From (Ontario Ministry of Health and Long-Term Care) policy to implementation: A retrospective look at a community-based patient-centered model of care for chronic pain

Figures & data

Table 1. Findings of the working group 2011 white paper.²⁴

Problems with diagnosis and management of chronic pain in Ontario

Lack of recognition and awareness of the magnitude of chronic pain problem; cost (human and monetary); and knowledge of how to diagnose and manage CNCP (by all providers). Lack of treatment modalities and services because effective CNCP programs/services are not readily available or accessible; effective drugs or nondrug modalities also are not available or accessible; lack of directory of services and programs that do exist. Lack of oversight, standardization, and education, namely, lack of unified policy for CNCP; lack of standards for pain programs/clinics; inadequate education and training in CNCP within the undergraduate curricula, postgraduate programs, and continuing health education for practicing professionals; and lack of accreditation for health care providers to deliver CNCP care. Lack of systematic treatment for populations, including all Ontarians, as well as most vulnerable people such as aboriginals, immigrants, elderly in long-term care, addicts with chronic pain, and the military. Lack of prevention services, specifically, lack of strategies to minimize transition from acute to chronic pain management; lack of self-management programs; and no funding of effective vaccine shown to prevent/reduce incidence of shingles/postherpetic neuralgia. Lack of accountability with no organized system able to measure outcomes or conduct research. Scarcity of chronic pain care delivery at the level of primary care resulting from a lack of supportive services for primary health care providers in managing chronic pain; guidelines/care pathways for chronic pain; availability of stepped-up comprehensive continuum of care for patients with chronic pain from primary care up to the tertiary care level; ongoing mentoring and continuing education to primary health care providers; and chronic pain management within integrated models of care at the primary health care provider level. Financial considerations, such as absence of remuneration specifically for managing patients with chronic pain at both a primary and specialty care level (i.e., no fee code for chronic pain care); lack of remuneration for team-based care involving allied health professionals, who are widely used by the public and important for multidisciplinary management; providing funds for treatment modalities that are shown to be ineffective while there is no funding for treatments that have been shown to work.

CNCP = chronic noncancer pain.

Table 2. Pillars of the Ontario comprehensive pain strategy (working group 2011 white paper).²⁴

Pillar	Definition
1. Oversight body	Body responsible for providing supervision, policy development, governance structure, monitoring, and reporting
2. Patient focused	Ensuring timely comprehensive assessment and management of the whole patient Ensuring that the patient’s needs and best interests are considered in each step of the care continuum
3. Primary care focused	Ensuring that the cornerstone of chronic pain prevention and management, the primary care physician, is supported and that his or her involvement is reflected in each step of the care continuum
4. Interdisciplinary care	Team-based care The patient is seen by the right practitioner at the right time in the right place
5. Chronic disease management framework	Care for CNCP should be managed within the framework developed to guide the effective prevention and management of chronic diseases
6. Reasonable access to the care continuum	Patients and physicians should be able to receive the care and assistance required in a timely manner
7. Stepped-up care in a care continuum	Self-help Seamless and timely transition from primary care to secondary and tertiary care as needed Develop and update care pathways Interdisciplinary in all stages
8. Continuous quality improvement	Define quality indicators, set system-wide improvement goals, and evaluate progress toward these goals
9. Evidence based	Synthesize best available evidence Set research agenda Create system-wide capabilities for relevant data collection Develop and translate guidelines into useful point of care tools
10. Accountability	Common framework for community and hospital clinics Outcome measures Evidence-based best practices
11. Consistency	Must meet established criteria (providers and centers) Develop unified policies and standards of care Develop standardized education and accreditation for programs, clinics, and providers
12. Prevention and early intervention	Provide prevention and early intervention (by implementing strategies to lessen transition from acute to chronic pain)
13. Education for patients and providers	Provide education for patients and providers (by introducing standardized pain curriculum in undergraduate and graduate training of health providers [medical and nonmedical] and ongoing education for practicing providers on best practices)
14. Data information (registry, research, supports)	Make provisions for data information (registry, research, supports) by underpinning future improvements, development of standards, prevention strategies, etc.; with system organization that provides a knowledge base for research; utilizing technology (telemedicine) to reach underserviced areas; providing warm and hot (telephone) consultation between primary care and pain specialists; and creating a single referral portal
15. Appropriate and sustainably resourced	Appropriately and sustainably resourced (so that providers and clinics have the right funding and resources required)

CNCP = chronic noncancer pain.

Figure 1. PWC patient flowchart.

Table 3. Service provisions at the PWC.^a

Service distribution	Manual therapy 97% CBT, psychological counseling 69% Mindfulness 65% ND services 59% Nutrition counseling 50% Massage therapy 47%
Frequency of services	Manual and exercise therapy (with chiropractors) 2×/wk for 9 weeks 1×/wk for 4 weeks 1×/mo for two sessions for follow-up
	Psychological counseling/CBT 1×/wk for 10 weeks 1×/2 wk for two sessions In 1 month for follow-up
	ND and nutrition counseling 1×/2 wk for two sessions (for each discipline) 1×/mo for two sessions (for each discipline)
	Massage therapy 1×/wk for 10–12 weeks Mindfulness class 2.5 h 1×/wk for 11 weeks (or one-to-one × 10 sessions)

^aEach patient who completes the program receives 65–80 h of one-to-one services including participation in our mindfulness program in his or her 3- to 4-month journey.

PWC = Pain & Wellness Centre; CBT = cognitive behavioral therapy; ND = naturopathic doctor.

Figure 2. The PWC outputs.

Chronic Pain Working Group: Summary of Findings, November, 08 2011, Ontario Medical Association, Ministry of Health and Long-Term Care

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