Community-based pain programs commissioned by primary health networks: key findings from an online survey and consultation with program managers

Keywords: chronic pain, community health: planning, COVID‐19, health service, primary health care, primary health network, secondary prevention.

Chronic non-cancer pain is a major public health issue (Blyth et al. 2019), and has been classified as a disease in itself through the World Health Organization (WHO-ICD 11; Treede et al. 2019). Chronic pain affects approximately one in five people in Australia (AIHW 2020), and is increasing due to the ageing population (Blyth et al. 2019).

Chronic pain can lead to poorer quality of life, depression and anxiety, loss of income and premature retirement, and create feelings of stigmatisation and exclusion (Australian Government 2021). The total economic cost of chronic pain in Australia is high, estimated as A$139 billion in 2018, through reduced quality of life, productivity losses and direct health system costs (Deloitte Access Economics 2019).

Multidisciplinary pain management programs have been shown to improve pain-related disability, mood and self-efficacy (Scascighini et al. 2008; Kamper et al. 2014). Although there are many types of multidisciplinary pain management programs, they often promote a self-management approach (Nicholas and Blyth 2016), and include pain education, psychological strategies (e.g. relaxation techniques, thought management, problem-solving, goal-setting, activity pacing) and exercise (Wilson 2017). Typically, programs are delivered by two or more healthcare professionals working in a collaborative, interdisciplinary manner in inpatient, outpatient or community settings (Scascighini et al. 2008; Wilson 2017).

Given the increasing demand for hospital-based pain services and long waiting times (Hogg et al. 2021), compounded by limited reach to regional and remote areas, the National Strategic Action Plan for Pain Management (Australian Government 2021) recommends greater involvement of primary care and more community-based pain programs.

Australian primary health networks (PHNs) are well placed to commission community-based pain programs to reduce the growing burden of chronic pain as commissioning bodies for local services to address local health needs (Commonwealth of Australia 2018). There is also evidence in the literature that community-based pain programs commissioned by PHNs can be effective; for example, the Turning Pain Into Gain program commissioned by the Gold Coast PHN showed increased pain self-efficacy among participants, increased alignment with Australian pain medication guidelines and reduced self-reported hospitalisations (Joypaul et al. 2018). PHNs are also well-placed to promote pain programs through their health professional networks and HealthPathways (online clinical and referral information portals), given that a lack of awareness of chronic disease programs and their target groups has been shown to be a barrier to health professional referral (Zurynski et al. 2021).

Our three-phased study (Fig. 1) aimed to improve knowledge, knowledge sharing, and knowledge use among PHNs about options to address the secondary prevention and management of chronic pain in primary care. Consultation with PHN program managers as part of Phase 1 of our study found a lack of awareness of initiatives to improve the secondary prevention and management of chronic pain implemented in other PHNs, and a desire for knowledge-sharing and greater collaboration.

Fig. 1.  Phases of the Chronic Pain Project.

Phase 3 of the study focused on PHN community-based pain programs, identified in the Phase 1 mapping of PHN chronic pain initiatives. The first component of Phase 3 established expert-agreed key elements and implementation enablers using an eDelphi consensus process (Walker et al. 2022). The second component, outlined in this paper, aimed to support PHN decision-making and build the evidence about community-based pain programs by: (1) describing current PHN community-based pain programs; (2) assessing their alignment to key elements and implementation enablers of pain programs identified by an expert consensus process (see Supplementary Table S1); and (3) describing PHN pain program adaptations during the COVID-19 pandemic, and program managers’ perceptions of the level of consumer engagement, what worked well and challenges implementing the adapted programs.

Eight PHN program managers of community-based pain programs who were consulted in Phase 1 of the study (Nov 2018 to Feb 2019) were invited in October 2020 to participate in an online survey and follow-up email consultation about their pain program to understand the features of their program and adaptations during the COVID-19 pandemic. The online survey was chosen as the most appropriate design, as it could be completed at the convenience of program managers, with the ability to stop the survey, gather information and restart the survey (Nayak and Narayan 2019). Program managers were also encouraged to upload relevant documents to the survey site to provide further information about their pain program. Follow-up email consultation aimed to enable clarification of survey responses and gaps in information to be addressed. Participants were given as much time as they needed to respond to the survey, upload additional files and participate in the email consultation. Data collection was completed by February 2021.

