2022
DRAFT FOR DISCUSSION Version 1.0 2022 health.govt.nz
Mamaenga roa Model of Care for people living with chronic pain
Office of the Chief Clinical Officers
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ii MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS Contents
Executive summary
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Population Need 7
1
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Appendix 1: Literature review of adult chronic pain 26
45
Current State 8
Proposed Model of Care for Aotearoa New Zealand
Summary of International Best Practice Evidence Principles
13
Operating Model within the new Health System
Appendix 2: Literature review of paediatric chronic pain
Introduction 2 Background 6
Bibliography
Next Steps 24
PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS iii
DRAFT FOR DISCUSSION
MAMAENGA ROA: MODEL OF CARE CHRONIC
FOR PEOPLE LIVING WITH
Chronic pain or mamaenga roa, can cause significant challenges for both individuals and society. Chronic pain is pain that persists or recurs for more than three months Living with chronic pain can make it hard to sleep, work and enjoy life. The aim of treatment of chronic pain is to reduce the impact of pain on life and day to day functioning for the person and their whānau
service design working in partnership across the stakeholders and using strategic priorities and best practice, aligns to the Health and Disability System Review’s recommendations (2020). The consumer and population focus to service delivery and the transparent, quality assured process for the workforce and sector organisations provides rigour and clarity to process.
Chronic pain is a significant and complex condition, which is highly prevalent in women, older people, Māori, and those with lower socio economic status. Yet, services are inequitable and not resourced to holistically address whānau living with chronic pain in Aotearoa New Zealand.
Clinicallymodelling.led
In response to sector engagement the Model of Care Framework has been developed to facilitate and support sector stakeholders who engage with Manatū Hauora (the Ministry of Health) to review and consider how best to meet Aotearoa New Zealand’s health needs. The process has been initiated by the Chief Allied Health Professions Office and is implemented in partnership with the Chief Nursing Office and Chief Medical Office.
Workforce resource, population demographics and the timely provision of services often impact the provision of national specialist services which are low volume but complex in need. The Model of Care Framework takes an inclusive whole of population perspective in its approach and transcends existing systems to establish the most appropriate model of care for New Zealand. Led by the Expert Advisory Group, the process will identify and utilise knowledge gained from international best practice, national exemplars, and data
DRAFT FOR DISCUSSION MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS 1
Executive summary
A Model of Care ‘outlines best practice patient care delivery through the application of a set of service principles across identified clinical streams and patient flow’ (Waikato District Health Board, 2004). This document serves to provide a framework on which a clinical community can standardise their approach and unify their methods of intervention to deliver the best evidence based care. The evaluation of Models of Care supports the review and integration of efficiencies and best practice within service delivery, that may otherwise go unrecognised.
It is intended that the mamaenga roa: model of care for people living with chronic pain described in this document will address the current service issues and move towards prompt, appropriate and evidence based delivery of pain care. This document builds on the previous workforce development, forecasts and strategic plans and the work of clinicians who have strived to provide services within existing infrastructure.
Introduction
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The Model ofCare Framework adoptedprovidesa guide to the development ofa specific model of care and health service delivery for New Zealand’s population. It is based on a collaborative and inclusive approach to objectively examine how current services are provided, how the workforce can be sustainable now and into the future, how it can be flexible to meet the changing needs of health care, and how there can be embedded and accountable clinical leadership for designing and implementing sustainable services within New Zealand. Manatū Hauora is keen to partner with sector stakeholders to facilitate a solution focused approach that supports a consumer centric and evidence based health and disability system.
It is recognised that health faces several challenges in delivering effective, efficient, and responsive services to our population. These challenges include high escalating demand for services, limited published peer reviewed evidence about optimal workforce utilisation and ongoing system and process changes. As our workforce continues to evolve, and the global pandemic impacts on the pipeline to supply trained professions, there is a need to proactively work towards reviewing and implementing evidence based models of care. This Model of Care Framework takes the opportunity to standardise and align process, to optimise the use of available workforce resources which can more effectively respond to increased demand and better utilise resources to improve outcomes provide greater value for money.
To address chronic pain in New Zealand, Manatū Hauora requested a multidisciplinary representative Expert Advisory Group (EAG) to develop a National Model of Care for chronic pain services.
Chronic pain, also referred to as persistent pain, is defined as pain that recurs or persists longer than three months. It is defined as a health condition in its own
This document aligns to the ICD 11 classification of chronic pain
Itright.isalso
referred to as ‘persistent pain’ in the literature and by those living with pain.
The New Zealand health and disability system is committed to fulfilling the special relationship between Māori and the Crown specified under Te Tiriti ō Waitangi (Te Tiriti). Meeting our obligations under Te Tiriti is necessary if we are to realise the overall aims of He Korowai Oranga: Māori Health Strategy (Ministry of Health, 2020a) and improve outcomes for the health and disability system as a whole. This includes a desire to see all New Zealanders living longer, healthier, and more independent lives.
Hauora Māori Models: Te Whare Tapa Whā
Where the principles of Te Tiriti underpin the Ministry’s commitment to Te Tiriti and guide the actions outlined in Whakamaua, they also apply to the wider health and disability system (Ministry of Health 2020c, 2020e) The Office of the Chief Clinical Officers (OCCO) seek to fulfil their obligations to Te Tiriti with reference to Whakamaua, pae ora and Tā Tātou Rautaki (Ministry of Health, 2019, 2020b, 2020d)
One model for understanding Māori health is the concept of te whare tapa whā the four cornerstones (or sides) of Hauora Māori.
ō Waitangi
For many Māori modern health services lack recognition of taha wairua (the spiritual dimension). In a traditional Māori approach, the inclusion of wairua, the role of the whānau (family) and the balance of hinengaro (mind) are as important as the physical manifestations of illness.
This model was developed by Sir Mason Durie, it has been widely taught within New Zealand health professions, is easily accessed and well understood within New Zealand. Te Whare Tapa Whā and has been a cornerstone to the chronic pain EAG’s thinking and model of care development:
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In aligning with Whakamaua, OCCO seeks to fulfil Te Tiriti principles through the following five strategic intentions.
Commitment to Te Tiriti
Te Tiriti obligations underpin Whakamaua: Māori Health Action Plan 2020 2025 (Whakamaua) (Ministry of Health, 2020e), which sets the government’s direction for Māori health advancement over the five years from 2020 to 2025. As part of the Allied Health Strategy 2021 2023, The Model of Care Framework will support the implementation of Whakamaua and work to identify opportunities to partner with Māori health professionals as we deliver on our objectives.
Taha tinana (physical health)
The capacity for physical growth and development. Good physical health is required for optimal development. Our physical ‘being’ supports our essence and shelters us from the external environment. For Māori the physical dimension is just one aspect of health and well being and cannot be separated from the aspect of mind, spirit and family.
With its strong foundations and four equal sides, the symbol of the wharenui illustrates the four dimensions of Hauora Māori.
Taha wairua (spiritual health)
Should one of the four dimensions be missing or in some way damaged, a person, or a collective may become ‘unbalanced’ and subsequently unwell. This is reflected in a contemporary understanding of pain, with strong evidence that mamaenga roa affects taha tinana, taha wairau, taha whānau and taha hinengaro and, in turn, these factors also influence pain and pain related disability.
The capacity for faith and wider communication. Health is related to unseen and unspoken energies. The spiritual essence of a person is their life force. This determines us as individuals and as a collective, who and what we are, where we have come from and where we are going. A traditional Māori analysis of physical manifestations of illness will focus on the wairua or spirit, to determine whether damage here could be a contributing factor.
Taha whānau (family health)
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The capacity to belong, to care and to share where individuals are part of wider social systems. Whānau provides us with the strength to be who we are. This is the link to our ancestors, our ties with the past, the present and the future. Understanding the importance of whānau and how whānau (family) can contribute to illness and assist in curing illness is fundamental to understanding Māori health issues.
Taha hinengaro (mental health)
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The capacity to communicate, to think and to feel mind and body are inseparable. Thoughts, feelings and emotions are integral components of the body and soul. This is about how we see ourselves in this universe, our interaction with that which is uniquely Māori and the perception that others have of us.
The membership of the EAG for chronic pain was coordinated by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. They engaged in recruitment across their multidisciplinary workforce and ensured that they also included consumer and Māori Health representation.
• Rural groups
Chronicpain affects all ages and genders, regardlessof location or socioeconomic status. Where services are proportionally lower in volume, they continue to demonstrate complexity in workforce resourcing, range of treatment services offered and inequitable access across populations, particularly:
Background
• People living with disability
• Intersectional communities
• Pacific Peoples
• Children and adolescents
• Māori
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It is intended that the Model of Care for Chronic Pain described in this document will address the service issues and move towards prompt, appropriate and evidence based delivery of care for people living with chronic pain.
• Women
As the Health System Reforms (2021), signify centralisation, this shift in focus offers momentum and opportunity for the implementation of national models of care. The benefits and efficiencies to be gained by coordinating and establishing a collegial model of care is evidenced in international literature (Starling, 2018). However, the scale of implementation using this Model of Care Framework for New Zealand, is pioneering. It seeks to meet population health need effectively, using best practice, the right mix of skills and maximising contemporary health technologies.
• Older people
New Zealand currently has an episodic, silo oriented delivery model of chronic pain services. These services differ in their resourcing, geographical availability, criteria for accessibility, treatment accreditation and provision. The EAG has considered paediatric and adult service provision, best practice treatments, resource requirements and equity of access within an inclusive bi cultural approach.
• Refugee and migrant groups
• Mismanagement of painconditions and inappropriate prescribingofopioidsand other drugs is also a risk for people living with chronic pain
Chronic pain is estimated to account for five per cent of the total health burden each year (Ministry of Health, 2013) More attention has been paid to understanding chronic pain in New Zealand over the last 10 years. The volume of research has risen, and the burden of chronic pain has become more visible, with lower back pain identified as the leading causeofmorbidity with an estimated 8.9years of healthy life lost due to disability (YLD) (Health and Independence Report, 2019).
• Māoriadults are at 1.4times more likely todevelop chronic pain issuescompared to non Māori adults.
• Disability from pain is high, impacting daily life activities, work and occupations.
• People with chronic pain may experience have poorer health related quality of life and limitations in daily functioning (Dominick, Blyth and Nicholas, 2011). In particular, the experience of pain has severe social, psychological, and biological dimensions.
• In New Zealand, the prevalence of chronic pain varies slightly by ethnicity (Māori: 23.2%; Pākehā (NZ European): 21.3%; Pacifica: 18.3%; Asian: 10.3%) (2020/2021 NZ Health Survey)
• Areas of high socio economic deprivation have a higher proportion of people with pain.
Summarising the burden of chronic pain in New Zealand:
• Chronic pain also results in higher use of health care.
Population Need
• Internationally, chronic pain is recognised as a major health problem that has considerable impact individually, socially, and economically.
• Long term inappropriate opioid use is associated with unemployment and/or receipt of government benefit, low income, multiple pain conditions, depression, suicidal ideation, childhood abuse or neglect, and alcohol addiction.
Living with chronic pain is a significant and complex condition Women, older people, Māori, and those in areas of higher socioeconomic deprivation have been found to be more at risk of developing chronic pain compared to other population groups
• The proportion of people with chronic pain increases with age This means that prevalence will rise in future as our population ages.
• More than one in five adults experience chronic pain.
