In Brief: Models of Care for Chronic Pain

Key Messages

• For chronic pain, 1 Canadian hub-and-spoke care model, 1 Canadian stepped care model, and 3 international stepped care models were identified and described.
• For other chronic medical conditions, 3 Canadian stepped care models, 2 Canadian hub-and-spoke models, 6 international stepped care models, 3 international hub-andspoke models, and 1 international Oncology Care Model were identified and described.
• Patient-related outcomes associated with the models of care for chronic pain include pain measures (e.g., intensity, duration), psychosocial outcomes (e.g., anxiety, depression), functional outcomes (e.g., disability, employment status), and health care utilization (e.g., opioid prescriptions, health care visits).
• Factors that could present as either barriers or facilitators to providing care for patients with chronic pain relate to funding, support, and collaboration from the government and locally; the presence of a centralized intake and referral system; and the ability to leverage existing resources.
• In Canada, there are provincial models, regional models, local models or programs, and there are some regions that do not have a formalized approach for providing care for patients with chronic pain.
• In addition to variations of the hub-and-spoke and stepped care models, examples of multi- and inter-disciplinary models of care for chronic pain were identified. Within the models, various components were described, which include referral pathways, centralized intake and triage, standardized care pathways, patient navigators, and individualized pain management.
• There appears to be considerable variation in the models of care used to address the care needs of patients with chronic pain. There was no single model that was used in an identical fashion in more than 1 situation. The various models of care were adapted to meet the needs of specific populations. Decision-makers should consider the needs of their patients and the specific needs of their jurisdiction when designing, adopting, or adapting a model of care for chronic pain.

Context

Chronic pain, which is defined as pain lasting longer than 3 months, is estimated to impact approximately 20% of the Canadian population. People with chronic pain often experience increased fatigue and a decrease in their quality of life and mental health. They also tend to be unable to fully participate in their personal and professional lives and use health care services more often. Chronic pain management typically involves physical, psychological, and pharmacological therapies as part of a multidisciplinary pain management plan. Due to the widespread prevalence of chronic pain and its associated burden, there is a need to identify optimal strategies to manage and provide care for this condition.

Technology

There is no standard or widely accepted definition for the term “model of care.” In the CADTH report, the term is loosely used to refer to a way of providing a health care service that has been shaped by theory, evidence-based practice, and defined standards. Models of care contain core elements and principles. They also include a framework for implementing and evaluating the care model.

Models of care that were selected as a focus of this report include:

• Hub-and-spoke: Normally consists of 1 centralized “hub” that offers specialized services or more intensive therapies. The hub is complemented by secondary clinics, which serve as the “spokes.” The spokes provide care that is more limited in scope, such as routine follow-up.
• Oncology Care Model: Provided by centres of Medicare and Medicaid in the United States, it is a model of care that is based around alternative payment methods for oncology care. It combines fee-for-service and performance-based payments based on 6-month episodes of cancer care.
• Stepped care: Interventions are normally organized into a series of steps based on the increasing intensity of therapy. Patients receive the most effective but least intensive therapy first and are either stepped up or down as needed.

Issue

Across Canada, there are efforts under way to identify and implement effective approaches for providing care for patients with chronic pain. There’s interest in knowing what models of care are being used in ABOUT CADTH CADTH is an independent, not-for-profit organization responsible for providing Canada’s health care decision-makers with objective evidence to help make informed decisions about the optimal use of drugs and medical devices in our health care system. CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec. June 2021 cadth.ca DISCLAIMER This material is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose; this document should not be used as a substitute for professional medical advice or for the application of professional judgment in any decision-making process. Users may use this document at their own risk. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not guarantee the accuracy, completeness, or currency of the contents of this document. CADTH is not responsible for any errors or omissions, or injury, loss, or damage arising from or relating to the use of this document and is not responsible for any third-party materials contained or referred to herein. Subject to the aforementioned limitations, the views expressed herein do not necessarily reflect the views of Health Canada, Canada’s provincial or territorial governments, other CADTH funders, or any third-party supplier of information. This document is subject to copyright and other intellectual property rights and may only be used for non-commercial, personal use or private research and study. Canada and internationally; what patient-related outcomes have been used with these models of care; what key issues and challenges have been faced when implementing the various models; and what lessons have been learned. Therefore, CADTH conducted an Environmental Scan to gather information on models of care that are being used in Canada and other countries to address care needs of people living with chronic pain. This information could be used to help inform the development of models of care for chronic pain in Canada. The scan also includes information on care models for other chronic, non-pain– related medical conditions, which may be useful for implementing models of care for chronic pain.

Methods

A targeted literature search and focused consultations with select stakeholders were used to inform the report.

Results

The literature search identified 38 sources of information. In addition, 15 stakeholder consultations were completed, which included participants from 10 Canadian provinces and territories: Alberta, British Columbia, Ontario, Saskatchewan, New Brunswick, Nova Scotia, Newfoundland and Labrador, Prince Edward Island, Quebec, and Northwest Territories. Participants were primarily health care providers and health consultants.