Integrated nurse care management to reduce pain interference for primary care patients in rural communities: results from a pilot study

Dear Editor, More than 27% of the 46 million individuals living in rural America experience chronic pain.1,2 Chronic pain reduces quality of life, functioning, and productivity.3,4 Rural residents with chronic pain more frequently receive pharmacologic interventions, especially opioids, despite their ineffectiveness.5,6 Meanwhile, multiple effective nonpharmacologic treatments for chronic pain exist, including cognitive behavioral therapy (CBT) and exercise therapy, but access remains limited.7 To improve access to nonpharmacological treatments for chronic pain in rural communities, we developed and piloted an integrated nurse care management (NCM) approach for chronic pain. NCM has been adopted for other chronic conditions, but has not been widely used for chronic pain. We assessed the feasibility of this integrated NCM model for rural-dwelling patients experiencing chronic pain to inform a future randomized, controlled trial testing whether the NCM model is effective in reducing pain interference. Using a single-arm, pre-post design, participants were recruited from 2 rural-serving health systems in Washington (HS1) and North Carolina (HS2). Eligible patients were 18 years of age or older, had a chronic pain diagnosis, had a Pain, Enjoyment of Life and General Activity (PEG) Scale score of 4 or higher and lived in a rural area as defined by the HRSA Rural Health Grants Eligibility Analyzer. Those with cancer-related pain, moderate to severe cognitive impairment, upcoming surgeries during the study period, or limited English proficiency were excluded. Recruitment occurred between May and October 2024, and health systems determined the outreach method. For HS1, patients were referred by providers; for HS2, patients were identified via an electronic health record (EHR) query. A multidisciplinary study team—including nurses, physicians, psychologists and social workers—adapted the NCM model, which included care coordination, CBT and referrals to a virtual exercise program, Tele-EnhanceFitness (Tele-EF). A nurse was identified from each health system and received training on care coordination and CBT through initial didactics followed by biweekly case-based learning with study team clinical psychologists. Nurses provided participants with 6 months of virtual intervention support. The intake visit included completion of a measurement-based care (MBC) tool to track pain, depression, anxiety and sleep; in addition, patients completed a social needs screener and developed pain care goals. Patients then met every 2-4 weeks with the nurse who provided CBT, which focused on behavioral activation and addressing barriers to activity engagement to help with pain, and care coordination, which included referrals for social needs assistance, coordinating pain care between providers and pain monitoring. Nurses referred participants who were ready to engage in exercise to Tele-EF, a virtual, certified instructor-led, hour-long group class held 3 days a week. We collected the implementation outcomes of reach, adherence, and fidelity.8 For reach, we tracked those eligible and those enrolled with a goal of enrolling 30 participants in 6 months.9 For adherence, we tracked the number of visits completed out of a target of 6 nurse visits, with a goal of at least 70% completing 4 of 6 visits.10 For fidelity, we tracked intervention components completed based on a 10-item checklist comprised of core intervention components with a goal of 70% average completion. We also collected preliminary effectiveness outcomes. The primary outcome was pain interference, and the secondary outcomes included the HEAL Initiative Common Data Elements for chronic pain. Data were collected at baseline and post-intervention via patient report for all outcomes except opioid use, which was extracted from EHRs. Categorical variables were summarized using frequencies, and continuous variables with means and SDs. Mixed-effects regression models were used to assess pre-post changes in effectiveness outcomes. Implementation outcomes were summarized descriptively. Analyses were conducted with SAS software version 9.4 (SAS Institute Inc.). The University of Washington Institutional Review Board approved this study. Of 445 patients contacted, 164 completed screening (36.9%). Of those screened, 43 were eligible, and 31 enrolled for a 72.1% reach rate. Enrollment yield was higher for provider referral (48.8% of contacted) than EHR-based outreach (3.7%). Two participants withdrew during the study, resulting in a final count of 29. Table 1 reports demographic characteristics. Demographic characteristics of sample. Participants completed a mean of 5.2 (SD 3.3) visits. Nineteen individuals (65.5%) completed at least 4 visits during the intervention period, although this varied from 46.7% at HS1 to 85.7% at HS2. In intake visits, 100% patient’s pain story was reviewed in 100% of visits, goals and care plans were made in 100%, social needs were addressed in 55.6%, and MBC tool results were reviewed in 70.4%. Across the series of follow-up visits, nurses delivered core intervention components for most patients. Specifically, the CBT model, movement skills, and Tele-EF were covered for 95.5% of patients; pain psychoeducation for 81.8%; MBC tool review for 77.3%; and care coordination follow-up for 63.6%. Overall, 20 patients (69.0%) were referred to Tele-EF, and 6 (20.7%) attended at least 1 Tele-EF class. Table 2 shows effectiveness outcomes. Compared to baseline, post-intervention scores showed a mean reduction in the primary outcome of pain interference of –0.9 (95% CI –1.7, –0.1). Pre-intervention and post-intervention patient outcomes. Risk ratio for dichotomized variables. P < .05. P < .01. This pilot demonstrates the feasibility of an NCM model in rural practices and indicates acceptability among patients. The sample reflects a high-burden rural population, and higher enrollment via provider referral suggests that trusted endorsement may be important for engaging patients in this context. Lessons from the pilot include need for specifying care coordination protocols, allocating administrative support for nurses to enhance adherence to follow-up appointments, and assigning multiple site interventionists to prevent the effects of unanticipated interventionist attrition. Notably, uptake of Tele-EF was low relative to referral, which will be addressed by improving training for nurses on exercise counseling and the referral process. We will also document participants who were already doing other forms of exercise and provide counseling on and engagement in exercise alternatives. To strengthen implementation, a learning collaborative with site personnel will be organized in the full trial to standardize operations, provide tailored support and share learnings. This full-scale hybrid type 1 effectiveness-implementation trial could demonstrate the NCM model’s impact on reducing pain interference and improving well-being. This work was supported within the National Institutes of Health (NIH) Pragmatic Trials Collaboratory by cooperative agreement UG3NR020930 from the National Institute of Nursing Research. This work also received logistical and technical support from the NIH Pragmatic Trials Collaboratory Coordinating Center under award number U24 AT009676 from the National Center for Complementary and Integrative Health (NCCIH), the National Cancer Institute (NCI), the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), the National Institute of Minority Health and Health Disparities (NIMHD), the National Institute of Neurological Disorders and Stroke (NINDS), the National Institute of Nursing Research (NINR), the National Institute on Aging (NIA), the NIH Office of Behavioral and Social Sciences Research (OBSSR), and the NIH Office of Disease Prevention (ODP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the NCCIH, NCI, NIA, NIAMS, NHLBI, NIAID, NIMHD, NINDS, NINR, OBSSR, or ODP, or the NIH. None declared.