• International evidence demonstrates that patients with pain related disability reported over twice as many primary care visits, and three times as many hospital admissions and Emergency Department (ED) visits as those who do not live with chronic pain
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• The most prevalent issues reported include trouble walking, sleeping, concentrating and maintaining their relationships due to their chronic pain,
Current State
Technology and data not well utilised
The Facultyof Pain Management’s report (2018) does not include children or adolescents and there are limited services available in New Zealand to this vulnerable population. It is recognised that children with chronic pain have a higher risk of disability as adults. It is important to teach chronic pain self management and coping strategies early on to provide opportunity to reduce long term disability and dependence on the health system, and instead improve function and quality of life
Acknowledgement is given to institutional racism and its impact on equitable access and provision of services and outcomes. There is active work going on to address racism in chronic pain services and for those affected living with chronic pain
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Inequitable service delivery, particularly affecting vulnerable groups
The EAG have highlighted several issues, as summarised below:
A diverse range of services are inconsistently provided by single discipline medical assessments to hospital based specialists, inclusive of but not limited to pain physicians, rheumatologists, surgeons, gynaecologists and multidisciplinary pain management teams where available. Some of these services have also been constrained by facilities, funding, and workforce availability.
Access limitations may be due to the roles and responsibilities within the whānau. For example, the whānau may depend on the income generated by this individual making it difficult to take time off work, there may be dependent children or there other whānau members may be needed to provide transport.
There is only a limited use of telehealth facilities and a reliance on either a visiting pain specialist or the person travelling to access care. Travelling is a potential burden on whanāu as it means time away from work, extra costs, and can exacerbate pain for the person seeking care Providing services via the use of technology can be challenging and is not always easy to use for clinician or the person. However, feedback from people who accessed pain services during the pandemic clearly identified the positive social
Inconsistent models of care across the system and variable access to and understanding of treatment options within primary care creates a fragmented health experience for the consumer and inequitable delivery of services provided across New Zealand.
Our population is multicultural and the predominance of a western paradigm in chronic pain services does not always provide appropriate support to these groups of consumers. The concept of chronic pain needs to be a ‘whole person’ view in line with cultural and spiritual beliefs. Chronic pain needs to be considered in terms of the family and social roles. However, there is a lack of research in understanding Pacific People and Māori experiences of accessing chronic pain services and their unmet needs in receiving culturally appropriate and safe care.
Stigma associated with chronic pain remains a significant challenge for the community, particularly in relation to those whose conditions appear to have no identifiable causes. Bean et al (2022), showed that greater stigma was experienced by those who used more opioids, had a mental health condition, viewed their pain as organic, and were unemployed. Stigma was associated with greater disability, depression and lower social support. Qualitative results supported quantitative findings, with three key themes identified: 1. “Faking It”: Others disbelieve pain and attribute it to drug seeking, laziness, or mental health problems, 2. A spectrum of stigma: Experiences of stigma vary from none to widespread, and 3. “I hide it well”: Concealing pain and avoiding stigmatizing situations lead to isolation & disability (Bean et al, 2022)People with chronic pain often experience scepticism from whānau and friends, and have difficulty finding health professionals to support them to manage the condition. This is reported to lead to unemployment, poorer mental health and a decreased quality of life.
There remains a lack of consistent and standardised data collected from across national pain services and a need to improve data coding to develop services.
Secondly, a disparity between ACC and Manatū Hauora funded services has contributed to the inequitable access by consumers of services available. A goal of the model of care is to increase clinician understanding of chronic pain. This, alongside careful consideration of the evidence which supports a specific treatment, should inform treatment decisions. Key entities need to work in partnership to address and meet the needs of our population in a coordinated and equitable manner.
Organisational drivers
There were two organisational drivers identified. Firstly, most chronic pain is managed in primary care with general practice responsible for patient care. There is an opportunity to take a holistic approach that includes individual preferences and involve partnerships between people with chronic pain, their whānau, service providers including transdisciplinary professional practices, and primary and community healthcare organisations. People with chronic pain should be able to access appropriate investigation and treatment in a timely and efficient manner.
Chronic pain is an unpleasant experience and people are often frightened that there may be underlying health issues that have not been adequately investigated or treated. People may be limited in their ability to access services to help with chronic pain. They may not always have a full understanding of the options available to them, the advantages/limitations of those options or a clear understanding of the mechanisms of chronic pain. In pain medicine, the outcomes are not about intervention to achieve pain reduction but improving quality of life and management of the disease.
Skills Mix
There is a need for the right skill mix to address prevention, acute response, and the management of chronic pain. Expansion of roles to include peer support, Māori health
connections provided by peer support with the use of technology. It was identified as both supportive for wellbeing and sustaining self management behaviours
Difficulty and stigma for people with chronic pain accessing care
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Whileliterature.thereis
There is promising evidence to suggest involving people with lived experience with a particular health condition in health service delivery and planning can lead to improved uptake of services and reduce stigma. Peer support facilitators for on going self management for persistent pain are currently limited in New Zealand, however research suggests that peer support facilitated by a variety of people can also improve experience, behaviours and health outcomes for people with chronic pain. Devan at al (2019) state that peer support can be valuable as an ‘an important skill for long term self management’ and providing ‘informational, appraisal, and emotional support’ with the potential to improve self efficacy.
Tables 1 and 2 below depict the variation and resource availability across a range of professions that exist to provide chronic pain services. As shown, the current size of the service and workforce is small. With increasing demand on the system a new approach is needed. A change in the service model for chronic pain is required and supported by the
providers and Kaiāwhina Māori in addition to specialist pain management physicians and allied health clinicians including psychologists, occupational therapists, nurse specialists, physiotherapists, pharmacists, social workers will assist in delivering the most effective care to people living with chronic pain. A broad skills mix provides an opportunity for collaborative care that is appropriate to patient need and desired outcomes, including working closely with mental health and addictions services.
a growing interest in postgraduate courses to upskill and specialise in pain knowledge and expertise, the level of training accreditation must be accessible, integrated, and achievable to a wider health workforce. The insufficiency of medical, nursing and allied health training positions available to grow professions into the pain specialty is recognised. To address the need to enable workforce growth new models of training integrated into care pathways must be developed New models of training integrated into care pathways maximise the skills and services needed, including training for all professions in transdisciplinary teamwork.
This breadth of skill requirement would influence population health, education of the workforce, and cultural safety. People requiring chronic pain services need to be provided with, have access to and be informed of the breadth of skill mix that can meet their needs. In addition to Rongoā providers in the community, the role of Kaiāwhina Māori (community social health workers) play a key role in identifying whānau who are struggling with their chronic pain and refer them to primary care practitioners. Often they accompany whānau to their general practitioner (GP) appointments and help to make sense of the clinical encounter. Upskilling Whānau Ora providers who often contract Kaiāwhina Māori will be an important aspect of skills mix to this new model of care to address inequities for Māori whānau with chronic pain
Workforce training
Auckland TARPS 5.2 1 3.5 0 4 1 ManukauCounties Chronic Pain Service (CPS) 1.85 2 1.4 0 2.2 0
Canterbury Burwood CentreManagementPain 2.55 0.5 3.4 0.5 3.8 1.9
Contracted FTE
Wairarapa (referred to CCDHB) 0 0 0 0 0 0
TakiManawaTe
Hauora Tairāwhiti ServiceManagementPain
MidCentral (referred to CCDHB 0 0 0 0 0 0
IslandSouth MarlboroughNelson PainMalignantNonPersistentService 0.8 1.6 0.6 0 0 2.0
Central Hawke’s Bay ServiceManagementPain
Waikato ClinicManagementPain 0.9 0 0.3 0 1.2 0.95
Table 1: Summary of current FTE resources for Adult Pain Services (note: to the best of our knowledge of secondary care services. No national data set available)
Bay of Plenty Chronic Pain Service 0.71 0.71 0.8 0 0.8 0.8
Contracted FTE
Capital & Coast Regional servicemanagementpain 3 1 1 0 2.2 0.8
CanterburySouth PainPersistentService 1 0.8 0.3 0 0 0 Southern PainPersistentService 1.6 1 0.5 0 1 0
West Coast (referred to CDHB) 0 0 0 0 0 0
Waitemata PainWaitemataServices 0.8 1 1 0 1 0
Taranaki PainPersistentService 0.5 0 0.2 0 0.3 0
Whanganui Chronic Pain Service 0.29 0.5 0 0 0 0
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Region DHB Service Medical Nursing Physio WorkSocial yPsycholog TherapyOccupational Northern Northland (NAPS)ServiceAreaNorthlandPain 0.1 1 0.5 0 0.5 0.2
Hutt Valley (referred to CCDHB) 0 0 0 0 0 0
Lakes (referred BOPDHB)to 0 0 0 0 0 0
Table 2: Summary of current FTE resources for Paediatric Pain Services
Northern Northland No dedicated service (Starship)AucklandWaitemata ServicePainComplex 0.7 0.4 0.6 0 0.8 0.6
Tairāwhiti
Central Hawke’s Bay No dedicated service CoastCapitalHuttMidCentralWhanganuiWairarapaValley&
IslandSouth MarlboroughNelson No dedicated service SouthernCanterburySouthWestCanterburyCoast
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ManukauCounties
Region DHB Service Medical Nursing Physiotherapy WorkSocial Psychology TherapyOccupational
Waikato No dedicated service BayLakesof HauoraTaranakiPlenty
Pain Team 0.2 0.2 0.05 0 0.1 0
ManawaTeTaki
Adults with chronic pain
• The need to adequately resource and tailor a pain service to suit the needs of young adults to run alongside paediatric and adult services
• Provide specialised pain services across inpatient, outpatient and outreach settings.
• Are informed by the best available evidence
The literature consistently shows the benefits of a sociopsychobiomedical approach to chronic pain management. The transdisciplinary team may include but is not restricted to a pain medicine specialist, nurse, physiotherapist, occupational therapist, pharmacist, and psychologist. Assessment for inclusion in a pain management programme should include appropriate screening to exclude underlying treatable disease, to discuss treatment options or the lack of them, and to introduce the concepts of persistent pain and pain management through education.
• Recognise the interaction of biological, psychological and social factors in the experience of and response to pain and aim to provide a suite of interventions and therapies to address these.
• Are oriented towards outcomes for both patients and the health system as a whole.
The emergent models have the following consistent themes:
Summary Internationalof Best Practice Evidence
• Align to principles of health promotion, prevention, and early assessment and intervention
• Are directed toward developing greater self management of chronic pain.
• Are interdisciplinary and operate across the interfaces of primary, community and acute health.
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The literature reflects the need for more effective management of pain, particularly for those who experience chronic pain. This necessitates a model of care which is inclusive of, yet far broader than, the traditional, biomedical approach which focuses on ‘curing’ pain. There are many examples of comprehensive approaches to chronic pain management internationally.
A group educational program prior to entry into the pain service has shown benefits for some patient groups. Pre assessment education can be used to enable those referred to
• The importance of child and whānau centred sociopsychobiomedical care and the benefit of intensive interdisciplinary pain treatment delivered in an outpatient or inpatient setting when indicated.
