Chronic pain is a challenge to manage and
treatment is often difficult to access. Hospital-based pain programs have long
wait lists and may not be well integrated with primary care.
Bruyère Academic Family Health Team (FHT) saw
a need to improve access to chronic pain management for their patients and set
out to develop a nurse-led model of care that would be integrated into the FHT.
Hillel Finestone, MD FRCPC, Isabelle Leclerc, RN, and Dr Elizabeth Muggah, MD
MPH CCFP at
Bruyère Academic Family Health Team
does the model of care include?
The intervention is led by a registered
nurse and includes two visits (more if needed). The focus of the visits is on
self-management principles which include educating patients about their chronic
pain and triggers for the pain, and helping them
set goals to improve pain and
The visits also explore opioid use,
risk for opioid-use disorder and, if needed, opioid tapering support.
Finally, we connect the patient to
resources available at the FHT and in the community such as counselling, exercise
programs, or pharmacist support. The
nurse closely collaborates with the primary care provider to coordinate care.
A cornerstone of the self-management
teaching is our Pain Explanation and Treatment Tool which we use to help
patients understand their pain “risk factors” and craft a treatment plan. This evidence-based
tool was created by one of our team members, a physiatrist who specializes in chronic
View the tool in PDF version here.
Adult patients with chronic pain who would
benefit from this intervention are identified in the electronic medical record
(EMR) or referred by a FHT physician or nurse practitioner.
From 2016-2018, we had a total of 125
participants (0.8% of our clinic population). The majority of patients were
female and the mean age was 59 years. Most patients at baseline had a pain
score on the Pain Numeric Rating Scale of more than 5/10 which is considered to be “intolerable.”
are we doing?
An evaluation was conducted between 2016
and 2018 to determine patient improvement across various outcome measures. A
summary of some of the measures is below.
- 46% of patients had 2+ visits
with a nurse
- 46% of patients reduced their
total opioid dosage (33% of patients decreased to 0 mg per day)
- 42% of patients had a
significant decrease in pain scores
- 61% had a decrease in their
pain interference scores
- 72% of patients achieved their
pain management goals
Qualitative data was collected from 36 patients,
administrators and clinicians about the program using an open-ended
questionnaire. Thematic and SWOT (strengths, weaknesses, opportunities and
threats) analyses were conducted.
Patients felt the program was important in
helping them manage their pain and they appreciated the continuity of care that
came from having the program embedded in the FHT. Clinicians and administrators
were happy with the reduced wait times for pain services, the evidence-based
tools and the non-pharmacologic focus.
lessons did we learn?
Based on our
experience thus far, this program has helped some of the most complex patients in
our practice manage their chronic pain and reduce the use of opioids. The
program is feasible, evidence-based and cost effective and could be scaled up
The essential elements
of this program include: training for the registered nurse, evidence-based tools,
mentoring opportunities, and access to community and allied health supports ideally
provided in an interdisciplinary primary care setting.
There has been interest in learning how to
implement this type of program across other primary care settings. A one-day
training program focused on self-management for chronic pain and understanding the
elements of our program will be offered March 2019 to primary care providers
and teams in the Champlain LHIN.
For more details, view the presentation A Successful Nurse-led Chronic Pain Program in Primary Care.
Members of the Bruyère FHT:
- Isabelle Leclerc, RN
- Dr Elizabeth Muggah, MD MPH
- Dr Hillel Finestone, MD FRCPC
- Metasebia Assefa, MSc candidate
Need help supporting your
patients in managing their pain? Visit the
Ontario Pain Management Resources website for a coordinated program
of tools from partner organizations across the province.