PROJECT STEP

Application of a mixed qualitative and 

quantitative approach to inform and evaluate 

implementation of the VHA’s Stepped Care Model 

of Pain Management at VA Connecticut 

Program for Leadership

Donaghue Medical Research Foundation and Mayday Fund

Core Investigator Team: Robert Kerns, Ph.D., Lindsey 

Dorflinger, Ph.D., Joseph Goulet, Ph.D., Allison Lee, M.A., 

Forrest Levin, M.S., Brent Moore, Ph.D., Linda Pellico, Ph.D., 

Chris Ruser, M.D., John Sellinger, Ph.D., 
Learning Objectives

• The learner will be able to:

– Describe the public health significance of chronic pain

– Describe the VHA’s Stepped Care Model of Pain 

Management (SCM-PM) 

– Describe several initiatives at the VA Connecticut 

Healthcare System to support implementation of the 

SCM-PM 

– Describe the mixed methods approach that was 

employed in Project STEP to inform and evaluate 

implementation of the SCM-PM at VA Connecticut
Polling question about characteristics 

of participants
Care of People with Pain: 

Findings of the IOM

•Pain care must be tailored to each person’s 

experience

– Financing, referrals, records management

 need support this flexibility

•Significant barriers to adequate pain care exist

– Gaps in knowledge and competencies for 

providers

– Magnitude of problem

• Half of primary care providers report 

feeling only “somewhat prepared”, 

27% report feeling “somewhat unprepared” 

or “unprepared”

• Inadequacies in subspecialty training

– Systems and organizational barriers
Barriers to Effective Pain Care

• System-level barriers

• Institutional

• Educational

• Organizational 

• Reimbursement-related

• Clinician-level barriers

• Evidence-based guidelines on 

assessment and treatment

• Adequate pain education

• Clinician collaboration

• Policies on appropriate use of 

opioids

• Insurance coverage

• Patient-level barriers

• Awareness of pain

• Insurance coverage

• Concern of opioids use and 

addiction

5 
Care of People with Pain

Recommendations 

• 3-1. Health care provider organizations should promote and enable self-management 

of pain as the starting point of management

• 3-2. Population strategy described in Recommendation 2-2 should include developing 

strategies to overcome barriers to care

• 3-3. Health professions education and training programs, professional associations, and 

other groups should provide educational opportunities in pain assessment and 

treatment in primary care 

• 3-4. Pain specialty professional organizations and primary care professional 

associations should support collaboration between pain specialists and primary care 

clinicians, including greater proficiency by primary care providers along with referral to 

pain centers when appropriate

• 3-5. Payers and health care organizations should revise reimbursement policies to 

foster coordinated and evidence-based pain care

• 3-6. Health care providers should provide consistent and complete pain assessments
Pain Management is a priority for VHA 

• As many as 50% of male VHA patients in primary 

care report chronic pain (Kerns et al., 2003; Clark, 2002)

• The prevalence may be as high as 75% in female 

Veterans (Haskell et al., 2006)

• Pain is among the most costly disorders treated 

in VHA settings; total estimated cost attributable 

to Veterans with low back pain was $2.2 billion in 

FY99 (Yu et al., 2003)

• Number of Veterans with chronic low back pain is 

growing steadily (Sinnott & Wagner, 2009)

7 
Concomitants of persistent pain

 Pain is associated with:

 poorer self-rating of health status,

 greater use of healthcare resources,

 more tobacco use, alcohol use, diet/weight concerns,

 decreased social and physical activities,

 lower social support,

 higher levels of emotional distress, and

 among women, high rates of military sexual trauma. 

(Kerns, Otis, & Rosenberg, 2003; Haskell, Papas, 

Heapy, Reid, & Kerns, 2008) 

8 
Frequency of Diagnoses1 among 

Operation Enduring Freedom/Operation Iraqi 

Freedom/Operation New Dawn (OEF/OIF/OND) 

Veterans

Cumulative from 1st Quarter FY 2002 through 1st Quarter FY 2013

Diagnosis (Broad ICD-9 Categories)a Frequency Percentb 

Infectious and Parasitic Diseases (001-139) 144,167 16.0 

Malignant Neoplasms (140-209) 13,016 1.4 

Benign Neoplasms (210-239) 64,424 7.2 

Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 302,719 33.6 

Diseases of Blood and Blood Forming Organs (280-289) 36,899 4.1 

Mental Disorders (290-319) 486,015 54.0 

Diseases of Nervous System/ Sense Organs (320-389) 415,543 46.2 

Diseases of Circulatory System (390-459) 198,140 22.0 

Disease of Respiratory System (460-519) 241,229 26.8 

Disease of Digestive System (520-579) 326,338 36.3 

Diseases of Genitourinary System (580-629) 142,687 15.9 

Diseases of Skin (680-709) 199,803 22.2 

Diseases of Musculoskeletal System/Connective System (710-739) 519,721 57.8 

Symptoms, Signs and Ill Defined Conditions (780-799) 478,267 53.2 

Injury/Poisonings (800-999) 267,407 29.7 

1Includes both provisional and confirmed diagnoses.

aThese are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of September 30, 2011; Veterans can have multiple

diagnoses with each health care encounter. The total may be higher than 899,752 unique Veterans because a Veteran can have more than one 

diagnosis and each is entered separately in this table. bPercentages reported are approximate due to rounding.