• Require a strong primary care network
• Shared decision making tools,
Previous experiences of racism in the healthcare setting and a lack of culturally responsive services, as well as support and access barriers for pain services likely contribute to the inequities in access and outcomes (Harris et al, 2006). The four main themes that emerged from research on Kaiāwhina Māori health workers’ perspectives on pain management for Māori were:
• health literacy approaches to pain management are urgently required
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Person centred care pathways with transdisciplinary specialist pain capacity can:
a chronic pain service to gain an accurate appreciation of the service and the opportunity to decide if it could meet their needs.
• Consideration of all aspects of an individual’s pain experience
• Pain assessments
• Enable models that work across regions to support seamless care and consistent access to specialty hubs
Research from 2018 found Māori who attended a chronic pain service presented with a significantly higher need for healthcare when measuring clinical outcome measures. As well as having higher pain, Māori presented with greater disability, higher levels of depression, anxiety, and stress, lower self efficacy to manage pain, higher levels of pain related fear and more catastrophic thoughts related to pain (Burri et al, 2018).
• Ensure equity in access and pain care to Māori, Pacific peoples, and rural remote communities
• the availability of, and referral practices to, specialist pain management services are limited for Māori communities (Devan et al, 2021).
Screening can be used to identify the factors which are likely to present as obstacles to recovery. It can stratify patients by psychosocial risk and can guide treatment decision making in a clinical setting as well as clarifying patient expectations of outcomes and goals for the programme prior to it commencing. Admission to chronic pain management programme should follow appropriate transdisciplinary assessment to confirm suitability and identify relevant individual goals. Treatment may be delivered face to face or remotely or through a combined approach. There are benefits to telehealth services for some patient groups.
• A need to screen patients to determine who is at risk of transitioning to chronic pain
• Māori have significant unmet need for culturally responsive pain management
Research and the 2020/21 NZ Health Survey has shown that Māori adults are 1.4 times more likely than non Māori adults to self report chronic pain (Gatchel et al, 2014). Māori are less likely to visit their general practitioner for pain management and experience barriers accessing specialist pain services in Aotearoa New Zealand (Taylor et al, 2004).
The following were identified as non pharmacological areas that can be improved through transdisciplinary sociopsychobiomedical care (Alberta Pain Strategy, 2019):
Māori experience of chronic pain
• that treatment of chronic pain in primary health relied exclusively on medication
• Improve early access to pain assessment, treatment, and management
The child and their whānau should be treated in a comprehensive and integrated manner with all aspects of the child’s development and well being attended to, including their cognitive, emotional, and physical health. The child’s educational, cultural, and social needs and goals must be addressed as part of the care management plan and treatment. Such programmes are developed to maximise age appropriate activities and are mindful of developmental and different social and emotional and cultural needs of the child and their whānau. Whānau involvement and education are core to successful paediatric pain management programmes. Programmes are developed to promote engagement and support children and their whānau to have an active role in care through communication and shared decision making around pain management plans and progress.
the lived experiences of pain among Māori is an important aspect to consider and to address in models of care to provide effective care (Pitama et al., 2011; Shipton, 2013).
The evolving standard of care for paediatric chronic pain involves a transdisciplinary treatment team that delivers child and whānau centred sociopsychobiomedical care. The child’s care should focus on, and be organized around, the health needs, preferences and expectations of the child, and their families and communities.
Paediatric chronic pain
Adolescent services are unique in that some cases involve a transition of a young person from paediatric to adult services while in other cases this is the young person’s first experience of chronic pain and treatment. The adolescent group generally ranges from 14 to 25 years. These chronic pain services have a focus on increasing independence and self management in treatment and in managing access to services and appointments.
Adolescents with chronic pain
Research supports the need for culturally appropriate pain management resources, services, and support to be adopted to address the current inequities in prevalence of chronic pain and access to pain services (McCavock, 2011). Literature supports further research and implementation of Māori models of health and wellbeing such as Sir Mason Durie’s Te Whare Tapa Whā model which describes a holistic view of health and wellbeing that reaches wider than the western biopsychosocial model. Research supports the need for a co designed mātauranga Māori service for chronic pain management that reflects Māori models of health and wellbeing and are culturally Understandingappropriate.
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Both Māori and Pasifika cultures have a holistic view of health with a larger emphasis on family and spiritual aspects than traditional Western models. There is little research on how these different cultural lenses may influence the impact and management of chronic pain in these populations.
In some situations, adolescents are treated within a paediatric programme, while in others, adolescents are included within the adult programme or, within a specialised adolescent service that is separate from both the paediatric and adult services. Maintaining engagement and support for adolescents/young adults is important
particularly given this can be a point of drop out from the service as independence is encouraged and parental involvement in treatment may decrease.
See Appendix One for a summary of the literature reviewed
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While paediatric services are whānau centred, adult services are more independently orientated. This be a challenging transition especially given the increased reliance on parental support that is seen in young people coming through the paediatric pathway. There is a focus on developing capacity to understand and appreciate the treatment options, explanations, and consequences and fully informed consent, developing the tools and skills needed to manage persistent pain independently.
5. Working as a team sustaining and shared understanding of working and across scopes of practice for best outcomes
6. Broader sociopsychobiomedical approach grounded by Te Whare Tapa Whā This includes the training of the workforces to facilitate informed choice for people with mamaenga roa/chronic pain to access a holistic range of care.
4. Use of technology where appropriate and with a whānau focus
1. Our Tiriti o Waitangi obligations and its principles are upheld. Te Whare Tapa Whā is woven throughout the model of care and this this applies for all New Zealanders. This holistic view of health aligns to evidence based international pain models of care
2. Multi disciplinary teams working transdisciplinary to ensure the appropriate skill mix are accessible and available, including people with lived experience as part of service development and delivery to enhance access and uptake of services.
The EAG agreed on the following principles for their approach embedded with an equity lens that includes equitable access to services, for the development of a national model of care.
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7. Timely access to the appropriate level of care.
3. Clear equitable pathways for care appropriate to the individual
Principles
The model below reflects the specific requirements and nature of the New Zealand health system taking into consideration the Health and Disability System Reform. It is intended to guide planning and delivery of the services provided through the localities and provider network model.
The key strategy pillar of the national model of care for chronic pain is the integration of services across the continuum of a person’s life stages with better access to pain specialist expertise and more focused training for localities to better understand and treat chronic pain in a community setting. This will deliver a national pathway to improve access to services, improved operational capacity, enable transdisciplinary care and services at all levels, and harness the value of peer support and self management of chronic pain.
• Embracing telehealth with local supports that provide equity of access to specialised services
The key aim of a National Model of Care for Chronic Pain is to improve the delivery of pain services to New Zealanders by:
The proposed changes in the service models across the care continuum for are summarised in the diagram below:
• Develop health literate systems and services to reduce unnecessary suffering and unmet need
• Implementing a consistent best practice model of care to improve pain outcomes and quality of life
Proposed Model of Care for New Zealand
• Deliver services that are integrated across settings, with a ‘one team’ culture to promote smooth transitions of care across paediatrics, adolescent, and adult pain services across all districts
• Foster an environment of clinical excellence through supported workforce upskilling, training, and development
Aims
• Provide culturally safe services, with a focus on Māori and Pacific people and their experiences with chronic pain
• Deliver services so people with persistent pain can self manage their condition, or support their children and loved ones to manage chronic pain
18 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
• Provide access to specialist advice to build capability in primary health care to better manage people with chronic pain
Localities and place based care Local professionalshealth with pain training & access to specialists
Whānau focused, patient led support
Transdisciplinary team of pain issueshighlyprovidingexperts,careforcomplexpainandoutreach to local communities and whānau
This will deliver a national pathway to improve access to services, improved operational capacity, enable transdisciplinary care and services at all levels.
Specialist networks Locality based care Peer Support Self management
Programmes and skills to put whānau in control and cope with chronic pain
Chronic Pain | Mamaenga roa Model of Care
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Figure 1: Mamaenga roa: Chronic Pain Model of Care
Tiriti-based practices and culturally safe care
• to promoting chronic pain self management and promote peer support
• to enable primary and community care to provide care including research, education, mentoring (peer review, clinical supervision, professional development), and support from specialist hubs
• to enable whānau in pain to be seen virtually, and reduce unnecessary travel
Locality based care & provider networks
Well resourced, coordinated, and integrated networks of providers will support the delivery of care to a locality.
Provider networks will also work to establish and support community based providers including Māori and Pacific providers, GPs, and other community care providers, to work together in comprehensive primary and community care teams making more
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In addition to providing specialist chronic pain services, the hubs aim to contribute:
It is expected that any chronic pain services need to align with other tertiary pain services and consider capacity to service inpatient workload, including acute, cancer and palliative care patients.
To give effect to the design principles of a national model of care, four hubs are expected, based on the provider network model in Te Whatu Ora Health New Zealand. The shape of these networks will be designed through a process led by Te Whatu Ora and Te Aka Whai Ora the Māori Health Authority in collaboration with locality stakeholders It is expected there will be a focus on integration across services so that people with more complex care needs have a better experience when accessing different parts of the health system.
Operating Model within the new Health System
• to appropriate utilisation of healthcare services related to pain
• to addressing unmet need and inequity in chronic pain service access across groups, especially for Māori and Pacific whānau
• to seamless transitions of care for paediatric, adolescent, and adult patients and their whānau
The main aims are to (1) co design and pilot test an initial version of the whānau focused (family and significant others) pain management programme in Māori with persistent pain; (2) evaluate the clinical and process outcomes of the whānau focused pain management programme.
As supported by the literature, this may mean that most paediatric and adolescent services are provided through provider networks, given the intensive pain management approach and specialist workforce required.
Research Methods
This is community based participatory action research (PAR) guided by a Māori centred research approach, both of which uphold community engagement and empowerment. In this study, the Tū Kotahi Māori Asthma & Research trust (Tū Kotahi) identified the research aim and I’m working with our Māori community partner Cheryl Davies from Tū Kotahi supported by Kaumātua from Kokiri Marae, throughout the research process. Our previous co design study with Tū Kotahi whānau living with persistent pain identified the need for a Marae based pain clinic and whānau focused pain management programme. Based on these inputs and in
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services available locally.
It is proposed that high complexity pain interventions or the most intensive transdisciplinary programmes are provided at one for the four regional hubs, while medium pain complexity and some ongoing case management services should be available through each locality, with support from the hub as required.
Partnering with Māori whānau to address inequities to pain management – A qualitative case study
Research Aim/Objective
A chronic pain self management programme offered in a community setting is a considered a recommended precursor to multi disciplinary chronic pain services
Figure 2: Interim Health NZ Locality & Provider https://www.futureofhealth.govt.nz/assets/Uploads/Documents/LocalitiesNetworks update for the Health Sector April 2022.pdf
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consultation with Wellington Pain Service clinicians, a 6 week whānau focused pain management programme (July August 2021) and the Marae based pain clinic was implemented in Kokiri Marae (ongoing). Whānau interviews were analysed using the General Inductive Approach.
Preliminary results from the whānau pain programme
Telehealth and virtual care
will use common clinical standards and guidance, using an integrated continuum of care approach.
One team culture with equitable and timely pathways to care
Persistent pain disproportionately affects Māori and their whānau. Māori face significant inequities in accessing specialist pain services and experience stigma and stoicism in expressing and managing pain. In line with the proposed Aotearoa New Zealand health system reform, this community based pain programme is a commitment to Te Tiriti obligations to address health inequities for Māori and a result of an ongoing meaningful partnership between Tū Kotahi, University of Otago, and Wellington Regional Pain Service.