The questionnaire was developed by the research team (SDM, PW and FB), informed by the list of key elements and implementation enablers established in the eDelphi consensus process (Table S1). The questionnaire was pilot tested with the Manager of the Pain Management Network, NSW Agency for Clinical Innovation, who provides support for NSW PHNs to commission pain programs to ensure that the questions were comprehensive and would be accurately interpreted by PHN program managers. Questionnaire categories included the following: ‘program name and background; PHN role, partners and commissioned providers; target population; program promotion and referral pathways; program format; program facilitation; program accessibility and appropriateness; COVID-19 adaptations to the program; program monitoring, evaluation and continuous improvement; and program costs, funding and other resources’. See Table S2 for the questionnaire.

Data sources included online survey data, email consultation data and data from additional files. A deductive content analysis (Miles et al. 2014) was undertaken by the authors (PW and SDM). Content categories were established a priori and derived from the categories in the questionnaire. The data were reviewed by the authors (PW and SDM) for validation, and any disagreements resolved by discussion and consensus.

In addition, summaries for each program were developed from the data. The summaries were reviewed by the authors (PW and SDM) and participating PHN program managers for accuracy and completeness, with gaps addressed and information clarified as needed.

A description of PHN pain programs is provided by content category across PHNs (Table 1). Program adaptations during the COVID-19 pandemic are outlined by PHN to highlight differences between PHNs related to the types of program adaptations, the level of consumer engagement, what worked well and the challenges implementing the adapted programs, as perceived by program managers.

Table 1.  Description of PHN community-based pain programs.

Table 2.  Topics frequently included in the content of PHN commissioned pain programs.

The research was approved by the University of Sydney Human Research Ethics Committee (HREC) Phase 3: Improving the prevention and management of chronic pain in primary care. Project number: 2020/342. The contents of this published material are solely the responsibility of the individual authors and do not reflect the views of the NHMRC or funding partners. The research was approved by the University of Sydney Human Research Ethics Committee (HREC) Phase 3: Improving the prevention and management of chronic pain in primary care. Project number: 2020/342.

Six of the eight invited PHN program managers (representing South Eastern NSW PHN, Nepean Blue Mountains PHN, North Western Melbourne PHN, Gold Coast PHN, Adelaide PHN and the WA Primary Health Alliance/WAPHA) participated in the online survey and email consultation. One PHN did not participate (no response on follow-up) and one PHN was excluded, as their pain program had concluded and a new pain program was in the procurement stage. Program managers sought further details about the key features of their pain programs from other members of their pain program team, such as the PHN program coordinator or the program facilitator (recruited by the commissioned provider) if needed, to address any information gaps.

All PHN program managers participating in the study provided one or more additional documents about their pain program; for example, documents related to program format and session details, description of the clinical pathway for the program, operational guidelines, facilitator’s guides, promotional materials provided to GPs, and budget outlines.

Table 1 outlines the key features of PHN community-based pain programs. Nine pain programs were represented in this study, with three PHNs commissioning two different types of pain programs; for example, for different target groups or regions of the PHN catchment. Most pain programs targeted adults with chronic non-cancer pain (including primary and secondary chronic pain). One pilot program targeted adults with subacute pain to prevent the progression to chronic pain.

PHN community-based pain programs were found to have a high level of alignment with expert-agreed key elements and implementation enablers of community-based pain programs (see Table S1).

Areas of alignment related to the key elements included providing ‘multidisciplinary care, led by health professionals, consumer focused, and continuous improvement and evaluation’, with the following area of non-alignment – ‘accessible and appropriate’ – with only one program identified for culturally and linguistically diverse communities, and an absence of programs for Aboriginal and Torres Strait Islander people or consumers living in remote locations.

Most PHN community-based pain programs enablers to implementation were aligned with the expert-agreed enablers; however, areas of non-alignment (with not all programs involving these enablers) included engaging program champions, establishing advisory groups to support implementation, using multiple funding streams, co-commissioning with relevant agencies, including family members and carers in response to consumer need, providing referrals for individual healthcare consultations, and developing standardised processes for ensuring feedback and patient outcome data are used as part of a continuous quality improvement cycle.