9 
PTSD 

N=232 

68.2% 16.5% 2.9%

42.1%

 6.8%

5.3% 

 10.3%

 12.6%

TBI

N=227 

66.8%

Chronic Pain

N=277 

81.5%

Lew et al., (2009). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussive Symptoms in 

OEF/OIF Veterans: The Polytrauma Clinical Triad. Journal of Rehabilitation Research and Development, 46, 697-702.

Prevalence of Chronic Pain, PTSD and 

TBI: sample of 340 OEF/OIF veterans
VHA Pain Management Directive

• Objectives of National Pain Management Strategy

• Pain Management Infrastructure

– Roles and responsibilities

• Stepped Pain Care Model

• Pain Management Standards

– Pain assessment and treatment

– Evaluation of outcomes and quality

– Clinician competence and expertise

11
National Pain Management Strategy

Objective is to develop a comprehensive, multicultural, 

integrated, system-wide approach to pain 

management that reduces pain and suffering for 

Veterans experiencing acute and chronic pain 

associated with a wide range of illnesses, including 

terminal illness. 

12
Empirical foundations 

Cleeland, C.S., Schall, M., Nolan, K., Reyes-Gibby, C.C., Paice, J., Rosenberg, J.M., 

Tollett, J.H., & Kerns, R.D. (2003). Rapid improvement in pain management: 

The Veterans Health Administration and the Institute for Healthcare 

Improvement Collaborative. Clinical Journal of Pain, 19, 298-305.

Kerns, R.D. (2007). Research on pain and pain management in the Veterans 

Health Administration: Promoting improved pain care for veterans through 

science and scholarship. Journal of Rehabilitation Research and Development, 

44, vii-x. 

Kerns, R.D. & Dobscha, S.K. (2009). Pain among Veterans returning from 

deployment in Iraq and Afghanistan: Update on the Veterans Health 

Administration pain research program. Pain Medicine, 10, 1161-1164. 

Kerns, R.D. (2013). Transforming pain care in the Department of Veterans Affairs: 

The role of the VA Pain Research Network (Editorial). Clinical Journal of Pain, 

29, 93-94.

Kerns, R.D., Philip, E.J., Lee, A., & Rosenberger, P.R. (2011). Implementation of the 

Veterans Health Administration National Pain Management Strategy. 

Translational Behavioral Medicine, 1, 635-643. 13
Veteran-Centered Pain Management

• Informed by chronic illness 

model

• Emphasis on team based 

integrated care

• Empowering Veterans 

through reassurance, encouragement and 

education 

• Conservative use of 

analgesics and adjuvant medications 

• Promotion of regular 

exercise and healthy and active lifestyle

• Development of adaptive 

strategies for managing pain

14
Advanced pain medic

VA Stepped

Pain Care

RISK

Advanced pain medic

diagnostics & interven

CARF accredited pa

rehabilitation

Comorbidities

Multidisciplinary Pain Medicine Spe

Teams; Rehabilitation Medicine

Behavioral Pain Management; Me

TreatmentRefractory

Routine screening for presence & severity of p

Behavioral Pain Management; Me

Health/SUD Programs

Routine screening for presence & severity of p

Assessment and management of common p

conditions; Support from MH-PC Integration; OEF

Post-Deployment Teams; Expanded care manage

Ph P i C Cli i P i S h l

Complexity

Pharmacy Pain Care Clinics; Pain Schools

Nutrition/weight management, exercise/conditioning, & su

l i df l dit ti / l ti t h i 

sleep; mindfulness meditation/relaxation techniques; enga

in meaningful activities; family & social support; saf

environment/surroundings 

sleep; mindfulness meditation/relaxation techniques; enga

in meaningful activities; family & social support; saf

environment/surroundings 
Polling Question:

What is your involvement in efforts to 

implement the SCM-PM in VHA?

• Involved in national SCM-PM transformative efforts

• Member of VISN and/or Facility leadership team 

responsible for implementation efforts

• Active participant in implementation efforts (e.g., 

involved in transformative efforts in primary care/PACT 

setting) 

• Researcher involved in evaluation or research relevant 

to the SCM-PM

• Not involved, but interested in learning more

• Not aware of this effort to implement the SCM-PM
Project STEP

Program for Research Leadership

Donaghue Foundation and Mayday Fund

• Evaluate processes of implementation to 

determine best practice models for 

broader dissemination and 

implementation.