To support patients with chronic pain with an appropriate level of accessible specialist care across their journey with chronic pain and supported to self manage their condition, the locality and the provider networks need to function as one service with consistent and coherent ways of working
Telehealth and virtual care options are expected to be a key strategy for improving access for people to ensure care is delivered close to home. For example, telehealth facilities in a community setting alongside resident expert team members within a locality could provide appropriate support for people to access specialist level chronic pain
Eight whānau living with persistent pain participated in the 6 week programme and the month Kokiri pain clinic is ongoing. For the whānau focused pain management programme, Te Whare Tapa Whā (the four cornerstones of Māori wellbeing) was used as a holistic framework focusing on the whānau wellbeing as a collective instead of the individual living with pain. The sessions were led by our Māori community partner (CD) and a pain management physiotherapist (HD). A dedicated session on Māori traditional treatment (Rongoā Māori) for pain management was led by a Rongoā practitioner. Supporting resources for the programme was co developed in collaboration with our Māori community partner, Wellington Regional Pain Service clinicians (DH), a Health literacy expert (SR), and a Māori illustrator. Preliminary analysis from whānau interviews suggests an enhanced understanding of persistent pain mechanisms (e.g. pain as an overprotective sensory system response) and provided whānau with "more tools to manage" their pain including Rongoā. A short video https://youtu.be/x1bewks Zhw capturing whānau experiences from the programme.
Discussion
Theseservices.services
• A workforce team consistent with the range of holistic services offered should be available at all hubs and will operate using a transdisciplinary team approach. This includes Rongoa practitioners, Kaiāwhina and Pacific navigators to build culturally safe services.
These teams will apply their collective specialist expertise to deliver a range of persistent pain services that will be integrated with, as well as support and enhance, those services provided by Māori, Pacific, and broader primary health care providers.
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• As the service is integrated, professional development and capability building in chronic pain management across the service, including timely access to specialists for advice for patients being managed locally is supported with regular meetings and strong relationships despite working in distinct settings.
Education and research into persistent pain
• To ensure there is equitable access to care, consistent triage and wait times should be established, as well as the use of telehealth to improve equitable access to rural communities.
• For this to be operationalised effectively, appropriate pathways for referral and/or consultation need to be well established, with shared clinical guidance, shared care approaches between primary care and specialist teams.
Provider networks will be expected to be resourced to collaborate with local tertiary educators, with the opportunity to develop clinician researchers within the hub team. Having specialised clinician researcher roles in hubs could make collaborative research feasible, which in turn helps to inform key clinical questions in terms of access, experience, and effectiveness.
a. Specialist nursing and allied health pain specialist workforce, 1.2 pain specialist FTE per 100,000, distributed across the four hubs (currently 0.8 pain specialist FTE per 100,000) to provide the medical leadership to ensure patient continuity of care and deliver the outcomes of the national model of care.
1.implementation:
4. Networked local resident pain expertise that support patients and links primary care and other specialist care
c. Not every patient requires team based care, but for those who do access to spiritual care, rehabilitation, psychosocial and mental health services, medical management and peer support networks.
The following recommendations have been agreed by the Expert Advisory Group to give effect to the design principles and progress this model of care towards
6. Workforce development and capability building consistent with a biopsychosocial model including whānau champions, Kaiāwhina and Pacific navigators to build culturally safe services.
7. Full utilisation of telehealth to support place based care to patients, provide education, improve the triage of referrals and to provide better access to specialist opinion in rural and remote areas.
Next Steps
Chronic pain speciality services are developed, implemented, and commissioned by Te Whatu Ora Health New Zealand.
3. Research, training, and service improvement for paediatric and Māori whānau living with chronic pain is prioritised to improve outcomes and reduce likelihood for adult chronic pain services.
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b. This would require sustained workforce growth over a period of time, with specialist pain nursing and allied health teams to increase FTE to enable the above ratios, and specialist pain physicians growing from 40 pain specialist FTE (2021) to 60 pain specialist FTE over medium long term.
2. Te Whare Tapa Whā as a holistic model of care for whānau living with living with chronic pain chronic pain, with four specialist hubs linked to localities ensure equitable access across New Zealand.
5. Gradual, sustainable growth of specialist medical, nursing, and allied health care resource with pain expertise:
9. Nationally consistent outcomes measures based on functional improvement, health related quality of life, timeliness, and access (i.e., the joint Australian and New Zealand electronic Persistent Pain Outcomes Collaboration (ePOCC)).
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8. National Clinical Network established that encompasses all pain specialities (chronic, acute, post operative, cancer, paediatric): as a clinical leadership group that contributes to national guidelines, quality, safety, education, supervision, and improvement of the services nationally.
Use of technology, triage systems, early intervention & escalation points
Appendix 1: Literature Review of Adult Chronic Pain
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Pain management services should be staffed and operate to accommodate the local requirements of all patient groups, including children, adolescents, the elderly, and those with complex needs.
Specialised Pain Management Services in a tertiary centre should always involve a multi specialty and multidisciplinary team.
Pre assessmentEnableeducationthosereferred to a pain service to gain an accurate appreciation of the service and the opportunity to decide if it could meet their needs
‘Individualised, multimodal, multidisciplinary pain management’ Medications (opioid and non opioid)
ACI NSW Agency for Clinical Innovation Pain Program?PatientProgramsManagementWhichforWhichAguidefor NSW Tier 3 and Tier 2 public health facilities providing pain programs for adults
High intensity group: Three or more staff (may include psychologist, physiotherapist, occupational therapist, nurse, psychiatry in paediatrics), with specific medical input (for medication and education).
STEPS: Self Training Educative Pain Sessions delivered by members of their multidisciplinary pain team to prospective pain service patients. Followed by a substantial reduction in waiting times for those wishing to still attend their pain service.
Core Standards for Pain Management Service in the UK (CSPMS)
MDT The multidisciplinary team must include medical consultants trained in chronic or acute pain medicine as appropriate, nurses, physiotherapists, psychologists, pharmacists, and often occupational therapists, and, where available, suitably trained GPs with a special interest (GPwSI) and SAS doctors.
To date, the most consistent evidence is that a background understanding and knowledge of cognitive behavioural management therapies, principles and methods is appropriate for all participating staff. 14. Recognition that co morbid conditions (e.g., spinal cord injuries, diabetes, Post Traumatic Stress Disorder, Major Depression, Personality Disorders) can complicate participation in a PMP and need to be addressed on an individual basis (e.g., with individual therapy in conjunction with PMP)
The multidisciplinary team must communicate regularly and effectively with the patient’s general practitioner.
The MDT should seek formal arrangements for inclusion of all clinicians involved in the provision of pain management services. This should include speciality doctors, GPs, and locum staff.
Specialist Pain Management Services in community and secondary care should always involve an MDT; how the MDT is delivered may vary according to local factors, e.g., in remote/rural areas.
Formal MDT meetings are desirable when managing complex pain cases. These meetings should involve representatives from the patient’s medical team, chronic pain specialists, physiotherapists, or psychologists.
A PMP may be a part of a series of interventions but should be planned to ensure effective engagement of the person and consistent support of their treatment providers.
PMP require staff with appropriate skills and training (so provision must be made to ensure this is the case for all staff).
Pain Management Best Practices Inter Agency Task Force USAandDepartmentReport.ofHealthHumanServices
All GPs should be able to assess pain, triage for serious pathology, assess psychosocial factors that may maintain disability and distress, and instigate simple pain management strategies, evaluate such strategies and triage to specialist pain management services if the patient is not responding or improving within eight weeks.
Use of education first. Patient suitability criteria determine what group patient is best
Team Team function
Clinical governance requires ongoing audit and data collection. All MDT and multi speciality teams should participate in audit and outcome data collection.
The multidisciplinary and multispecialty team must have adequate administrative support.
Restorative ComplementaryBehaviouralInterventionaltherapiesprocedureshealthapproaches&integrativehealth
Evaluation of outcomes (in terms of achievement of specific goals and common functions, e.g., disability, mood, pain, health care utilisation) is essential (e.g., 1/12, 3/12, 6/12, 12/12 follow up)
Individual patient: Practitioners with appropriate skills, working in coordinated way (e.g., clinical psychologist + physiotherapist + GP/Specialist)
Low medium intensity group: Two or more staff (may include psychologist, physiotherapist, occupational therapist, nurse). Coordinated with medical management
Admission to PMP should follow appropriate multidisciplinary assessment to confirm suitability and identify relevant individual goals.
PMP typically conducted by an MDT that works in a interdisciplinary way.
• explain the ‘whole person’ approach
Found that many gained enough ideas on pain self management at these sessions not to need more help by the pain service Davies and colleagues have been careful to emphasise that this level of intervention is unlikely to be enough for the more disabled and depressed patients, especially those who have become more reliant on medication to cope Those patients who have to make major lifestyle changes in order to live with their chronic pain will still need the help of sorts of programmes outlined further in this document
• provide early access to information following referral
• to maximise clinic time.
• provide exposure to information and resources
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• triage appropriate patients for priority assessment
• begin patient engagement, manage expectations, and promote readiness
• provide the opportunity for patients to opt out if the model is not aligned with their expectation
The objectives are to:
STEPS approach can provide a useful introduction to a pain service and promote more efficient use of scarce resources. Currently 10/19 NSW pain services offer a pre assessment pain education and orientation programme.
Pain clinic services can be offered via telehealth to Aboriginal people using Healthdirect Australia’s videocall and other platforms.
The service can be offered in several ways directly to a person in their own home, to the GP’s room, to the Aboriginal Medical Service or to the hospital.
education and training in pain management will give medical, nursing, and allied health professionals in the public and private sectors the knowledge and resources to deliver such care. Education in the biopsychosocial processes underpinning acute and chronic pain will give health professionals an accurate conceptualisation of pain and underpin care.
consultationsTelehealth with Aboriginal people for pain management
Participants are referred from primary care and secondary care specialists (orthopaedic surgeons and rheumatologists, in particular). In both cases, referral may be initiated at the request of the individuals. Most individuals will have received specialist care. Ensure meaningful communication about pain management between practitioners and patients, and between practitioners
Pain NationalAustraliaPainStrategy
Develop and evaluate patient centred service delivery and funding models for pain management in the community which provide interdisciplinary assessment, care, and support as a part of comprehensive primary health care centres and Comprehensiveservices
Optimal to ensure a health or community worker is in attendance, as well as any family members desired.
28 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
Best practice pain management often requires coordinated interdisciplinary assessment and management involving, at a minimum, physical, psychological, and environmental risk factors in eachTrainpatient.and support health practitioners in best practice pain assessment and Establishmanagementandpromote systems and guidelines to ensure adequate management of acute, chronic and cancer pain
Organisational factors (Black Flags), which include the sickness certification process, lack of alternative employment, lack of access to services to assist return to work and lack of interest in rehabilitation from employer (Krause et al., 1998; Young et al., 2005). (2++)
Assessment for inclusion in a PMP should include appropriate medical screening to exclude treatable. disease, to discuss treatment options or the lack of them, and to introduce the concepts of persistent pain and pain management, if this has not already been done. This may be done in primary or specialist settings, according to expertise. Although GPs may be adequately trained in pain management, many more will seek advice and guidance from specialist services. Until GP training is reviewed and improved, issues of participant safety would indicate that specialist advice is recommended (CMO Report: Donaldson L. (2009).
