title: Comprehensive assessment of chronic pain management in primary care: a first phase of a quality improvement initiative at a multisite Community Health Center.
abstract: BACKGROUND
  The objective of this study was to conduct a comprehensive formative assessment of chronic pain management in a large, multisite community health centre and use the results to design a quality improvement initiative based on an evidence-based practice model developed by the Veterans Health Administration. Improving quality and safety by incorporating evidence-based practices (EBP) is challenging, particularly in busy clinical practices such as Federally Qualified Health Centers (FQHCs). FQHCs grapple with financial constraints, lack of resources and complex patient populations.
  
  
  METHODS
  The Promoting Action on Research Implementation in Health Services (PARIHS) Framework served as a basis for the comprehensive assessment. We used a range of measures and tools to examine pain care from a variety of perspectives. Patients with chronic pain were identified using self-reported pain scores and opioid prescription records. We employed multiple data collection strategies, including querying our electronic health records system, manual chart reviews and staff surveys.
  
  
  RESULTS
  We found that patients with chronic pain had extremely high primary care utilisation rates while referral rates to pain-related specialties were low for these patients. Large gaps existed in primary care provider adherence to standards for pain care documentation and practice. There was wide provider variability in the prescription of opioids to treat pain. Staff surveys found substantial variation in both pain care knowledge and readiness to change, as well as low confidence in providers' ability to manage pain, and dissatisfaction with the resources available to support chronic pain care.
  
  
  CONCLUSIONS
  Improving chronic pain management at this Community Health Center requires a multifaceted intervention aimed at addressing many of the problems identified during the assessment phase. During the intervention we will put a greater emphasis on increasing options for behavioural health and complementary medicine support, increasing access to specialty consultation, providing pain-specific CME for providers, and improving documentation of pain care in the electronic health records.
authors.affiliation: Community Health Center, Inc., Middletown, CT 06457, USA. andersdr@chc1.com
authors.forename: Daren
authors.initials: D
authors.lastname: Anderson
authors.forename: Sissi
authors.initials: S
authors.lastname: Wang
authors.forename: Ianita
authors.initials: I
authors.lastname: Zlateva
mesh_terms: D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use; D059350:Chronic Pain / Q000188:drug therapy*; D002985:Clinical Protocols; D003153:Community Health Services / Q000458:organization & administration*; D004363:Drug Utilization; D005260:Female; D006801:Humans; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D008875:Middle Aged; D008913:Minority Groups / Q000706:statistics & numerical data; D059408:Pain Management / Q000379:methods*; D011204:Poverty Areas; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D058996:Quality Improvement / Q000458:organization & administration*; D014481:United States
chemical_list: D000701:Analgesics, Opioid