• Changes in group and organizational 

processes and evaluation of pain 

management and organizational outcomes 

are examined as the model is adopted.

• Qualitative and quantitative analysis will 

evaluate components of program 

implementation. Data will include 

administrative, outcome, and interviewbased measures.

17
Sources of Data Collection

• Qualitative data from primary care providers and 

nursing staff, and specialists, regarding their 

experiences caring for patients with pain

• Manual extraction of indicators of quality of pain care 

from primary care provider progress notes

• Automated electronic health record and 

administrative data extraction examining key 

dimensions of pain care consistent with SCM-PM (e.g., 

guideline concordant care, opioid risk mitigation 

strategies) 

– Pain Cohort (moderate to severe pain)

– Opioid Cohort (receipt of long term opioid therapy, i.e., >90 

days)
Qualitative data from providers and 

nursing staff Time 1 questions:

• How would you describe your role as a staff member working with chronic 

pain patients?

• Describe some barriers that you feel limit your ability to manage chronic 

pain. 

• Describe some of the positive aspects of caring for patients with chronic 

pain. 

• What are some of the negative aspects of caring for patients with chronic 

pain? 

Follow-up assessment questions:

• Has your care for Veterans with chronic pain changed over the past X 

months? If yes, please describe the changes.

• What activities/initiatives/changes within VACHS have taken place within 

the past X months that have improved your care of Veterans with chronic 

pain (if any)?

• What are the continuing barriers that you feel limit your ability to manage 

Veterans with chronic pain? 
Baseline Qualitative Assessment

Primary Care Providers

Themes identified: 

Barriers:

 Inadequate training

 Organizational impediments

 Clinical quandaries and the frustrations that accompany them

 Issues related to shared care among PCPs and specialists

 Antagonistic aspects of provider-patient interactions

 Skepticism

 Time factors 

Facilitators:

 Intellectual satisfaction of solving difficult diagnostic and management problems

 Ability to develop keener communication skills

 Rewards of healing and building therapeutic alliances with patients

 Universal protocols

 Availability of complementary and alternative medicine resources 

 Multidisciplinary care
Baseline Qualitative Assessment

Specialty Clinics

Survey administered to Pain Medicine, Neurology, 

Rehabilitation Medicine, Chiropractic Medicine

Themes identified:

• Barriers

– Communication between patients and other 

providers/Coordination between clinics

– Resource limitations

– Demand exceeds capacity

– Patient attitudes/beliefs about pain management

• Facilitators: 

– Multidisciplinary approach/team approach/support

– Good communication between provider/patient
Baseline Qualitative Assessment: 

Nursing Staff

Themes identified:

• Barriers

– Primacy of Medications

– System Issues

– Personal Barriers

– Challenging Interpersonal Aspects of Patients

– Clinical Quandaries 

– Dealing with Failure

• Facilitators

– Patient Centered Care

– Team Based Care
VACHS

VISN 1

Implementation Timeline

National VHA 2009 2010 2011 2012

Summer Series 

On Pain

National Pain 

Management Strategy 

Leadership Conference

VA/DOD Clinical Practice 

Guideline for Management 

of Opioid Therapy for 

Chronic Pain

PACT Training

Publication of the VHA Pain 

Management Policy and Stepped 

Care Model for Pain 

Management Directive

VISN 1 Strategic Plan for Pain

Sharing Best Practices- Interdisciplinary 

Meeting on Chronic Pain Management

Standards of Opioid Renewal Training

Pain in Primary Care: Patient Centered Approaches

Methadone Prescribing Advisory

Grand Round Series on Pain

Pain SCAN-ECHO

Workshop on Communication - Train the Trainers

Project STEP

Compréhensive Pain Management Center 

(CPMC)

Primary Care Pain Workgroup

Peer Support Workgroup

Methadone Policy Standardization Training 

Standarized Opioid Refill Process

Templated Note for Methadone

Pain Reassessment and Opioid Management (PROM)

Primary Care Survival Guide to Chronic Pain

Piloted Pain Templete in CPRS

Specialty Clinic Round Table meetings

Pain Rehabilitation School

Veteran's Pain Education Program (V-PEP)

Rapid Process Improvement Workshop

Integrated Pain Clinic- Primary Care (IPC)

Opioid Reassessment Clinic

Clinician Education Series-Communication Training

VISN 1 Strategic Plan for 

Pain

Primary Care Pain Workgroup

PC Peer Support Workgroup

Primary Care Survival Guide to Chronic Pain

Pain in Primary Care: Patient Centered 

Approaches

Piloted Pain Templete in CPRS

Specialty Clinic Round Table meetings

Rapid Process Improvement Workshop

Integrated Pain Clinic- Primary Care (IPC)