Pain programs were adapted during the COVID-19 pandemic in a range of ways, such as online ‘live’ Zoom sessions, topic-specific pre-prepared videos, social media closed Facebook groups, telephone and telehealth for individual consultations, and text messages and emails as reminders. In jurisdictions that allowed face-to-face programs, consumer participant numbers were reduced to allow for social distancing (with more sessions conducted), larger rooms were used and innovative ideas, such as the ‘silent disco’ with participants wearing headsets from a close location (e.g. balcony, their car), were explored. Overall, there was a decrease in the number of consumer enrolees in the pain programs, although program managers reported positive feedback from consumers who participated in the programs.

Adaptations during the COVID-19 pandemic stimulated program redesign in three PHNs. North Western Melbourne PHN plans to offer consumers after the end of COVID-19 restrictions both non-face-to-face and face-to-face options, and to deliver the program in a mixed model where required; Gold Coast PHN plans to provide both non-face-to-face and face-to-face options; and South Eastern NSW PHN is currently piloting an online pain program in addition to their face-to-face pain program. Table 3 outlines the types of program adaptations, the level of consumer engagement, what worked well and challenges implementing the adapted programs, as perceived by PHN program managers.

Table 3.  Adaptations to PHN community-based pain programs during the COVID-19 pandemic.

PHNs are well-placed to commission pain programs to reduce the growing burden of chronic pain (Joypaul et al. 2018). Current barriers for PHNs to commission pain programs, identified in Phase 1 of the study, include competing priorities and limited resources, and a lack of reimbursement under Medicare (Australia’s national public health insurance scheme) for group-based programs. A possible solution to improving the capacity of PHNs to commission pain programs is co-commissioning with state and territory health departments (Swerissen et al. 2018), Local Health Networks (Freeman et al. 2021), Aboriginal Community Controlled Health Organisations (Davis and Gordon 2018), and other agencies. However, a recent study found that there is variation in how well PHNs are currently collaborating with ‘state and territory actors’, ranging from poor relationships through to strong cooperation and co-commissioning, with factors affecting the level of collaboration/commissioning including characteristics of the state health department, geography, PHN funding and regulations, ambiguities in the federal/state divided responsibilities for primary healthcare, and the extent of use of collaboration mechanisms and strategies, such as reciprocal board memberships and multi-actor agreements (Freeman et al. 2021).

This study identified that PHN pain programs usually target adults with chronic non-cancer pain, with only one pilot program targeting adults with subacute pain to prevent the progression to chronic pain. Given the growing burden of chronic disease and specifically chronic pain (Blyth et al. 2019), there is a need for PHNs to provide greater support for the secondary prevention of chronic pain (Walker et al. 2021). Risk factors for developing chronic pain after surgery or injury are well known, and often modifiable and early intervention to prevent chronic pain and associated disability is crucial (Nicholas et al. 2011; Katz et al. 2019). There is a role for multidisciplinary and integrated pain programs that identify and manage people at risk of developing chronic pain to overcome the disconnect between hospital-based acute postoperative pain management and chronic pain management in general practice (Glare et al. 2019). The Toronto General Hospital Transitional Pain Service, while situated in the hospital setting, is an example of this model, targeting patients at risk of developing chronic pain in the post-surgery phase, and providing multidisciplinary pain management, and has been shown to reduce pain intensity, pain-related interference, pain catastrophising, symptoms of anxiety and depression, and opioid use (Katz et al. 2019).

This study identified a gap in PHN pain programs specifically for Aboriginal and Torres Strait Islander people. Pain programs for Aboriginal and Torres Strait Islander people are crucial, as they are at higher risk of disabling musculoskeletal pain, with pain conditions often co-existing with other health conditions and socioeconomic disadvantage (Lin et al. 2019), and they experience barriers to accessing best-practice pain management, including geographical and financial factors (Davy et al. 2016), poor communication by health professionals who lack cultural sensitivity (Lin et al. 2019), and institutional racism and discrimination (Artuso et al. 2013). Community-based pain programs co-designed with Aboriginal Community Controlled Health Organisations, Aboriginal health workers and local communities could help to address this gap. The literature highlights how chronic disease self-management programs could be adapted for Aboriginal and Torres Strait Islander people by providing easy access to programs, including no cost and transport; permitting flexibility in attendance; using a group format; program staff prioritising relationship building; implementing personalised and integrated care; by empowering participants to self-manage with regular feedback to individuals; and by ensuring community ownership of programs (Parmenter et al. 2020). In addition, developing culturally appropriate supporting resources using visual formats, narratives, metaphors and avoiding medical jargon has also been shown to be important for Aboriginal and Torres Strait Islander people (Lin et al. 2017).

