Step One: Support and Training for Primary Care

Having the infrastructure for research and analysis in place has allowed the VA to rapidly implement the Stepped Care Model for pain management by developing several training programs for primary care and increasing the number of specialty-care clinics for pain medicine. One such program, the VA/DoD collaborative Specialty Care Access Networks — Extension for Community Healthcare Outcomes (SCAN ECHO) project, simulates residency training using video technology to remotely supervise patient care and follow cases longitudinally. Rolled out in the summer of 2011, in the model of the ECHO Program established by the University of New Mexico, SCAN ECHO now has nine VA participating regional tertiary centers (Albuquerque; Ann Arbor, MI; Denver; Cleveland; Los Angeles; San Francisco; Richmond, VA; Tampa, FL and West Haven, CT. )

By the fall, several more centers will be online in various locations around the country. In addition, the military is planning deployment of this model to connect primary-care providers to specialists throughout its system’s many remote sites.

“A pain-specialty team that might include a pain-medicine specialist, a psychologist, physical therapist, psychiatrist or addictionologist, social worker and others gathers in a conference room with video capability. Several practitioners from various distant locations network into the teaching center and present their cases to the team and are then supervised on the management of cases, just like in a residency training program,” said Gallagher.

In addition, short lectures are given so that primary-care providers receive didactic training related to the actual cases being presented.

This spring, a group of VA and DoD experts held the first conference focused on developing a national library of peer-reviewed, referenced, evidence-based lectures that will support the SCAN ECHO program.

SCAN ECHO “is a transformational project for the VA, because it really focuses on bringing specialty skills to the veteran where they are, rather than having them travel long distances to get these kinds of services. For veterans who are in pain, traveling is often a very difficult thing. For the DoD, this technology can be used to bring specialty care to outposts all over the world,” Gallagher said.

The VA uses technology to support primary care and leverage the network’s resources in other ways, as well. Using the electronic medical record, for instance, a pain specialist anywhere can do an e-consultation to advise a primary-care provider, without ever seeing the patient.

The West Haven VAMC provides cognitive behavioral therapy (CBT) for pain by telephone, and a network in Florida has weekly phone calls run by a pharmacist and a primary care pain specialist, a “pain champion,” where people call in to talk about their cases and hear a short lecture. The Tampa VAMC, which has a rehabilitation program accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), brings in leaders from other centers to learn how to establish their own pain rehabilitation programs. The VA also is considering establishing mini-residencies in pain medicine.