Bringing Chronic-Pain Care to Rural Veterans: A Telehealth Pilot Program Description

Abstract

Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic-pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive–behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encounters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion.

People with chronic pain who reside rurally are at elevated risk of negative outcomes. Rural areas of the United States have been affected disproportionately by the opioid public-health crisis, as evidenced by higher rates of opioid prescribing, opioid misuse, substance use disorders, and unintentional overdose (e.g., Dowell, Haegerich, & Chou, 2019; Lund, Ohl, Hadlandsmyth, & Mosher, 2019; O’Brien, 2015; Palombi, St. Hill, Lipsky, Swanoski, & Lutfiyya, 2018). The co-occurrence of chronic pain and opioid use disorder is associated with increased suicide risk and the co-occurrence of other psychiatric diagnoses (e.g., mood, anxiety, trauma-related, substance-use, or personality disorders), which can complicate effective care for these patients (Barry et al., 2016; Bernardy & Montaño, 2019; Dowell et al., 2019; Oliva et al., 2017).

Problem Description and Available Knowledge

Opioid medications are not only risky, but also do not clearly improve chronic-pain outcomes or confer functional benefits over less risky pain medications (e.g., Chou et al., 2015; Krebs et al., 2018). Research-based clinical-practice guidelines (Department of Veterans Affairs & Department of Defense, 2017; Dowell, Haegerich, & Chou, 2016) generally discourage long-term opioids for chronic pain, and instead support the delivery of biopsychosocial alternatives as first-line treatments for chronic pain, including pain education, cognitive–behavioral therapy, physical therapy and paced-exercise treatments, and self-management. Biopsychosocial modalities are effective for improving functional status (Becker et al., 2018; Gatchel, Peng, Peters, Fuchs, & Turk, 2007). They may be enhanced when combined through a comprehensive interdisciplinary approach, which may also include nonopioid medications and complementary and integrative medicine (Department of Veterans Affairs & Department of Defense, 2017; Gatchel, McGeary, McGeary, & Lippe, 2014). Evidence-based psychotherapies—such as Cognitive–Behavioral Therapy for Chronic Pain (Ehde, Dillworth, & Turner, 2014; Murphy et al., 2014), Acceptance and Commitment Therapy for Chronic Pain (e.g., Veehof, Trompetter, Bohlmeijer, & Schreurs, 2016), Motivational Interviewing (e.g., Alperstein & Sharpe, 2016), and mindfulness or mind– body interventions (Garland et al., 2019; Maglione et al., 2016)—are safe and potent elements of comprehensive chronic-pain care that can be viable alternatives to opioids (Majeed, Ali, & Sudak, 2019).

However, effective treatment modalities for chronic pain and co-occurring conditions are not always accessible to patients who are likely to benefit from them. Comprehensive chronic-pain services are not covered by all health care systems and insurance plans (Keogh, Rosser, & Eccleston, 2010), and rural patients are more likely to be uninsured (Centers for Disease Control, 2018). The availability of interdisciplinary chronic-pain teams in the United States has decreased sharply in recent years (Schatman, 2018), and this problem is compounded in rural areas, where few specialty pain providers practice (Arout, Sofuoglu, & Rosenheck, 2017; Breuer, Pappagallo, Tai, & Portenoy, 2007; Department of Health and Human Services, National Center for Health Workforce Analysis, 2014; Eaton et al., 2018). In addition, geographical inaccessibility can exacerbate other barriers to care, such as limited mobility, lack of transportation, financial difficulties, and co-occurring medical or psychiatric concerns (Department of Veterans Affairs, Office of Rural Health, 2019; Rural Health Information Hub, 2016). Patients with chronic pain who reside rurally are thus high in need, but subject to significant disparities. Telehealth has been proposed as one solution to more equitably distribute specialty pain resources that tend to be concentrated at large urban medical centers.

Rationale for Telehealth

Telehealth is a flexible and evidence-based method for clinical service delivery known to reduce treatment barriers, increase access to care, yield outcomes comparable to those for in-person interventions, and promote treatment attendance and high patient satisfaction (e.g., Chen et al., 2019; Hilty et al., 2013; Kinley, Zibrik, Cordeiro, Lauscher, & Ho, 2012; Mochari-Greenberger, Peters, Vue, & Pande, 2017; Osenbach, O’Brien, Mishkind, & Smolenski, 2013; Pruitt, Luxton, & Shore, 2014; Veazie, Bourne, Peterson, & Anderson, 2019). Benefits of telehealth include increased patient access to pain services, convenience, reduced travel costs, greater accessibility, increased safety, and coordinated care (Connolly et al., 2018; Hilty et al., 2013; Mochari-Greenberger et al., 2017). Telemental health shows good efficacy for chronic pain and related conditions, and the telehealth modality appears comparable with in-person pain care (e.g., Herbert et al., 2017). More than 60% of U.S. health care institutions offer telehealth as part of standard care (Office of Health Policy, Office of the Assistant Secretary for Planning & Evaluation, 2016), including in the public (e.g., Department of Defense, Indian Health Service, Medicaid, Medicare), private, and integrated sectors (Elliott, 2016; Tuckson, Edmunds, & Hodgkins, 2017).