Many different healthcare professionals including doctors, nurses, psychologists, physiotherapists, and occupational therapists play a part n effective pain management care.
These potential obstacles to return to work should be assessed early and addressed in the treatment process. The level of motivation to work should be routinely highlighted in the assessment process.
It is recommended that obstacles to recovery be assessed in three main domains (Watson et al., 2010): Psychosocial factors (Yellow Flags), which include fear avoidance beliefs, catastrophizing, attitudes to work and working, psychological distress and pain coping strategies (Nicholas et al., 2011). (2++)
Professional development
The Alberta Pain Strategy 2019 2024 Shifting away from the traditional medical model of pain management and treatment and instead looking at ‘the whole person’ using a modified biopsychosocial model.
within local management structures and in the daily running of the team and programme is crucial. The discipline or title of the leader(s) is less important than the identification and recognition of these roles. Consideration should be given to professional and clinical support and supervision and necessary resources for the post holder(s)
A PMP is delivered by an interdisciplinary team where some competencies are shared, and some are unique to professions All staff use cognitive behavioural principles to deliver their component(s) of the PMP.
Screening should be used to identify the factors which are likely to present as obstacles to recovery. These are likely to be, for example: fears about being physically active with pain, the participant’s perceptions about the safety of their job and the attitude of the participant and the employer towards chronic pain and the workplace (Shaw et al., 2009; Nicholas et al., 2011). (2+)
All staff working as part of an interdisciplinary PMP should have adequate access to continue within discipline education and development specific to the area of pain, as well as to their own broader areas of professional interest. This should entail attending relevant national meetings and special interest groups and networking with fellow professionals in PMPs outside their geographical area.
Teamstructures.workingThecoexistence
LeadershipLeadership
of staff with a shared purpose does not make a team. Working together as a team requires frequent and regular times to meet and arrive at shared understandings of participants’ needs and staff provision. Team members also need to appreciate one another’s areas of unique and shared Allexpertise.staffcan
Multimodal Pain Strategies, including Appropriate Pharmacologic Interventions The best treatment for acute pain is a multimodal approach involving both pharmacologic and non pharmacologic treatments (psychological, physical therapy, and a wide variety of other therapeutic options) (Tick et al., 2018; U.S. Department of Health and Human Services, 2019).
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Pain management treatment should be offered when indicated by persistent pain causing distress, disability, and a negative impact on quality of life. Treatment is usually offered as a group treatment, but individual therapy is more appropriate for some people.
Perceptions about work (Blue Flags), which include physical job demands, ability to modify work, job stress, workplace social support or dysfunction and job satisfaction (Shaw et al., 2009). (2++)
As part of a PMP, education should be provided by all members of the interdisciplinary team, according to their expertise, using an interactive style to enable participants to raise and resolve difficulties in understanding material or in applying it to their situations or problems.
Access: Improve access to multimodal resources, a modified biopsychosocial approach, and interdisciplinary teams for people with chronic pain and their support systems to ensure optimal and equitable access to pain care for all Albertans.
British Pain Society –Guidelines for Pain ProgrammesManagementfor Adults
benefit from discussion with the clinical psychologist or equivalent on the application of cognitive and behavioural principles to their area of work.
Evidence informed care for chronic pain includes a biopsychosocial, interdisciplinary approach. Not every patient requires team based care, but for those who do, access to rehabilitation (physiotherapy, kinesiology, occupational therapy), psychological services (including addressing social and financial barriers to treatment), and medical management is essential for high quality care.
PMPs consist of methods to promote behaviour change and promote well being. They include education on pain physiology, pain psychology, general health, and pain self management. PMPs also contain guided practice on exercise and activity management, goal setting, identifying, and changing unhelpful beliefs and ways of thinking, relaxation and changing habits which contribute to disability. Participants practise these skills in their home and other environments to become expert in their application and in integrating them into their daily routines. Methods to enhance acceptance, mindfulness and psychological flexibility are also recommended.
In depth triage criteria
Most NHS staff are accustomed to management hierarchies within their discipline True interdisciplinary teams require cross discipline management
ClinicalPharmacistNurseOTPhysiotherapistPsychologistMedicalsupport workers Administration
While not incorporated within the traditional biopsychosocial model, also recognize that the spiritual aspect of health is important to many, and as such, we will be incorporating this element into our approach for pain
the historically uncoordinated development of pain services across Alberta has resulted in a combination of duplication of services, silos of unrelated services with differing philosophies of care, and large gaps in access.
Though opioids have a role to play in acute pain, opioid prescribing needs to be done in conjunction with a multimodal strategy, including the use of non opioid medications, patient education, adequate patient monitoring and follow up, and with opioid stewardship regarding duration, escalation, and tapering. Strategies for improved management of acute pain and early recognition of patients at risk of
PMPs are delivered in a group format to normalise pain experience, to maximise the possibilities of learning from other group members and for economy. However, an important addition to this document is the recognition that the content of PMPs may in some circumstances be best provided on an individual basis.
A Transitional Pain Service comprehensively addresses the problem of chronic pain preoperatively, postoperatively in hospital, and in the outpatient setting. This service, which may take place in an inpatient or outpatient setting, may improve patients’ pain trajectories, preventing the transition from acute to chronic pain, while reducing suffering, disability, and healthcare utilization and opioid dose escalation.
30 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
theme that emerges from the literature is that the effective assessment and management of pain requires a continuum of care involving a range of healthcare disciplines working in collaborative partnerships with those in pain (Pain Australia, In2011).Alberta,
The goal is to support patients through the stages of surgical recovery. This service works in an interdisciplinary model, focusing on multimodal analgesia with the support of a team including nursing, anaesthesiology, psychology, pharmacy, and with access to addictions specialists.
developing chronic pain offer important preventative options in decreasing the prevalence of chronic pain (Breivik & Stubhaug, 2008; De Kock, 2009; Pain Australia, 2011).Akey
• Shared decision making tools, including pain medication tapering strategies upon discharge.
Innovative models and Virtual Health strategies are necessary to make this possible, regardless of geographic location, e.g., Alberta Telehealth.
• Consideration of all aspects of an individual’s pain experience, described by the biopsychosocial model for pain.
• Pain assessments.
• A need to screen patients to determine who is at risk of transitioning to chronic
Transitionalpain
the following are identified as non pharmacological areas that can be improved through multimodal care:
Pain Service Certain factors increase the risk of developing chronic pain, such as poorly managed acute pain, opioid use, mental health conditions such as anxiety and depression, pain catastrophizing, and trauma symptoms (Hinrichs Rocker et al., 2009; Theunissen et al., 2012).
Understand the complexity of pain and that the approach to pain management will differ based on the type of pain as well as the illness trajectory. As such, recognize an accurate diagnosis is important, in conjunction with a careful explanation of pain, and the need for an interdisciplinary team approach and evidence informed treatments.
management and referring to it throughout the Strategy as a modified biopsychosocial model.
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Telehealth is suited to the needs of patients who are unable or unwilling to seek care in clinic (e.g., disability, stigma, other access issues). There is a paucity of reliable information about the efficacy of telehealth services for these patients.
Clear that scientific rigour of most pain related telehealth studies is less that optimal.
Priority settings and actions led by governments with consumers
Empowering consumers
Empoweredmanagementconsumersand carers
Specialist pain medicine physicians bring a multi disciplinary focus objective of restoring functionality and enabling individuals to live as independently as possible.
Education, training, and support for health professionals
Develop national clinical guidelines on pain and support for health providers to provide best practice pain management as outlined in the National Pain Strategy
4 funded positions for the two year pain medicine training program. Mainly funded by DHBs. Demand for training positions regularly exceeds supply.
Physiotherapist or other allied health professional such as an OT, pharmacist and may include a dietician and social worker or Nursescounsellorare an important part of MDT
Based on FTE ratio of one per 100,000 patients around 47 FTE is required. This is a deficit of 36.
32 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
Empowered and supported carers and families
Supportive workplaces and insurance systems
Integrated primary health networks
Interdisciplinary pain
4 currently training in accredited units (2 TARPS, one each in Wellington and Christchurch). 4 Others have completed training time but have outstanding assessments.
Integrated care including electronic health systems
Coordinated research and knowledge base
Active advocacy and influence peak groups
People living in pain can be best supported in primary care with only a small proportion requiring tertiary care
Current New Zealand workforce estimated at 11 FTE specialist pain medicine physicians (from 35 Pain Medicine Fellows).
Development of overarching education strategy to promote evidence based pain management education
National Strategic Action Plan for Pain ofAustralianManagementDepartmentHealth
Validated assessment and monitoring tools for chronic pain
Telehealth to link specialist services
At its maximum the existing training allocation would produce four specialists every two years, meaning that the current training system should produce the required amount of pain specialists in 15 years (up to 30 specialists) to maintain the existing workforce available.
Three accredited training units Auckland Regional Pain Service (TARPS), Burwood Hospital Christchurch and Wellington Regional Pain Unit.
Limited ability to increase NZ’s pain medicine workforce by recruiting international medical graduates as there are very few comparable pain medicine training programmes internationally.
Capable community support groups
Specialist pain medicine physicians accessible across the sector
Sapere The problem of chronic pain and scope improvementsfor in patient outcomes
Maintaining workforce requires an additional 23 trained specialists in the next 15 years. Assuming there are currently 35 Pain Medicine Fellows and 65 per cent are aged over 50, so would retire within the next 15 years.
Interdisciplinary Pain management Treatment is not ‘one size fits all’
Funding models that underpin affordable and coordinated health services
Review Article: aheadweManagement:ofComprehensiveAReviewTelehealthforPainWhereareandtheway
Solid evidence of the benefits of multidisciplinary care from experience internationally and in Australia. Controlled trials show that integrated medical, physiotherapy, and psychological interventions using cognitive behavioural methods can be more effective than usual care in limiting the impact of recent onset back pain, especially where psychological and social risk factors are present.
Situation likely to worsen as pain medicine workforce is aging. 65% of specialists are currently aged 50 years and over.