Opioid Reassessment Clinic

Clinician Education Series-Communication Training
Quality of Care Data Extraction

• Examination of quality of care of chronic pain

– Documentation of pain assessment, treatment planning, 

and reassessment (outcomes), and patient education

• Consistent with goals of VHA National Pain 

Management Strategy, which include continual 

monitoring and documentation of outcomes of pain 

treatment, and multifactorial assessment that 

includes:

– Pain intensity

– Pain interference

– Physical capacities
Quality of Care Data Extraction

• Creation of data extraction tool

– Quality of care coding tool developed through 

literature review and VA/DOD policies and 

guidelines, with input from pain mgmt providers

• Specific focus on pain assessment, treatment 

planning, and reassessment

• Coding manual defined with operational 

definitions

• Acceptable inter-rater reliability 

– (Cohen’s kappa .78 -.91) 
Quality of Care Data Extraction

• Two cohorts identified for each year 

examined: 

– Pain cohort (pain score ≥ 4 during that year)

– Opiate cohort (opiate prescription > 90 days during 

that year)

• Random sample of 200 patients – linked to a 

primary care appt – pulled for each cohort in 

each year

• Primary care note is assessed for quality of 

pain assessment, treatment planning, and 

reassessment using data extraction tool
Manual Chart Extraction Data:

Quality of Care Indices

0 

10

20

30

40

50

60

70

80

90

100

2008-2009 PAIN > 4

2011-2012 PAIN > 4

2008-2009 OPIOID

2011-2012 OPIOID

*

* 

* 

* 

* 

* 

* 

* 
Automated EHR data extraction

• All patients receiving care in a specific year (e.g., 

July 2008-June 2009)

• Applied a large set of metrics designed to capture 

evidence of guideline concordant pain care 

consistent with SCM-PM

• Two cohorts identified:

– Patients reporting presence and intensity of pain of 4 

or greater on numeric pain rating scale at primary 

care visit

– Patients receiving long term opioid therapy defined as 

receipt of opioid medication for >90 consecutive days
Automated EHR Extraction

Specialty Care Services

Pain Cohort

0 

5 

10

15

20

25

30

35

40

45

2008 2009 2010 2011

Percentage

MH Consult

MH Visit

PT Consult

PT Visit

Pain Consult

Pain Visit

Chiropractic Consult

Chiropractic Visit

* 

* 

* 

* 

* 

* 
Automated EHR extractions:

Use of co-analgesics

Pain Cohort

0 

5 

10

15

20

25

2008 2009 2010 2011

Percentage

Sedative/hypnotic

Topical

NSAID

Antidepressant

Anticonvulsant

* 

* 

* 

* 
Automated EHR Extraction

Opioid Therapy Standards

Opioid Cohort

0 

10

20

30

40

50

60

70

80

90

2008 2009 2010 2011

Percentage

Year

Opioid Agreement

UTOX

* 

* 
Automated EHR Extraction

Use of Co-Analgesics

Opioid Cohort

0 

5 

10

15

20

25

30

35

40

45

50

2008 2009 2010 2011

Percentage

Sedative/hypnotic

Topical

NSAID

Antidepressant

Anticonvulsant

* 
Automated EHR Extraction

Specialty Care Services

Opioid Cohort

0 

10

20

30

40

50

60

2008 2009 2010 2011

Percentage

Year

MH Consult

MH Visit

PT Consult

PT Visit

Pain Consult

Pain Visit

Chiropractic Consult

Chiropractic Visit

* 

* 

* 

* 

* 

* 
Publications

• Kerns, R.D., Philip, E.J., Lee, A., & Rosenberger, P.R. (2011). 

Implementation of the Veterans Health Administration National 

Pain Management Strategy. Translational Behavioral Medicine, 1, 

635-643.

• Rosenberger, P.H., Philip, E., Lee, A. & Kerns, R.D. (2011). VHA 

National Pain Management Strategy: Implementation of stepped 

pain management. Federal Practitioner, 28, 39-42.

• Lincoln, L.E., Pellico, L., Kerns, R.D., & Anderson, D. (2013). Barriers 

and facilitators to chronic non-cancer pain management in primary 

care. Journal of Palliative Care and Medicine, S3, 001. 

doi:10.4172/2165-7386.S3-001. 

• Pellico, L.H., Gilliam, W.P., Lee, A., & Kerns, R.D. (2012). Hearing new 

voices: Nurses and Medical Assistants experience caring for chronic 

noncancer patients in primary care. Manuscript under review. 
Thanks!!

robert.kerns@va.gov