Telehealth Within VA

VA has been using telehealth interventions successfully since the late 1950s (Wittson, Affleck, & Johnson, 1961), and is the largest Federal provider of telehealth care (Elliott, 2016). In the 2018 fiscal year, 2.29 million episodes of care were provided by telehealth to 782,000 VA patients (Elliott, 2016). In recent years, telehealth has been used in evidence-based practice rollouts within VA mental health settings, including at VA Maryland (Koch, 2012), VA New England (Godleski & Grant, 2014), VA New York Harbor (Chen et al., 2019), and VA Puget Sound (Caver et al., 2019).

Relative to the general population, U.S. military veterans are more likely to reside rurally (Department of Veterans Affairs, National Center for Veterans Analysis & Statistics, 2016), experience chronic pain (Nahin, 2017), be treated with opioids (Bennett, Elliott, & Golub, 2015; Department of Veterans Affairs, Office of Suicide Prevention, 2016; Lund et al., 2019), die by accidental opioid overdose (Bohnert, Ilgen, Galea, McCarthy, & Blow, 2011), and die by suicide (Department of Veterans Affairs, Office of Mental Health & Suicide Prevention, 2019), which suggests that rurally residing veterans with chronic pain are at particular risk of negative outcomes and health care disparities. In 2016, Congress passed the Comprehensive Addiction and Recovery Act (CARA, 2016), which mandated that VA take new steps toward opioid safety, including the creation of interdisciplinary pain teams to provide biopsychosocial chronic-pain care. However, many rural VA facilities continue to experience barriers to delivering comprehensive chronic-pain care on site, so telehealth solutions are being explored.

Specific Aims

The purpose of the Pain Telehealth pilot was to assess the feasibility of delivering behavioral chronic-pain care to patients at community-based outpatient clinics (CBOCs) in a highly rural region of the United States with limited access to biopsychosocial chronic-pain care outside of its urban hubs. We describe the development of the pilot program, comment upon lessons learned and limitations, and outline a plan for program expansion and future evaluation since obtaining new funding.

Program Description

Context

The Pain Telehealth pilot program began in May 2016 within the Pain Psychology subset of chronic-pain care, with a goal of providing direct telehealth services for chronic pain to rural patients at their local community clinics. As noted earlier, the pilot program was launched in a region of the United States with a large rural patient population and a large number of patients who were prescribed opioids. The Pain Telehealth pilot included one hub site, a large academic medical center, that served four spoke clinics, of which two were designated rural (75% to 99% of enrolled patients were living in a rural census tract) and two urban (27% to 70% rural patients) using the VA classification system (Veterans Health Administration Support Service Center Capital Assets, 2019; West et al., 2010; see Table 1). When the program began in 2016, more than 5,000 enrolled primary care patients were on long-term opioids, of whom approximately 5% were on high-dose opioids greater than 120 mg morphine equivalent daily dose (Department of Veterans Affairs, 2016), suggesting a high need for services. Clinical services were added gradually, beginning with pain psychoeducation and then expanding to cognitive–behavioral psychotherapy groups, opioid-safety interventions, and acupuncture education.

Table 1.

VISN 20 TelePain Hub and Spoke Sites Note.

VA Medical Center (VAMC)	Spoke sites	Rurality
Puget Sound VAMC	Bremerton CBOC	Urban
	Mount Vernon CBOC	Urban
	North Olympic Peninsula CBOC	Rural
	South Sound CBOC	Rural
Anchorage VAMC	Fairbanks CBOC	Urban
	Kenai CBOC	Rural
	Juneau CBOC	Rural
	Mat-Su CBOC	Rural
White City VAMC	Grants Pass CBOC	Urban
	Klamath Falls CBOC	Rural
Planned expansion Boise VAMC	Caldwell CBOC	Urban
	Mountain Home CBOC	Rural
	Twin Falls CBOC	Rural
Mann-Grandstaff VAMC	North Idaho CBOC	Urban
	Wenatchee CBOC	Urban
Roseburg VAMC	Brookings CBOC	Rural
	North Bend CBOC	Rural
Walla Walla VAMC	La Grande CBOC	Rural
	Lewiston CBOC	Urban
	Richland CBOC	Urban
	Yakima CBOC	Urban

Note. VA = Veterans Health Administration; CBOC = community-based outpatient clinic. Adapted from “VAST Snapshot 2—VHA Station Listing” by Department of Veterans Affairs, VHA Support Service Center (2019).