ActiveSkilledKnowledgeablethroughcommunitieshealthpractitionershealthprofessionalbodies and colleges
Shortage increased risk of stress and burnout
MDT likely to ClinicalPhysicianincludepsychologist or psychiatrist
Educate clinicians on specific chronic pain diagnostic coding and measurement resources
Enable models that cross provincial boundaries to support seamless care and consistent access to specialty hubs
Connect this portal and integrate pain related content with other online resources (e.g. federally funded platforms like ‘Wellness Together Canada’ and the ‘Knowledge Development and Exchange youth mental health HUB’
Typically, usually present to primary care providers
Many primary care providers report lack of confidence in their paediatric MSK clinical skills and thus may unnecessarily report these children who may be difficult to assess to sub specialists (paediatric rheumatologists or chronic pain programmes)
System reform and innovative person centred pathways and models of care Designed to build specialist capacity
Review of existing decision plain support systems available
Highlighted need to adopt a biopsychosocial approach
National mechanism to develop and disseminate pain related guidance and best practices in the organisation and provision of care
Integrate individuals with lived and living experience into training education and curricula development
Integration of Coordinatedservices and integrated health services across sectors are an essential ingredient to the successful implementation of CMP HarnessingMoCstechnology to improve access
‘Goal two people have equitable and consistent access to a continuum of timely, evidence informed, and person centred pain care and supports across jurisdictions’
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Align with international best practices
An advantage of these therapies is that they can enable non specialists and peers to be trained to provide pain management support, thereby improving access particularly to children and adolescents living in rural remote areas
Interprofessional assessment and management MoC = ‘evidence informed policy or framework that outlines the optimal manner in which condition specific care should be made available and delivered to consumers’
Ensure adequate connection of rural, remote, and indigenous communities to speciality networks, hubs, and services
Creation of a public database of health practitioners who have completed pain management training courses
Models of care for addressing
Mechanism needs to include dedicated activities that support knowledge translation and mobilisation as well as ongoing review and evaluation of guidelines over pre determined intervals
Develop a 6 month workplace based certificate in clinical pain medicine for GPs
MBS item for pain education
An Action Plan for Pain in Canada Health Canada
Ensure these online platforms have telephone options and adequate means of access for those without adequate internet services
Encourage health professionals working with Indigenous Peoples to understand Indigenous specific definitions of pain and hurt, how it is expressed, preferences for treatment and management, and concepts of Two Eyed Seeing
Pre Licensure education and training
StinsonandandMusculoskeletalchronicpainhealthinchildrenadolescentsetal
How best to develop and implement innovative person centred care pathways (such as stepped care, hub and spoke models, or transitional pain services) to improve early access to pain assessment, treatment, and management
Virtual treatment, self management, and peer supports
Evidence subspecialists are overburdened, resources are managed inefficiently, and unnecessary costs are incurred (e.g., children undergoing unnecessary, costly, and sometimes painful investigations)
MoC’s implemented through:
Ensure that clinicians understand their obligations to treat or redirect patients regardless of pain condition, complexity of symptoms, and/or history or current use of opioids
‘Goal three people living with pain and health professionals have the knowledge, skills and educational supports to appropriately assess and manage pain based on population needs. The broader community understands pain as a legitimate, biopsychosocial condition and stigma is reduced’
National pain specific online portal for people to access an interactive repository of services, information, and resources, with appropriate psychosocial supports for navigation of resources as needed
specific materials and engagement activities to provide prescribers with guidance on the quality use of medications
National standards and guidance
MBS item for GPs with specialist qualification in pain medicine
Expand training opportunities for health practitioners in pain management
Young people (children and adolescents) should not be viewed as ‘little adults’
Movement towards building consumer capacity to reduce care disparities related to geographical, financial or health literacy barriers through digital health tech E.g., telehealth, online interventions, and mobile apps
Enable staff in telehealth and general referral systems to link people to necessary chronic pain resources and supports
Focus on not only profession specific but also interprofessional competencies that recognise the full range of professions relevant to pain
Create capacity to spread existing and develop new best practice education/training programs and initiatives across Canada at the community, regional, provincial, and national levels
Health system organisation and delivery of care
Critical factor in the development of an effective pain management plan is face to face discussion by consumers and team members on the relative importance of factors identified by them in the patient AND ongoing communication between team members and patients on the progress of the pain management strategy.
Results that a primary care nurse trained in delivery of a telehealth CBT or SC treatment can produce statistically significant benefits among patients with chronic low back pain, with benefits comparable between the two interventions.
Cultural safety of chronic pain clinics should be reviewed in regard to both assessment and management procedures
Findings suggest that the outcomes of internet delivered programs may be maintained over the long term. Clinically significant decreases were maintained at 12 and 24 month follow up for disability, depression, anxiety, and average pain level measures.
Inequity in outcomes from New Zealand Chronic Pain Services Lewis et al, 2021
In NZ ACC provides funding for people with, or at risk of developing chronic pain related to an accident or injury to attend private pain management services
Clinicians should take the time to explore spiritual components and cultural beliefs relating to pain, as well as the impact of pain on whānau health and cultural and social activities
Emphasis needed on self management and long term strategies to maintain the gains obtained during treatment
The Pain Course: 12 and 24 month outcomes from a RCT of an Internet Delivered Pain Management Program Provided with Different Level of Clinician Support Dear et al 2018
Nurses in primary care settings who were trained with behavioural pain therapies could reduce the number of referrals to speciality mental health or pain clinics where behavioural pain therapies are usually available only in limited supply.
Findings suggest that carefully developed and administered internet delivered PMPs, provided with different levels of clinician support had reduced distress and disability maintained over two years.
The results from recent, high quality, clinical trials of telehealth interventions for chronic pain suggest that these treatments can have significant benefits for pain outcomes ad that they be better suited to the future model of medical care in shifting from hospital or clinic based to home based care.
RCT of nurse delivered CBT versus supportive psychotherapy telehealth interventions for chronic back pain Rutledge et al 2018
At treatment end, there were significantly poorer scores for Pacific people compared to Europeans for several of the DASS 21 and PCS subscales, while there were no differences between European, Māori and Asian ethnicities. At follow up, almost all outcome measures were poorer for Māori compared to European, and several of the DASS 21 and PCS subscales were poorer for Asian and Pacific people compared to Europeans.
More prominent disparities in the psychosocial variables
A cost effectiveness analysis of an internet delivered pain management program delivered with different levels of clinician support results from an RCT Dear et al 2021
Findings suggest Māori responded well during the treatment period but that this was not maintained once treatment ceased
34 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
Ethnic disparities in access to chronic pain management services have been reported in both New Zealand and internationally.
** Different cultures have different beliefs and frameworks for experiencing, interpreting, and managing pain, some of which may clash with the biopsychosocial framework currently implemented by pain management clinics. For example, spirituality and the concept of whānau rather than individual health are integral components of health for Māori, Pacific people, and some Asian cultures. Clinicians have previously acknowledged the importance of spiritual beliefs in managing pain and it is known that adherence to treatment improves when patients and clinicians share cultural beliefs.
Would be useful to determine the validity of the current questionnaires in Māori, Pacific, and Asian populations in New Zealand
Traditional cultural beliefs and practices can be meaningfully incorporated into management when they are concordant with evidence based pain management principles
Results suggest that telehealth, nurse delivered CBT, and SC treatments for chronic back pain can offer significant and relatively comparable benefits.
Need to address communication barriers
Primary health care providers attended ECHO participants were physicians, NPs, pharmacists, and allied health professionals
Across modality, the existing evidence suggests that technology assisted psychological interventions are efficacious for improving self management of chronic pain in adults. All modalities have been shown to provide benefit and no clearly superior modality has emerged.
‘The Doctor doesn’t need to see you now:’ reduction in general practice appointments following group pain management Clare et al 2019
ECHO Ontario Chronic Pain/Opioid Stewardship includes an interprofessional group of CP experts, the ‘hub.’
Patients living with chronic, non malignant, musculoskeletal pain are frequent visitors to GP services, placing a large burden on resources. Study showed 43.3% decrease in the number of GP appointments in the yar following a Pain Management Program (PMP).
Across all services that provided data, Europeans were overrepresented by 9% while Pasifika and Asians were under represented by 58% and 49% respectively. Māori patients scored significantly worse than Europeans in all clinical assessment measures, while Pasifika and Asian patients score worse on the majority of measures.
Ethnic disparities in access to chronic pain services are evident by the marked under attendance of Pasifika and Asian ethnicities. Māori, in particular, also have a greater need for healthcare related to pain.
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Ethnic disparities in attendance at New Zealand’s chronic pain services Lewis, Upsdell 2018
The pain course: exploring predictors of clinical response to an Internet delivered pain management program Dear et al 2016
ECHO Extension for community healthcare outcomes. Uses case based learning and videoconferencing to connect specialists with providers in underserved areas. ECHO aims to increase capacity in managing complex cases in areas with poor access to specialists.Collaborative model of tele health education and care management that empowers participating clinicians to provide expert level care in their own communities.
A systemic Review of Technology assisted Self Management Interventions for Chronic Pain Heapy et al 2015
The hub team includes physicians (pain medicine, addiction, family medicine, neurology, physiatry and psychiatry), psychologists, nurse, social worker, PTs, OTs, pharmacists, chiropractor and medical librarian, and a telemedicine technician 59% were prescribers or PAs and NPs who have an indirect influence on the prescriber they work with. 18% were pharmacists and RNs and the other 23% were allied health professionals.
Evaluation of an innovative tele education intervention in chronic pain management for primary care clinicians practising in underserved areas Furlan et al, 2019
The Hub connects with multiple primary healthcare providers, the ‘spokes’ in Ontario using video conference once a week
The current findings suggest that a broad range of patients may benefit from emerging Internet delivered pain management programs and that it may not be possible to predict who will or will not benefit based on patient’s demographic, clinical and psychological characteristics.
Current pain management apps often use evidence based pain management BCTs.
Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents (Review) Fisher et al, 2019
Results showed that ECHO significantly improved participants’ knowledge regarding CP assessment, treatment, and opioid prescribing.
However, there were limited data for mixed chronic pain conditions to draw conclusions from these outcomes, particularly at follow up. Satisfaction with treatment was described in the trials and was generally positive. Six trials described side effects which were not linked to receiving psychological therapies.
For telehealth initiatives to be successful there needs to be greater public awareness and understanding of the potential benefits of telehealth. Empowering patients as partners in the delivery of healthcare may be an important factor in the growth of telehealth services.
Study shows that ECHO improved providers’ self efficacy and knowledge. All professions improved self efficacy, but the groups of physicians, PAs and NPs had the highest gain in self efficacy compared to the other professions. Evaluated outcomes from a multidisciplinary group practising in Ontario. Suggestion that the project may be used as a template for creating other educational programs on other medical topics.
Available 5568/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC644at:
36 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
Found no beneficial effect of therapies for reducing pain intensity for children with other types of pain. Further, did not find beneficial effects of remotely delivered therapies on physical functioning, depression, or anxiety post treatment for headache and mixed chronic pain conditions.
Systematic evaluation of commercially available pain management apps examining behaviour change therapy (BCTs) Gamwell et al, 2021
Awareness, experiences and perceptions of telehealth in a rural Queensland community Bradford et al, 2015
Psychological therapies delivered remotely (primarily via the Internet) were helpful at reducing pain for children and adolescents with headache when assessed immediately following treatment. However, did not find a beneficial effect for these children at follow up.
