A technology-enabled collaborative learning model (Project ECHO) to upskill primary care providers in best practice pain care

Introduction

Chronic pain affects one in five people in Australia (AIHW 2020) and has a high economic burden, estimated as A$139 billion in 2018, through reduced quality of life, productivity losses and direct health system costs (Deloitte 2019).

Multidisciplinary team-based care underpinned by the biopsychosocial model of pain is considered best practice pain care (Nicholas 2022). Given the long waitlists for multidisciplinary tertiary pain services and their limited reach into regional Australia (Hogg et al. 2021), it is critical that we upskill primary care providers in best practice approaches (Australian Government Department of Health 2019; ANZCA 2023). Ensuring equity of access to pain management education is an important consideration, as many primary care providers are unable to access face-to-face training, particularly those living in regional areas (Slater et al. 2014).

Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based collaborative tele-education model that has been implemented in Australia and internationally to upskill healthcare professionals in a range of conditions and reduce healthcare disparities (Zhou et al. 2016; McBain et al. 2019; Moss et al. 2021). ECHO networks for chronic pain have been successfully implemented internationally (Furlan et al. 2019; Hassan et al. 2021); however, evidence in the Australian context is limited (De Morgan et al. 2021; Moss et al. 2023).

Project ECHO’s five guiding principles are: (A) Amplification: use videoconference technology to leverage scarce resources; (B) Share Best Practices: to reduce disparities; (C) Case-based learning: to master complexity and increase self-efficacy; (D) Web-based database: to monitor outcomes and showcase impact; and (E) Everyone participates: ‘all teach, all learn’ (Moss et al. 2020). Project ECHO uses a Hub and Spoke model to promote knowledge exchange between a multidisciplinary Hub team (often associated with a tertiary hospital setting) and healthcare professional spokes (often associated with the primary care setting). ECHO sessions are virtual and have two components: (1) a didactic presentation by a hub panel member; and (2) a case presentation by a spoke healthcare professional followed by group discussion and feedback by hub panel members. See Fig. 1 for the program logic of the SA Chronic Pain ECHO Network.

Fig. 1.

Program logic of the SA Chronic Pain ECHO Network.

The SA Chronic Pain ECHO Network was established as part of the National Pain Management Education Project led by the University of Sydney and funded by the Australian Government, Department of Health and Aged Care (Grant GO2810; 2020–2024) to build health workforce capacity and capability in pain management and as a response to supporting implementation of the National Strategic Action Plan for Pain Management. The SA Chronic Pain ECHO Network was implemented as part of an ECHO Hub established by the South Australian Postgraduate Medical Association (SAPMEA). The SA Chronic Pain ECHO Network was implemented between July and November 2022 and was not intended as an ongoing program, consistent with other ECHO programs implemented by SAPMEA, with funding provided for 10 ECHO sessions only (75 min duration) over a 20-week period (fortnightly ECHO sessions).

The SA Chronic Pain ECHO Network was accredited with the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) for continuing professional education (CPD) points. All other healthcare professionals were able to self-claim CPD points with their respective professional associations.

Although the standard didactic and case presentation format was used for most ECHO sessions, for the last ECHO session, a case presenter was not available, and this component was replaced by a question and answer discussion. The recordings and slides from the didactic presentations and links to relevant healthcare professional and consumer resources discussed in the ECHO sessions were provided on SAPMEA’s webpage after each session.

ECHO hub panel members represented a range of professional disciplines including two specialist pain medicine physicians (shared position), a general practitioner (GP) with expertise in pain management, an Australian Physiotherapy Association (APA)-titled pain physiotherapist, and two clinical psychologists with expertise in pain management (shared position). The facilitator was a GP recruited by SAPMEA.

Refer to Table 1 for an outline of the curriculum topics. Each didactic presentation was developed by one to three hub panel members and shared with other hub panel members, the GP facilitator and the evaluation team for review and feedback to ensure that the content was based on current best practice pain care aligned to a biopsychosocial approach (NICE Guideline [NG193] 2021; Nicholas 2022). Hub panel members were also provided with the empirically-derived consumer pain care priorities framework (Listen to me, learn from me) developed by Curtin University as part of the National Pain Management Education Project to support Hub panel members to develop didactics aligned to high quality person-centred pain care.

Methods

Data sources

Data sources included analysis of program records (learning needs assessment, enrolment survey data, program participation data) and online surveys of healthcare professionals including a satisfaction survey after each ECHO session (n = 106 across the ECHO series of 10 sessions), a case presenters survey (n = 7) and an outcome survey after all 10 ECHO sessions in the series (n = 11). Refer to Fig. 2.

Fig. 2.

Evaluation methods.

Results

Discussion

Healthcare professionals often lack the knowledge, confidence and skills to provide best-practice pain care underpinned by a biopsychosocial approach (Ng et al. 2021). Our study demonstrated that the ECHO Network model was an acceptable and effective interdisciplinary education model for upskilling primary care providers, including GPs and healthcare providers from diverse professional disciplines, in best practice pain care. Our study also highlighted that the ECHO Network model could help overcome the education barriers imposed by distance, with one-third of healthcare professionals participating in the SA Chronic Pain ECHO Network working in regional SA.