Program development was led by staff within the Pain Clinic, in consultation with collaborators throughout the hospital. Efforts were guided by a staff psychologist with specialties in treatment of substance use disorders and chronic pain, and a staff anesthesiologist with specialties in pain and addiction who was also the clinic director. A needs assessment was conducted early in the development of the program to identify program goals and project stakeholders. Other pain clinic clinicians (i.e., physicians, psychologists, psychology trainees, nurse practitioners, pharmacists, and registered nurses) and administrative staff provided services for the program as a part of their regular duties. Most clinical services were provided through the part-time work of two psychologists and the rotating trainees that they supervised. A more detailed description of the clinical services is included below.

Funding

No funding was provided for the conduct of this quality improvement (QI) initiative. The Pain Telehealth pilot itself was an unfunded feasibility project conducted by Pain Clinic staff.

Ethical Considerations

In accordance with local policy, the current project was reviewed by the hospital QI committee, who determined in conjunction with institutional review board representatives that the activities met QI criteria and therefore were approved without the need for research review.

Infrastructure Requirements

At minimum, a codec, computer, and monitor were needed to provide Pain Telehealth care to veteran patients through clinical video telehealth. All clinicians were required to be certified in telehealth using standard VA procedures that involve online didactic training and a live skills evaluation. Regulatory documents, including a memorandum of understanding and telehealth service agreements, had to be approved by clinical leadership at the hub and spoke sites to specify the roles of staff at each site and to develop emergency plans. Approximately 25 new clinics were requested at the hub and spoke sites to allow for appropriate scheduling and billing. Clinic staff created a consult menu to allow for referral to the program, and a local clinical applications coordinator built the consult menu into the electronic medical record. Extensive coordination and education was done between the Pain Telehealth clinical champion and stakeholders, which included affiliated hospital departments (i.e., primary care, substance use, mental health, and primary care–mental health integration), CBOC staff, the facility telehealth coordinator, the local telehealth committee, the local telemental health program, and information technology. Space and scheduling were arranged with local telehealth clinical technicians and schedulers at the spoke sites.

Referral Process

Patients with chronic pain were typically referred to Pain Telehealth through a consult placed by a primary-care or mental health referring provider. Then nursing triage staff within Pain Clinic determined patient eligibility for the program, and medical services assistants contacted patients for scheduling. To ensure the safety of participants while they participated in pain education classes prior to an in-person intake with a comprehensive pain team, the consult required the referring provider to address several inclusion and exclusion criteria that pertained to the previous three months: absence of suicide ideation, homicide ideation, or psychosis that would interfere with telecare; engagement in any type of VA mental health care; awareness of in-person care options with preference to participate via telehealth; and willingness to travel to a participating CBOC.

Clinical Services

Participating patients received the standard of care for all patients referred to specialty pain services at this facility, with some modifications for telehealth participation. Specifically, patients typically began by completing large-group pain education via telehealth; the four 120-min classes were cofacilitated by an interdisciplinary team of pain providers, and included orientation, education about the biopsychosocial approach to chronic-pain management, review of clinician-provided services, and discussion of self-management strategies. Pain education is a core component of pain self-management and has been found to reduce pain interference among rural patients (e.g., Thorn et al., 2011). Patients who completed the classes were invited to schedule an in-person 60-min intake with a pain psychologist and pain medical provider. The intake included chart review, collaborative discussion of an initial self-management plan, and typically within-clinic referral to other evidence-based comprehensive Pain Clinic services, such as pain psychotherapy, physical therapy, acupuncture, interventional pain procedures, mindfulness practice, and peer support. Patients then followed up with the interdisciplinary team every 1–3 months to assess functional gains and consider any necessary modifications to the treatment plan.