Emphasis on improvementsfunctionalinpresence of pain (rather than immediate analgesia as with acute pain)
Self regulation of physiological responses to pain (e.g., HR, breathing rate, skin temperature and muscle
OT: Maximising age appropriate activities of daily living, self care, academic and family Desensitisationactivities
Explanation of differences of acute vs chronic pain
Behavioural exposures Aim to improve functioning by reducing avoidance Parent Importantcoachingrolein managing pain and maintaining or improving function Reducing parent distress and shifting to an encouraging function
Sleep hygiene, CBT Psychological conditions that may be a contributing factor and an outcome to chronic pain condition
share the primary goal of improved functioning across domains
8 week online psychological intervention for children & parents Other technology symptom self monitoring, intervention delivery involving goal setting, improving functioning, coping skills training & practise
Emphasis of the non protective nature of chronic pain
RCT comparing Fibromyalgia integrative training vs traditional CBT demonstrated significant improvements in disability and greater decreases in pain intensity compared to CBT only
RequiresEnvironmentalSocialPsychologicalBiologicaldisability:acomprehensive and multidisciplinary approach psychological, physical, and Interventionsoccupational based in realm of rehab and typically delivered by an MDT (including medicine, nursing, psychology, PT and/or OT)
Review found remotely delivered psychological therapies were beneficial at reducing pain intensity across pain Allowgroupsaccess for patients Remotely interventionsdeliveredmaynot be appropriate for all patients more complex patients would likely benefit from more intensive Augmentedtreatmentsandvirtual reality
Variability in terms of: FrequencyOrganisationStructureof treatment across Distinctiondisciplines is in outpatient vs inpatient Functionalmodelsimprovements in Severalboth programs offer both inpatient and outpatient triaged to level of care based on individual need
Length of stay Flexible based on patient need Fixed 3 week
Group based psychological Benefitinterventionsofshared experience, social support E.g., ‘The Comfort Ability’ Delivered to children and DevelopmentCBTparentsbased of plan to support AddressapplicationsInternetimprovementfunctionalandmobileaccessbarriers for paediatric pain management WebMAPservices
Appendix 2: Literature Review of Paediatric Chronic Pain
Somereductionevidence for role of yoga and Identifyingmassageand addressing negative Acceptancecognitionsandvalue bases
Goals of ToleranceJointEndurFlexibilityStrengthimprovingancestabilityforweight bearing PromoteProprioceptionBalanceCoordinationindependence and return to functioning → active interventions have more significant role than passive interventions (e.g., massage, MovementTENS) in presence of pain
DRAFT FOR DISCUSSION MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS 37
To be considered an IIPT must include 3 or more disciplines housed within the same facility who work in an integrated manner to provide treatment day hospital or an inpatient typicallysetting require patient to participate in exercise based therapies (PT and OT) as well as psychological interventions for total 8 hours/day
Found to be effective tool for reducing pain sensations in patients with acute pain
One day workshops
MindfulnessRelaxationPsychoeducationtension)trainingbased stress
Changes understandingconceptualofpain and principles that researchoutcomes,painEvidencedeliveredindividuallyandutCommonlybiopsychosocialpreparesbiopsychosocialguideapproachchildrenfortreatmentsMDTapproach,canilisefreeonlineresourcescomplementantailoredapproachbytherapistinadultssuggestingeducationimprovesbutpaediatricismorescarce
studies indicate decrease in anxiety, pain catastrophising, disability and improvements in school improvementsattendanceinpain severity and physical and psychological IIPTfunctioningprograms
exercises (including ACT)
Monodisciplinary rehabilitation treatments have been found to be inferior to multidisciplinary and interdisciplinary treatment approaches, where physical and occupation therapy are combined with psychological rehabilitativeUniqueinterventiontopaediatricapproaches is the emphasis on including parents to optimize treatment OutpatientInpatientRehabilitativeoutcomesadherence can be suboptimal highlights importance of thorough assessment and delivery of tailored services that best meet need of child and family
Harrison LE, Pate JW, Richardson PA, Ickmans K, Wicksell RK, Simons LE. Best evidence for rehabilitationtheof chronic pain part 1: Paediatric pain. Journal of clinical medicine. 2019 Sep;8(9):1267.
Social support discussion boards, goal sharing, group based DigitalchallengesbasedACT moderate to large effects in primary and secondary outcomes
Rehab for chronic pain applies the biopsychosocial model which accounts for factors that contribute to and maintain pain symptoms and related
Overview Pain education Psychological interventions Physiological and rehabilitative interventions Addressing comorbidities & optimising outcomes Interdisciplinary Outpatient Pain Treatment Intensive interdisciplinary pain treatment (IIPT) Emerging Pain Treatment Intervention Formats
Physical and occupational Focustherapiesonimproving physical Engagingfunctioningin avoided activities Self management approach
Overview Pain education Psychological interventions Physiological and rehabilitative interventions Addressing comorbidities & optimising outcomes Interdisciplinary Outpatient Pain Treatment Intensive interdisciplinary pain treatment (IIPT) Emerging Pain Treatment Intervention Formats
Guidelines on the Management of Chronic Pain in Children WHO 2020 Capacity ScreeningTreatmentAssessmentresponsesSymptomsAssessmentEducationstrengtheningandtrainingofpainandtreatmenttoolsmodalitiesforandtreatment of adverse effects of interventions Communication and support strategies for children and their families
Psychological interventions
No difference found between treatment and control post treatment or follow up for: Health related quality of life Role patientActivity(depressionEmotionalfunctioningfunctioningoranxiety)participationandglobalimpression of change improved post treatment in the treatment group
biopsychosocial nature of pain Collaborative Socialestablishmentgoalandeducational support Community or home based support for children and Carefamiliespathways that revolve around child and families schedule and educational Caretimetabletoavoid disruption to child’s routine physical and social Attentionenvironmentstomaintenance and sustainability of intervention and long term outcomes Continually approachesseekingwhichsustain and augment care and positive outcomes
Physical interventions
Pain Science Education is commonly implemented with several resources currently available, yet evidence for its use is rehabilitativeUniquescarce.topaediatricapproaches is the emphasis on including parents to optimize treatment
Continued research on effectiveness of VR within pain rehabilitation is needed
multidisciplinaryComprehensive and interdisciplinary treatment based on behavioural medicine approaches are needed for children and adolescents with persistent pain.
Innovativeoutcomes. pain treatment intervention formats such as mobile applications and virtual reality enhance the delivery and reach of evidence based pain.adolescentsneededofcontemporaryrymultidisciplinary/interdisciplinaComprehensivetools.treatmentbasedonunderstandingpain(neuro)scienceareforchildrenandwithpersistent
When psychologica therapies were examined as a group, they Smallprovided:benefitscompared to any control for the outcomes of reducing pain intensity 50% pain reduction (very low certainty) and functional Globaldisabilityjudgement of satisfaction post treatment and at follow up Patient global impression of change was also improved post treatment and at follow
beneficial effects were demonstrated for the outcomes of: 30% pain reduction Heath related quality of life
Optimising communication/educationAppropriateinterventions on
38 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
Noup
When compared to standard care or an active control PT had beneficial effects on: pain intensity and functional disability immediately post notreatmentbenefits were noted at longer term follow up for these outcomes
No benefits were reported for other outcomes
of a smooth transition from child to adult services for adolescents
Emotional functioning (both depression and anxiety)
Facetherapiestoface reduced: Pain intensity post treatment Pain by 50% or more post treatment and at follow up Disability post treatment and at follow Increasedupactivity participation post treatment and satisfaction at follow up
Remote Reducedtherapiespainintensity post Hadtreatmentbeneficial effects on 50% pain reduction, satisfaction, and impression of change post treatment and at follow up
These studies of PT interventions included few participants and had serious limitations (risk of bias) in study design and execution. The body of evidence for all outcomes was therefore assessed as very low certainty, both immediately post intervention and at longer term follow
Face to face vs remote (internet, smartphone, CD ROM or manuals) for CBT, ACT, behavioural or relaxation
Minimal studies for each drug Includedclass RCTs were small and may not have had sufficient power to detect statistically significant differences in the incidence of less common adverse events
Overview Pain education Psychological interventions Physiological and rehabilitative interventions Addressing comorbidities & optimising outcomes Interdisciplinary Outpatient Pain Treatment Intensive interdisciplinary pain treatment (IIPT) Emerging Pain Treatment Intervention Formats
Reassessing disease status Pain usingcontrolvalidated tools appropriate to child’s age developmental status mode of communication culture
As children age care teams must ensure that appropriately tailored services evolve to meet the child’s need in terms
One randomized controlled trial and 9 nonrandomized treatment studies were identified and a meta analysis was conducted separately on: pain intensity, disability, and depressive symptoms revealing positive treatment effects. At posttreatment, there were large improvements for disability, and small to moderate improvements for pain intensity and depressive Thesymptoms.positive effects were maintained at short term follow up. heterogeneity.demonstratedFindingsextreme
Role functioning and sleep quality post treatment and at follow up
DecisionCapabilitiesof:making capacity FacilitationActivitiesInterestsViews
Hechler T, Kanstrup M, Holley AL, Simons LE, Wicksell R, Hirschfeld G, Zernikow B. Systematic review on treatmentinterdisciplinaryintensivepainofchildren with chronic pain. Paediatrics. 2015 Jul 1;136(1):115 27.
More than half of the treatments included 5 disciplines (7 studies). Most frequently, the treatments included medical (9 studies), psychological (10 studies), and methodologinumbereffectsevidencecomputed.metaschoolheterogeneityBecauseattributedtreatmentEffectsdays).16Meaninterventionsphysical(10studies).treatmentdurationwasdays(SD5.3;range:527innonrandomizedstudiescannotbetoIIPTalone.ofsubstantialinmeasuresforfunctioningandanxiety,analysescouldnotbeThereispreliminaryforpositivetreatmentofIIPT,butthesmallofstudiesandtheircalweaknesses
Use of ‘booster sessions’ for effective interventions can be used to enhance outcomes over the long term
Pharmacologicalup interventions
DRAFT FOR DISCUSSION MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS 39
MDT approachesmulticomponentStrongapproachessupportforCBTforacute and chronic Multidisciplinarypain treatment approaches PsychologicalPhysicalPharmacologicalincludingorOT
Results need to be interpreted with caution because of the lack of RCTs and the study weaknesses of the NRSs. However, they suggest that the collaborative treatment goal to improve functioning despite ongoing pain may be achieved immediately in children and maintained at short term follow up. This is important given that the affected children suffer for an average of 3 years before initiating IIPT.
suggest a need for more research on IIPTs for children.
40 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
Preparation proceduralpsychoeducationefficacypainpreparationpsychoeducationandforproceduralresearchtosupportofeffectsandinreducingpain
Exercise and alternative Exerciseapproachesthrough PT and OT are key components of MDT Yoga,approachacupuncture, massage, tactile stimulationtranscutaneousprogressivedesensitisation,weightbearing,electricalnerve
Distraction
Overview Pain education Psychological interventions Physiological and rehabilitative interventions Addressing comorbidities & optimising outcomes Interdisciplinary Outpatient Pain Treatment Intensive interdisciplinary pain treatment (IIPT) Emerging Pain Treatment Intervention Formats
Agoston AM, Sieberg CB. neurologySeminarstreatmentNonpharmacologicofpain.Ininpaediatric2016Aug1 (Vol. 23, No. 3, pp. 220 223). WB Saunders.
Systematic reviews and meta analyses of randomized controlled trials of psychological interventions have demonstrated evidence for psychological approaches intreating procedural pain and multiple types of chronic pain, including musculoskeletalabdominalheadaches,pain,andpain.
CBT Brief, goal oriented Commonlypsychotherapyresearched and supported for management of paediatric Combinationpainof cognitive and behavioural techniques that involve a variety of cognitive skills and SpecificstrategiesbehaviouralCBTtechniques for paediatric pain CBT framework used to teach children strategies to identify and restructure maladaptive pain related thoughts and address behaviours that might contribute to pain related directingGoalsdisabilityinclude:attention away from enhancingpain sense of control over diminishingpain negative thoughts related to pain that may contribute to emotional modifydistresspain sensations, promote self control and self management, increase functioning, and reduce maladaptive behavioural responses to pain
Within groups analysis of patients functionalinterventionimprovementsshowedinterdisciplinaryreceivinginterventionssignificantpretopostinpainintensity,disability,anxiety,
Overview Pain education Psychological interventions Physiological and rehabilitative interventions Addressing comorbidities & optimising outcomes Interdisciplinary Outpatient Pain Treatment Intensive interdisciplinary pain treatment (IIPT) Emerging Pain Treatment Intervention Formats
decreased anxiety and fear Reduction in avoidance Relaxationbehaviour resourcesDevelopmentperipheralheartprocessesfeedbackcontrolBiofeedbackUsefunctioningtermsSuppassociatedbutFocusandCBTACTtherapyAcceptanceSProgressiveDiaphragmatictechniquesbreathingmusclerelaxationelfimagery,guidedimageryandcommitmentforchronicpain(ACT)incorporateselementsofwithfocusonacceptancemindfulnessstrategiesisnotsymptomcontrolratherreducingdistresswithpainortineffectivenessinofselfreportedandqualityoflifeoftechnologyawarenessandthroughreceivingfromphysiologicale.g.,respiration,ratevariability,skintemperatureofonlineCBT
Review of the effectiveness of interdisciplinary interventions in the management of paediatric chronic pain. Patients randomised to interdisciplinary interventions reported significantly lower pain intensity 0 1 month post intervention compared with patients randomised to the control groups.
