Six-month outcomes of an integrated primary care prevention and management program for chronic low back pain (LBP)

Background Accessible interdisciplinary, patient-centered and integrated primary care programs for chronic pain are needed for averting chronicity and improving patient outcomes. We sought 1) to develop an interdisciplinary low back pain (LBP) primary care program, and 2) to evaluate the program’s implementation and impact on patients’ physical and mental health over 6 months. A quasi-experimental pre-test/post-test design was used, and participants completed baseline, 3 and 6 months post-intervention evaluations. Referral and program process indicators were measured. Methods Clinically meaningful change in patient reported outcome measures of pain interference and intensity, physical function, depression and anxiety were defined a priori and evaluated. A multilevel regression analysis was performed to evaluate the impact of the program on change in individuals’ pain interference over 6 months. Results Forty six percent of participants were seen within 60 days of referral to the LBP program, and 464 individuals completed the program. The majority (≥ 60%) experienced a clinically meaningful improvement for pain intensity and interference at six months. A greater proportion of those with moderate (71%) or high risk (81%) of chronicity showed an improvement in pain interference than those with low risk (51%). A similar pattern emerged for depression and self-efficacy, but not for anxiety. Significant predictors of improvements in pain interference included higher prognostic risk of chronicity, younger age, sex, and lower baseline disability. Conclusion Results supported an improvement in participants’ confidence to manage their LBP. Future research will compare alternative modes of delivery (e.g. telehealth) and stratification approaches to further tailor resources to individuals’ needs.

Integrated primary care and social services for older adults with multimorbidity in England: a scoping review

Background As the prevalence of older adults with multimorbidity increases, greater integration of services is necessary to manage the physical and psycho-social needs of this cohort. This study describes and summarises current evidence, clinical provision and progress towards integrated primary care and social services for older adults with multimorbidity in England. Methods A scoping review was conducted involving systematic searches of a range of electronic academic and policy databases. Articles were screened and extracted in duplicate by two independent reviewers. Data were extracted onto a charting sheet and thematic synthesis was used to summarise findings. Articles were included if published in English and related to primary care, social care and multimorbidity in older adults in England. Conceptually, the review was framed using the Rainbow Model of Integrated Care. Results The search yielded 7656 articles of which 84 were included. Three themes were identified: (1) a focus on individual level services rather than multi-level or multi-sector integration, with an increasing emphasis on the need to consider broader determinants of population health as critical to integrated care for older adults with multimorbidity; (2) the need for policymakers to allow time for integration to embed, to enable new structures and relationships to develop and mature; and (3) the inherent tension between top-down and bottom-up driven approaches to integrated care requires a whole-systems structure, while allowing for local flexibilities. Conclusions There is limited evidence of multi-level and multi-sector integration of services for older adults with multimorbidity in England. The literature increasingly acknowledges wider determinants of population health that are likely to require integration beyond primary care and social services. Improving clinical care in one or two sectors may not be as effective as simultaneously improving the organisation or design across services as one single system of provision. This may take time to establish and will require local input.

Practical Opportunities for Biopsychosocial Education Through Strategic Interprofessional Experiences in Integrated Primary Care

Even with the expansion of primary care teams to include behavioral health and other providers from a range of disciplines, providers are regularly challenged to deliver care that adequately addresses the complex array of biopsychosocial factors underlying the patient's presenting concern. The limits of expertise, the ever-changing shifts in evidence-based practices, and the difficulties of interprofessional teamwork contribute to the challenge. In this article, we discuss the opportunity to leverage the interprofessional team-based care activities within integrated primary care settings as interactive educational opportunities to build competencies in biopsychosocial care among primary care team members. We argue that this approach to learning while providing direct patient care not only facilitates new provider knowledge and skills, but also provides a venue to enhance team processes that are key to delivering integrated biopsychosocial care to patients. We provide three case examples of how to utilize strategic planning within specific team-based care activities common in integrated primary care settings—shared medical appointments, conjoint appointments, and team huddles—to facilitate educational objectives.