Comprehensive treatment options available by telehealth included pain education classes (described above), pain psychotherapy groups, acupuncture education, and opioid-safety education. For efficiency, clinical services were typically offered in hybrid format, wherein some veteran patients participated in person with a clinician and others joined simultaneously via telehealth from a CBOC location. During the pilot, pain psychotherapy groups included two evidence-based approaches for treating chronic pain: Cognitive–Behavioral Therapy for Chronic Pain (Murphy et al., 2014), and Acceptance and Commitment Therapy for Chronic Pain (Vowles & Sorrell, 2007). Groups were offered in a series of eight 90-min sessions using standardized protocols adapted for group delivery, and typically were cofacilitated by a psychologist and a psychology trainee. Acupuncture education classes provided an introduction to acupuncture and its place within biopsychosocial pain care; they were facilitated by an acupuncturist and a psychologist. Opioid education classes reviewed the benefits and risks of opioids, to assist primary-care providers in obtaining informed consent for long-term opioid therapy (Department of Veterans Affairs, 2014); classes were cofacilitated by a physician, pharmacist, and psychologist. Over time, the clinic offered additional services over telehealth, including screenings for participation in the Functional Restoration Program. Individual pain psychotherapy was planned but not offered during the pilot because group modalities could make more efficient use of limited clinical rooms, telehealth equipment, and staffing.

Early Accomplishments and Barriers Encountered

Program Accomplishments

Below we describe some accomplishments of the Pain Telehealth program in expanding technological resources, improving telehealth and chronic pain training for providers, and preliminarily assessing clinical impact.

Technological.

The pain clinic had to construct a significant amount of technological infrastructure to enable the delivery of Pain Telehealth services. Given the unfunded nature of this pilot program, the clinic acquisitioned underused equipment from other departments, including video teleconferencing units, web cameras, and software. In addition, new IT capabilities were added to clinical rooms, software was installed on telehealth equipment, specialized calls were created to allow the joining of multiple sites in video teleconferences, and consults and templates were developed to facilitate patient referrals through the electronic medical record.

Training and personnel.

About 21 pain clinicians (i.e., 80% of current clinic staff) were certified in telehealth as part of their regular duties. Specialties of those staff included physician, psychologist, pharmacist, physical therapist, physician assistant, advanced practice nurse, and registered nurse. In addition, six psychology interns and postdoctoral fellows were trained in telehealth modalities of chronic-pain care.

Clinical impact.

We obtained counts of telehealth encounters delivered within each relevant clinic at the one hub site and four spoke sites. Counts were completed independently by two raters, who showed excellent interrater reliability (ICC = 1.00; Cicchetti, 1994). Only completed visits were counted through this method, and not no-show or cancellation outcomes. The program delivered 501 complete encounters to patients at the four CBOC spoke sites between May, 2016 and September, 2018.

Preliminary assessment of patient population using VA operations data.

Because this project was unfunded, we lacked the personnel and protected staff time to collect patient-reported clinical outcomes or to extract data from the medical record specific to the Pain Telehealth program. However, we were able to partner with researchers affiliated with VA Health Services Research & Development who, as part of a larger operations project, were collaborating with regional administrative leadership to evaluate scale up and spread of best practices for chronic pain and opioid safety. Using VA administrative data, we identified outpatients who had a high likelihood of needing pain services—that is, those who had at least one clinical or telephone encounter in a primary-care or mental health clinic that was associated with an ICD-9 or ICD-10 musculoskeletal pain-related diagnosis, and also had at least one more musculoskeletal pain diagnosis charted in the 90 days prior to the qualifying visit (Goulet et al., 2016).

Within this cohort of patients with a need for chronic-pain services, we identified 126 unique patients between January 1, 2016 and September 30, 2018 who received at least one specialty pain encounter via telehealth. We examined characteristics of this subset with the goal of understanding who was accessing Pain Telehealth services.

For the subset of 126 patients who received Pain Telehealth services, the sample was primarily White (81.7%) and male (88.1%), with an average age of M = 59.1 (SD = 13.1). In terms of rurality, 46.0% of patients were categorized as nonmetropolitan based on their residential zip code mapped onto U.S. Census Tract Rural-Urban Commuting Area Codes. Common co-occurring conditions included major depression (42.9%), posttraumatic stress disorder (PTSD; 34.9%), nicotine or tobacco use disorder (11.9%), alcohol use disorder (7.1%), and opioid use disorder (5.6%). That suggested that patients who received Pain Telehealth were similar to VA patients who utilize in-person specialty pain care per previous literature (e.g., Arout et al., 2017), including showing relatively high rates of co-occurring mental health conditions (e.g., Barry et al., 2016; Bernardy & Montaño, 2019; Oliva et al., 2017; see Table 2).

Table 2.