DRAFT FOR DISCUSSION MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS 41
For both procedural and chronic Exposurepainand Systemicdesensitisationpsychologicalhabituation →
systematic review and subset meta analysis. British journal of anaesthesia. 2019 Aug 1;123(2):e359 71
Conclusions: disabilityalsoSignificant12postpreinterventionfoundSignificanthowever,measuresusingrandomisedMethodologicallychrangeshowinterdisciplinaryOverall,interventionspromiseinprovidingaofclinicalbenefitsforildrenwithchronicpain.robustcontrolledtrialsstandardisedoutcomeareneeded,toguideclinicalcare.reductionswereinpainintensitytoimmediateintervention,andat3andmonthfollowuppoints.improvementswerefoundinfunctionalpreinterventionto
Liossi C, Johnstone L, Lilley S, Caes L, Williams G, Schoth DE. Effectiveness of chronicinterventionsinterdisciplinaryinpaediatricpainmanagement: a
Overview Pain education Psychological interventions Physiological and rehabilitative interventions Addressing comorbidities & optimising outcomes Interdisciplinary Outpatient Pain Treatment Intensive interdisciplinary pain treatment (IIPT) Emerging Pain Treatment Intervention Formats
Fewacceptance.differences were found between thoseinterventionsreceivinginterventionpainrevealedBetweenforinterdisciplinaryexamineThepreinterdisciplinaryintensitysignificantSixteeninpatientsetting,conductedFifteendifferenthealthcarectimeofvariedInterdisciplinaryinterdisciplinarysubsequentandbiopsychosocialroadmapincorrectmodelsuggestssummarisedLiossilastingrecurringdefinedPaediatricPCPfoundanddifferingheterogeneityoutpatientdeliveredinterventionsininpatientvssettings.Significantduemainlytooutcomevariablesinterventioncontentwasinmostanalyses.chronicpain(PCP)isaspersistentorpainofanyaetiologylongerthan3months.andHowardrecentlytheevidencethatapurelybiologicalofPCPisoutdatedandandprovidedaforitsassessmentformulation,andmultimodal,management.interventionsintheircontent,numbersessions,andfollowuppoints,althoughallwereoordinatedbytwoormoreprofessionalsofdisciplinesinterventionswereinanoutpatientand13studiesinansetting.studiesclearlyreportedreductionsinpainbypatientsreceivinginterventionstopostintervention.aimofthisreviewwastotheeffectivenessofinterventionsthemanagementofPCP.groupsanalysessignificantlylowerintensity01monthpostinpatientsinterdisciplinarycomparedwithinthecontrolgroup.
depression, catastrophising, school attendance, school functioning, and pain
immediate post intervention and 3 month follow up, anxiety preintervention to immediate post intervention, 3 and 12 month follow up points, depression pre intervention to immediate post intervention and 1 month follow up, catastrophising preintervention to immediate post intervention and 3 month follow up, school attendance and school functioning preintervention to 3 month follow up, and pain acceptance preintervention to immediate post intervention.
Overall, the results of the pre post analyses agree with those of Hechler and colleagues’ former review, which reported significant reductions in pain intensity, disability, and depression from pre treatment to immediate post treatment and short term follow up (2e6 months). We also agree with this former review in advising caution in the interpretation of results, however, because of high levels of heterogeneity observed in most analyses.
42 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
Significant heterogeneity was found in most analyses, however. Although the pattern of results remained the same in subsequent sensitivity analyses (except for school attendance which was no longer heterogeneitysignificant),also remained high in most instances.
DRAFT FOR DISCUSSION MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS 43
A web based international survey was used to collect information. The survey contained 86 questions seeking professionalrespondentdemographic data and information about the pain program with which the respondent was affiliated at the time organization,(programtypes of pain problem treated, professionals involved, services provided, size of the program, research, professional training, public education and advocacy, and funding Respondentssources).were 136 paediatric pain experts representing different specialties located in 12 countries. Most respondents indicated that ideal programs would have a multidisciplinary staff; provide a wide range of treatments for different chronic pain problems; integrate research, formal clinical training of specialists, and public education and advocacy into their activities; and be an accredited part of the public health system.
The results of this survey show that most current chronic pain treatment programs function as outpatient multidisciplinaryservices,innature, are based on a biopsychosocial model of pain, and provide cognitive behavioural therapy based recommendations,painrequiredstaffedshowThebeingprofessionalsandhighlighttreatments.psychologicalTheseprogramsresearchwithtrainingeducationoffutureandadvocacyintegralparts.resultsofthisstudyalsothatnotallprogramsarewiththeprofessionalsformultidisciplinarycentres,accordingtoIASPwhich
Miró J, McGrath PJ, Finley GA, Walco GA. Paediatric chronic pain programs: current and ideal practice. Pain reports. 2017 Sep;2(5).
Overview Pain education Psychological interventions Physiological and rehabilitative interventions Addressing comorbidities & optimising outcomes Interdisciplinary Outpatient Pain Treatment Intensive interdisciplinary pain treatment (IIPT) Emerging Pain Treatment Intervention Formats
Self regulation of HR, skin temp, muscle tension
Reinforcement of positive coping, reward risk(PPST).Paediatricadaptation(SBST)STarToutpatientsscreeningtreatmentbetterAnpositivecommunicationsystems,andmodellingcopingemergingapproachtomatchpatienttoinvolvesusingtoolstostratifybyriskofpoorclinicalcome,suchastheKeeleBackScreeningToolandthepaediatricofthistool,thePainScreeningToolAllocationtothehighgroupforbothofthese
38 Nationwide paediatric chronic pain programs in the
Selfbarrierspaced nature and lower risk of Limitationsstigmaof equity of access to technology and response to individual needs
For patients who continue to struggle with their pain symptoms and have difficulty engaging in recommended treatments, more intensive treatment approaches may be Afterwarranted.participation in a 3 week intensive andsymptomsintensitydomainsshowedtreatment.intensiveevidencedemonstratedHechlermetaAfollowweretreatmentdepressionsymptomsimprovementsreportedmonthsymptomsinup.treatmentimprovementsreportedpainoftreatmentencompassingprogrammultidisciplinarydomains,asample57adolescentswithchronicandtheirparentssignificantphysicalattheendofand3monthfollowAdditionalimprovementsanxietyandsomaticwerereportedat3followup.Parentssignificantintheirofanxiety,andstresspostandthesechangesmaintainedat3monthup.recentsystematicreviewandanalysisperformedbyandcolleaguespreliminaryforpositiveeffectsofinterdisciplinarypainOverall,patientsimprovementsintheofdisability,painanddepressiveatposttreatmentshorttermfollowup
Meta analysis found multi disciplinary outpatient pain management clinical displayed superiority to no treatment, waiting list and single discipline interventions (e.g., sole pharmacology or physical therapy).
Internet based CBT Benefits in reducing access
The evolving standard of care for paediatric chronic pain involves a multi and often inter disciplinary treatment
44 MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS
Explanation of chronic pain, nonprotective nature of persistent pain signals and Explanatprocessingion of theories behind focus of treatment
Parent to,toTeachinginvolvementoperanttechniquesguideparentsinrespondingmanaging,andcopingwith child’s pain
Jan;6(1):49management.Pain201661.
Emotional distress in parents
Flor and colleagues’ results indicated that along with reductions in pain, patients receiving CBT.didapproximatelytherapyrecommendednevermedication,recommendedpatientsSpecifically,suboptimal.outpatpaediatricrecommendationsAdherenceinitialdisabilitycomplaints,decreasedfewerpatientsoutpatientpaediatrichavepoints.treatmentutilizationdisabilityintreatmentmultidisciplinaryreportedincreasesmoodanddecreasesinandhealthcareatboththeendofandfollowuptimeSimilarpositiveresultsbeenobservedinmultidisciplinarypainclinicswithreportingsignificantlydoctorvisitsandpain,somaticandfunctional3monthsaftertheirpainclinicevaluationtotreatmentinamultidisciplinaryientpainclinicisoftenalmostathirdoffailedtoinitiatechangesinslightlyfewerbegannewphysicalinterventions,andhalfofpatientsnotenterrecommended
DayOutpatientInpatientUSA.hospital treatment
Group based CBT Promotes peer support, reduces feelings of isolation and feeling misunderstood Benefits can extend to parents
Simons LE, Basch MC. State of the art in biobehavioural approaches to the management of chronic pain in childhood.
Parents receive training on reinforcement of positive coping, reward 3group,comparedlimitationsReductioncommunicationsystemsinpainandactivityposttreatmentwithwaitlistcontrolgainsmaintainedatamonthfollowup
include physicians, nurses, physical therapists, and psychologists. Thus, although current paediatric chronic pain programs provide a range of focal treatments, they need a wider variety of professionals, if they are to provide the best treatment possible.
Optionsteam for biobehavioural treatment are expanding to be both face to face and remotely accessible, with increasing precision in targeting known psychosocial risk factors that impact Screeningrecovery.toolsthat stratify patients by psychosocial risk have the potential to be easily implemented in a busy clinic setting, arming providers with key clinical information to guide treatment decision making.
Self regulation of physiology e.g., relaxation training, biofeedback, hypnosis
Overview Pain education Psychological interventions Physiological and rehabilitative interventions Addressing comorbidities & optimising outcomes Interdisciplinary Outpatient Pain Treatment Intensive interdisciplinary pain treatment (IIPT) Emerging Pain Treatment Intervention Formats
Effect sizes for internet delivered CBT for pain were promising but below those found for internet delivered CBT for anxiety and depression for Examplechildrenofweb based family CBT to adolescents with chronic pain (Palermo & Adolescentscolleagues) receive pain education, relaxation training, and other CBT skills
tools is driven by the tools’ psychosocial recommended.accuracycanquantitativeabnormalitiesincludeofincreasingneeded.youthtreatmentImplementationvariables.ofastratifiedapproachamongwithchronicpainisstillAdditionally,ourunderstandingthepatientphenotypetoanypotentialsensoryassessedviasensorytestingpotentiallyenhancetheoftreatments
BehaviouraldiffusioncognitiveCguideddiaphragmaticProgressive(biofeedback)relaxationbreathing,imageryognitivetechniquesreframing,cognitiveexposure
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DRAFT FOR DISCUSSION MAMAENGA ROA: MODEL OF CARE FOR PEOPLE LIVING WITH CHRONIC PAIN OFFICE OF THE CHIEF CLINICAL OFFICERS 45
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