2023 HSR&D/QUERI National Conference

1078 — Pathways into complementary and integrative health therapies among Veterans with chronic pain: A qualitative chart review

Lead/Presenter: Rendelle Bolton
All Authors: Bolton RE (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System), Tam M (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) Wetzel K (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) D’Amaddio S (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) Elwy AR (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) Brolin M (The Heller School for Social Policy and Management, Brandeis University)

Complementary and integrative health (CIH) therapies (e.g., yoga, acupuncture, meditation) are included in VA guidelines as front-line treatments for managing chronic pain and are being integrated as part of VA’s Whole Health (WH) System of Care. This model, implemented at 18 Flagship medical centers, incorporates person-centered communication with multiple approaches (e.g., health coaching, skill-building classes) to support health and well-being. However, patients with chronic pain use CIH at varied rates across these Flagship sites. To better understand this variation, we characterized how patients with chronic pain came to be involved in CIH, examining how patient-provider communication may influence CIH engagement.

We conducted qualitative chart reviews for 60 randomly-selected patients with chronic pain participating in CIH at the 2 highest CIH-utilizing and 2 lowest-utilizing Flagship sites. We deductively coded clinical notes entered between Oct 2017 and Sept 2019 to identify all documented WH/CIH-related discussions, capturing encounter context, patient interest, and treatment recommendations. We developed timelines for each patient, mapping patient-provider communication about WH/CIH up to first use. We used constant comparison to examine patterns of how patients first came to be engaged in CIH, contrasting high-utilizing and low-utilizing sites.

We found three key differences between high and low CIH-utilizing sites: (1) which providers recommend WH/CIH and why, (2) the role of WH coaches, and (3) prior experience with CIH. PROVIDER RECOMMENDATIONS: In high-utilizing sites, a wide range of healthcare providers frequently discussed WH/CIH options with patients, referring them to WH to address chronic pain. In low-utilizing sites, fewer providers raised WH/CIH, with physicians and mental health providers most often initiating conversations. Patients were more often connected to CIH for non-pain needs, including weight loss and mental health concerns. WH COACHES: WH coaches in high-utilizing sites educated referred patients about WH/CIH options during orientation appointments and linked them to CIH for chronic pain while simultaneously addressing their other life goals through individual coaching appointments. Pathways into CIH in low-utilizing sites were more varied, with more patients being referred directly into CIH or other types of non-WH services by providers. These patients had limited engagement with WH coaches. PRIOR EXPERIENCE: We observed two unique patterns in low-utilizing sites. Patients who reached WH either proactively requested referrals for CIH therapies previously used in non-VA settings, or they expressed repeated reluctance to engage in CIH due to past negative experiences, resulting in elongated timelines.

In sites where more patients utilize CIH, a wider range of healthcare providers, including health coaches, are engaging patients in conversations about CIH/WH and connecting them into these therapies to target chronic pain. Patients in low-utilizing sites reached CIH for non-pain reasons, with prior experience influencing uptake.

Communication between healthcare providers and patients is an important mechanism through which patients can learn about and become engaged in WH/CIH. However, there is need for greater uniformity in connection pathways. As VA spreads WH, coaches may help reduce variation by consistently educating patients about WH/CIH and serving as a connector when physicians may not always have the time to do so.