	480 (14.4)	750 (17.1)	0.508
	Neurologic or orthopedic surgery, n (%)	663 (19.9)	693 (15.8)	<0.001
	Rheumatology, n (%)	120 (3.6)	136 (3.1)	0.419

Notes:

* Stata’s “xtmixed” yielded P=0.052.

Abbreviations: EHR, electronic health record; N/A, not applicable; SD, standard deviation.