What is an Integrative Pain Care Plan?
The development of a Pain Care Plan occurs within an agreed model of care that is specific to a particular health system or health service. Pain Care Plans are person-centred and individualised treatment plans which are based on a biopsychosocial assessment of the person’s pain, pain impact and contributing factors, and also takes into account the person’s preferences and resources. The plan should include the goals/outcomes that the person bring treated has identified as important to them and agreed on with their clinician. The clinical assessment findings should be synthesized into a case formulation and confirmed as accurate by the person being treated. In the care plan, the treating clinician should identify which aspects of the formulation (for example, pain experience, mood, activity level, and sleep) will be targeted by the different interventions and plan how these interventions will be sequenced and delivered. The clinician should explain the care plan to the person being treated to make sure that there is a shared understanding of what is to come and of the respective roles of the person being treated and the treating clinician(s) in implementing the plan.
Pain care plans are ideally based on an interdisciplinary approach that is aligned with the specific case formulation. Central to an interdisciplinary approach is a multidisciplinary team with an agreed approach to diagnosis, treatment aims and plans that include follow-up and review. As described in Fact Sheet 1, integrative pain care is defined as the carefully planned integration of multiple evidence-based treatments– offered to an individual suffering from pain – that strives to be individualized (“person-centered”), mechanism-guided, and temporally coordinated. Furthermore, integrative care may combine treatment strategies from different areas of complementary/alternative medicine, traditional medicine, or both. Combining any interventions – whether this involves blending conventional approaches with other approaches or not – requires coordinated collaboration between practitioners and the person with pain.
What is a Model of Care?
As outlined above, development and delivery of integrative pain care plans optimally occurs within an agreed model of care embedded in a healthcare setting. A model of care has been defined as a jurisdiction (or setting)-specific evidence-informed framework that sets out what care should be received and how it should be delivered within that setting with localisations and adaptations based on local resources, infrastructure and population needs (Speerin et al, 2020). The model of care should also include delineation and agreement on the roles and responsibilities of the patient and their healthcare providers within the model of care. In practice, there are many healthcare settings where integrative care is currently being delivered in the absence of a coherent model of care.
There are significant variations, even across high-income countries, in the extent to which interdisciplinary models of care are enabled through the provision of multidisciplinary teams. In other words, the presence of a multidisciplinary team alone does not ensure the care will be provided in an interdisciplinary way. Such care requires careful planning as well as regular communication within the treating team.
What are the Benefits of Using Integrative Pain Care Plans?
A model of care, that integrates different interventions/approaches, increases the potential for targeting the various manifestations and maintenance factors of clinical pain conditions. Also, it is more likely to ensure the care plan matches each person’s preferences and goals. An additional benefit is that implementing specifically targeted and combined interventions minimizes redundancy and maximizes the chances of treatment synergies. This is particularly relevant in settings where resources are limited (e.g. low- and middle-income countries), and where benefits could be maximised through a combination of available pain management resources (e.g. affordable medications with simple education and physical therapy strategies).
What are the Challenges to Including an Integrative Approach in a Pain Care Plan?
In addition to the challenges identified in Fact Sheet 1, there may be health system-based constraints, such as funding restrictions (e.g. for two or more health professionals treating the same patient at the same time or as part of an established team) or lack of agreement on relative responsibilities between different healthcare providers. These challenges are common globally but more pronounced in low socioeconomic regions with limited skilled health workforce (Sharma et al, 2019). Patient expectations may also prove a barrier for example when there is discrepancy between care expected and care received, or when patients have not been actively engaged and have not understood the model of care being implemented through their pain care plan.
Health care professionals with pain expertise and particularly those with dual pain and integrative care expertise, may not be available in a range of settings (e.g., low- and middle-income countries and rural and low socio-economic regions of high-income countries) to implement such pain care plans. Innovative solutions will be required to provide high-value pain care, for example co-designing interventions with the end-users (both clinicians and consumers). When multidisciplinary pain clinicians are not available, especially in rural areas, cross-training health professionals may provide value. Examples could include training community health workers or health assistants to provide exercise or care that promotes self-management and training allied health professionals to include behaviour change principles in their treatment. In many rural settings, where general practitioners are rarely available, these inter-professional approaches should be a priority area for research and evaluation.
Summary and Conclusions
Integrative pain care is necessary to address biological, psychological, and social domains of pain. Local adaptations may be necessary to match the health systems needs and resources available. Success stories from one country, may be tried and tested in another, where the health systems and cultural values are similar (for example, Cardosa et al, 2012).
- Cardosa M, Osman ZJ, Nicholas MK, Tonkin L, Williams A, Aziz KA, Ali RM, Dahari NM. Self-management of chronic pain in Malaysian patients: effectiveness trial with 1-year follow-up. Translational Behavioral Medicine 2012; 2 (1):30-37
- Sharma S, Blyth FM, Mishra SR, Briggs AM. Health system strengthening is needed to respond to the burden of pain in low- and middle-income countries and to support healthy ageing. J Glob health 2019; (2): 020317.
- Speerin R, Needs C, Chua J, Woodhouse LJ, Nordin M, McGlasson R, Briggs AM. Implementing models of care for musculoskeletal conditions in health systems to support value-based care. Best Pract Res Clin Rheumatol 2020; 34 (5): 10154