A Practice Facilitation-Based QI Approach to Improve the Management of Non-Cancer Chronic Pain in Older Adults

Context: To improve non-cancer chronic pain and opioid management among older adults, the Oklahoma (OK) Primary Healthcare Improvement Cooperative implemented a multi-faceted, person-centered, scalable primary care intervention in the Reducing Inappropriate Opioid Use in Seniors in Oklahoma (RISE-OK) Study.

Objective: Describe the framework used to document practice facilitation (PF) activities in RISE-OK.

Study Design and Analysis: 3-stage, modified step-wedge design. Descriptive statistics were used to summarize PF activities.

Setting or Dataset: Practice facilitators recorded activities in an Electronic Practice Record (EPR) in REDCap. Semi-structured EPR notes included practice objectives, support strategies, and change tactics organized using the Lean Six Sigma DMAIC method (DETERMINE opportunities for improvement, MEASURE current performance and processes, ANALYZE performance data, IMPROVE performance, and CONTROL improved processes).

Population Studied: 31 OK primary care practices; half were rural; half were health-system owned.

Intervention/Instrument: Practices completed a baseline assessment to 1) assess existing pain and opioid management protocols, 2) identify areas for improvement, and 3) prioritize interventions for implementation. At each PF visit, practices focused on at least 1 objective and facilitators recorded the DMAIC change tactics used at that visit.

Outcome Measures: 11 defined practice objectives for the RISE-OK intervention and 24 DMAIC tactics.

Results: Practices received 407 in-person and 37 virtual PF visits from Feb 2022 to Aug 2023. The 3 objectives selected most often were Implement age-tailored pain plan (n=172, 39% of PF visits), no overdoses or suicide deaths (n=134, 30%), and safer opioid prescribing (n=123, 28%). Overall, 1,285 DMAIC tactics were used. DETERMINE tactics (e.g., detail guidelines; n=539, 42%) and MEASURE tactics (e.g., audit charts; n=479, 37%) were most commonly used. ANALYZE tactics (e.g., identify waste; n=156, 12%), IMPROVEMENT tactics (e.g., modify existing protocol; n=90, 7%), and CONTROL tactics (e.g., process training, n= 21, 2%) were used less often.

Conclusions: Practices spent most of their time in preliminary stages of implementation, suggesting that longer duration practice improvement efforts may be needed. This likely reflects the complexity of chronic pain and opioid management in older adults for which many practices lack effective and efficient care delivery processes.