Stepped Care
Evidence-based care models for older adults with chronic musculoskeletal pain focus on both medical management and behavioral interventions, and these approaches involve collaboration between care teams and their patients to set and achieve pain management goals, said Kelli D. Allen, PhD, an exercise physiologist at the University of North Carolina Thurston Arthritis Research Center, Chapel Hill. Care needs to be multifactorial and multidisciplinary to be effective.16
“Not only does it require multiple professionals to deliver care to older adults, but the care is complex in terms of how it is operationalized,” she said. “If you’re doing optimal management of osteoarthritis or back pain, you need to operationalize treatment recommendations. What therapy is done by whom? How do you move patients between therapies?”17
Obesity, pain and other factors often lead adults with musculoskeletal conditions to be physically inactive, so rheumatology care providers are interested in behavioral interventions that include exercise, said Dr. Allen.18,19 Models include stepped care, collaborative care and stratified care.
“Stepped care models begin with a low-intensity or low-resource treatment, and then step up if the patients do not make clinically relevant improvements. They mirror what you’d do in a clinical setting. You can also step down,” she said. “The idea is to deliver the right care at the right time to the right person. Hopefully, that optimizes outcomes, and also reduces costs and saves resources.”
Collaborative care models involve providers from different disciplines who work together to treat patients and monitor their progress, said Dr. Allen. “These programs involve varying degrees of integration. Ideally, it’s more than co-located care. The idea is really working together on a patient’s treatment plan.
“Stratified care models include initial risk stratification based on some type of standardized assessment, and then care is provided based on that risk.”
Stepped care models for pain management have been the most widely implemented and tested of the three approaches, and are the basis for the VA’s pain management strategy.20 Step 1 of the VA’s approach is self-care based on the biopsychosocial model, and using various behavioral tools to help people manage their pain.
“These include weight management, exercise and conditioning, and mindfulness. There may be referrals elsewhere, but it is implemented and managed in the primary care space,” said Dr. Allen. “If their pain is treatment refractory, then in step 2, they’d go on to see other specialty referrals. If there is continued pain or other comorbidities that are preventing progress, then step 3 is referral to interdisciplinary pain centers or other specialty care, but this is reserved for patients who failed to achieve benefits from the therapies in earlier steps.”
Stepped care models require measurement via telephone-based or electronic medical record-based tools to assess how well a patient’s therapy is working, she said.