This study also identified a gap in PHN pain programs specifically for people from culturally and linguistically diverse and refugee backgrounds, although most PHN pain programs provided interpreters as required. One notable exception was identified – a pain program implemented by Adelaide PHN, co-designed with consumers and relevant services (Survivors of Torture and Trauma Assistance and Rehabilitation Service, STTARS). Culturally appropriate community-based programs are vital to increase participation and enable positive participant experiences (Montayre et al. 2020; Zurynski et al. 2021). The literature highlights that there has been very few initiatives in these population groups implemented by former Medicare Locals or commissioned by PHNs, with a small number of notable exceptions (Ziersch et al. 2020). Key factors associated with the likelihood of former Medicare Locals and PHNs implementing initiatives related to refugee and migrant health, identified by Ziersch et al. (2020), were the extent to which refugee and migrant health was an identified priority, state government policy context and nature of funding mechanisms, levels of collaboration with migrant and refugee organisations and communities, and formal engagement mechanisms and local champions.

This study described how PHNs rapidly adapted their pain programs to a non-face-to face format during the COVID-19 pandemic, and highlighted the potential for commissioning digitally enabled programs to overcome barriers, such as geographic barriers, transport costs, mobility difficulties and workforce shortages (Slater et al. 2016). There is a growing interest in online pain programs, with varying levels of clinical contact (Dear et al. 2018b). Although there is evidence of effectiveness (Dear et al. 2018b; Smith et al. 2019) and cost effectiveness (Dear et al. 2021) of online pain programs accessed directly by the public, there is a paucity of evidence about the feasibility, acceptability and effectiveness of online pain programs that are integrated into routine care delivery (Dear et al. 2018a; Lim et al. 2021). Furthermore, there is limited evidence about the feasibility, acceptability and effectiveness of using technology for group-based exercise, cognitive behavioural therapy or education, an important component of face-to-face pain programs (Gentry et al. 2019).

The COVID-19 pandemic precipitated the rapid introduction of eHealth pain management (Eccleston et al. 2020; Shanthanna et al. 2020; Fritz et al. 2021). Considerations identified in the literature for the ‘virtual’ delivery of multidisciplinary pain management include providing training and support for health professionals and patients to use the new technologies, developing strategies to establish and maintain patient engagement and motivation, and enabling communication and coordination of the multidisciplinary care team (Tauben et al. 2020; Fritz et al. 2021).

Further research is needed to understand the optimal methods for digitally enabled pain programs, the barriers and enablers to consumer access to these programs, and specific population groups that may benefit most from these programs.

This study represents nine PHN community-based pain programs with six PHN program managers participating in the study. Although program managers sought further details about the key features of their pain programs from other members of their pain program team, such as the PHN program coordinator or the program facilitator (recruited by the commissioned provider), if needed to address any information gaps, it is recognised that the scale of the project is small in terms of participant numbers, and a more-in-depth approach would add value to the study, especially in terms of understanding consumer engagement in the programs, what worked well and challenges implementing the adapted programs during the COVID-19 pandemic.

Further research is also warranted about the feasibility, acceptability, and enablers and barriers to implementation of digitally enabled pain programs informed by a theoretical implementation framework, such as the Consolidated Framework for Implementation Research (Damschroder et al. 2009). Research is needed to explore local contextual factors, and the perspectives of PHN executive level staff, key PHN pain program team members and commissioned providers, and consumers.

The findings provide a greater understanding for researchers and PHN decision-makers of the key features of community-based pain programs commissioned by PHNs, their alignment with expert-agreed key elements and implementation enablers, the targe population gaps, and the types of adaptations during the COVID-19 pandemic. The findings also illustrate the potential for using digitally enabled delivery methods to increase accessibility to pain programs with further research warranted.

The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

The authors declare that they have no competing interests.

Funding for this research was provided from the Australian Government’s Medical Research Future Fund (MRFF). The MRFF provides funding to support health and medical research and innovation, with the objective of improving the health and wellbeing of Australians. MRFF funding has been provided to The Australian Prevention Partnership Centre under the MRFF Boosting Preventive Health Research Program. Further information on the MRFF is available at www.health.gov.au/mrff. This research was also supported by the Sydney Medical School Foundation, University of Sydney.

Supplementary material is available online.