Participants in the ECHO Network also reported a better understanding of the importance of patient-centred care such as validating the patient experience and learning about the whole person, reflected in the consumer pain care priorities framework (Listen to me, learn from me), empirically derived from Australian people with lived experience of pain, carers and healthcare professionals (Slater et al. 2022). Although the ECHO Network model provided the opportunity for discussion about how to apply patient-centred communication in consultations with patients living with chronic pain, further educational opportunities are needed to practise these skills (Ng et al. 2023).

Participants in the ECHO Network also reported improved awareness of the importance of multidisciplinary team-based care, with most GPs indicating an intention to increase referrals to allied health practitioners. Multidisciplinary team-based care is a key recommendation of the Australian Government, Strengthening Medicare Taskforce Report (2022) (Australian Government 2023), building on the direction outlined in the Australian Government Australia’s Primary Health Care 10 Year Plan 2022–2032 (Australian Government 2022). However, a reported barrier to applying the learnings from the ECHO Network was difficulty forming a co-located multidisciplinary team within general practice. Workforce capacity building in teamwork, collaboration and care co-coordination for co-located and non-co-located multidisciplinary teams is critical and further education could be provided by Australian Primary Health Networks given their remit of supporting the primary care workforce (Australian Government 2018).

Two-thirds of primary care providers who participated in the SA Chronic Pain ECHO Network managed patients with compensable workplace injuries. Improving healthcare professionals’ knowledge and confidence in applying the biopsychosocial approach to pain care to support injured workers to stay at work or return to work is critical (Beales et al. 2016), and has shown to reduce disability and the psychosocial consequences of chronic pain and prolonged work absence (Furlan et al. 2022). Although the SA Chronic Pain ECHO Network improved the self-perceived knowledge and confidence of primary care providers in best practice pain care, the ECHO Network model also has the potential to be implemented in compensable settings, with insurance case managers and medical assessment panels, to improve claims management and outcomes for injured workers.

A key learning of the SA Chronic Pain ECHO Network for healthcare professionals was the importance of promoting social connection and participation in community groups as a management strategy for chronic pain. Social prescribing is ‘a means of enabling GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services’ (RACGP 2020). Implementing social prescribing initiatives is one of the highlighted actions in the Australian Government Australia’s Primary Health Care 10 Year Plan 2022–2032 (Australian Government 2022) for people at risk of developing poor health outcomes. Most social prescribing models involve a link worker or care navigator such as a general practice or community nurse who assist people to access suitable activities and support (Oster et al. 2023). Greater investment is needed in social prescribing, with Australian Primary Health Networks well-placed to implement these initiatives (Thompson et al. 2022).

Although the SA Chronic Pain ECHO Network was associated with improved self-perceived knowledge and confidence to manage patients with chronic pain, a significant proportion of healthcare professionals (42% across the ECHO series) identified barriers at the clinical, service and system level to applying the learnings. Similar to findings from other studies (Ng et al. 2021; Ng et al. 2023), lack of time during consultations to deliver biopsychosocially informed care (such as listening to patients, teaching patients about self-management, helping patients to set goals and referring them to appropriate community activities) is a major challenge within the current Australian primary care system. The proposed Australian Government MyMedicare primary care reform (2024–25) aims to offer greater support for general practice in the management of complex chronic disease through blended funding models that support longer consultations for people who need it most (Australian Government 2023). Another potential primary care reform strategy that could take pressure off GPs and improve health outcomes is enabling practice nurses to work to their full scope of practice in chronic disease prevention and management, including best practice pain care (Halcomb and Ashley 2019).

Greater Australian and state government investment in multidisciplinary community-based pain self-management programs co-commissioned by Primary Health Networks (De Morgan et al. 2022) and state governments could also reduce pressure on GPs and tertiary specialist clinics. These programs have been shown to be effective in improving patients’ confidence in undertaking daily activities and work, improving patients’ functional capacity and quality of life, reducing opioid usage and reducing hospitalisations (Joypaul et al. 2019). Access to these programs could be increased by adaptation to a virtual or hybrid format, demonstrating similar outcomes to face-to-face formats, although drop-out rates may be higher (Buhrman et al. 2016).

Conclusions

The ECHO Network model was found to be an acceptable and effective interdisciplinary education model for upskilling primary care providers in best practice pain care aligned to a patient-centred, biopsychosocial approach to pain management. However, primary care providers perceived barriers to translating this knowledge into practice at the clinical, service and system level. The SA Chronic Pain ECHO Network was funded for 10 sessions over 20 weeks, with further investment from Primary Health Networks, Local Hospital Networks and key stakeholders required to sustain the SA Chronic Pain ECHO Network.

Supplementary material

Supplementary material is available online.