Characteristics of Subsample of Veterans With Chronic-Pain Needs Who Received Pain Telehealth Services

Characteristic	n or M	% or SD
Age, M, SD	59.1	13.1
Gender, female, n, %	15	11.9
Rurality, nonmetropolitan,a n, %	58	46.0
Race, n, %
White non-Hispanic	103	81.7
Black/African-American	9	7.1
Asian/Pacific Islander	4	3.2
American Indian or Native Alaskan	2	1.6
Unknown/Missing	8	6.3
Ethnicity, Hispanic, n, %	8	6.3
Past year diagnosis, n, %
Major depression	54	42.9
PTSD	44	34.9
Bipolar disorder	4	3.2
Alcohol use disorder	9	7.1
Opioid use disorder	7	5.6
Cannabis use disorder	15	0.8
Nicotine use disorder	15	11.9
Total, N, %	126	100.0

Note. VA patients who had a chronic musculoskeletal condition diagnosis at a VA outpatient visit (Goulet et al., 2016).

^aAdapted from “2010 Rural-Urban Commuting Area (RUCA) Codes” by Cromartie (2016). n = 56 who had a residential zip code that did not match a RUCA code.

Unexpected Barriers

The primary challenges and barriers to rollout of the pilot program centered around the time required to build new telehealth infrastructure and the availability of personnel and resources allocated to program development. First, technical difficulties and systemic infrastructure barriers slowed program startup. Because the local facility lacked a centralized system for developing a new telehealth program, each aspect (e.g., regulatory documentation, clinic builds, technical advisement, equipment ordering, IT consultation, service planning, space acquisition, move support) had to be undertaken independently, in consultation with decentralized content experts across the facility, region, and nation. At the time of pilot initiation, most CBOC sites throughout the region were found not to have the necessary telehealth equipment to support the service. All sites eventually received equipment through an unrelated expansion of general VA funding for telehealth, but otherwise Pain Telehealth would have been delayed at some CBOCs. Other local barriers (e.g., hiring freezes/delays, space shortages, unfilled positions) caused significant delays for tasks such as clinic creation and equipment ordering. These have been noted as barriers by other authors as well (e.g., Adler, Pritchett, Kauth, & Nadorff, 2014; Veazie et al., 2019), both inside and outside VA.

Second, the program was developed without funding, and was initiated using only existing VA resources and personnel. Without sufficient administrative or technical resources, clinical staff needed to learn to conduct support tasks, including equipment setup and troubleshooting, clinic creation, development of program documentation, staff training, and scheduling. Although existing clinical resources were stretched remarkably to accommodate the development of the program framework, this approach reduced efficiency and increased demands upon staff. This meant that clinicians conducted program-development activities in addition to their regular clinical and research caseloads, which was onerous and included significant work outside their duty hours. It became apparent that the program would remain limited in its offerings and confined to the local pilot area without dedicated clinical and support staff to support expanding services.

Conclusions and Next Steps

Summary

The Pain Telehealth pilot program met its primary aim by demonstrating the feasibility of providing evidence-based behavioral pain services by telehealth to patients at local CBOCs. The program converted hundreds of in-person encounters to telehealth encounters, which likely reduced transportation costs for patients and increased the ability of rural patients to participate in behavioral pain groups and other evidence-based chronic-pain care. In addition, the project resulted in a number of administrative, technological, training, and clinical accomplishments, including expanding the number of providers certified in telehealth, establishing regulatory agreements between hub and spoke sites, building 25 new clinics to allow for appropriate scheduling and coding of telehealth encounters, and designing consults to allow for referrals to a telehealth pain program.

Strengths

The program showed three particular strengths. First, the preparations made during the pilot enabled the program to launch into widespread regional expansion, which is described further below in Next Steps. Second, we developed the program through extensive consultation with diverse stakeholders and advisors that included local telehealth experts, clinical partners in several departments, CBOC providers, technical staff, and hospital administrators. The close collaboration allowed us to build a local program that truly met the needs of the VA organization and its stakeholders. By tailoring the program to our local context, we were able to see relatively strong uptake of Pain Telehealth in this 2-year pilot, as evidenced by the 501 encounters that were documented in this time period. Third, Pain Telehealth showed promise in supporting several high-priority VA initiatives, including opioid safety, CARA, and ongoing suicide-prevention efforts.

Limitations

We also note some important weaknesses that limit our ability to draw inferences about the utility of Pain Telehealth and may reduce generalizability to other clinical settings. One limitation of this unfunded pilot program was that we were unable to systematically collect data on various aspects of utilization that would be helpful to guide future implementation efforts (e.g., there was no systematic process in place for tracking referrals to Pain Telehealth). Additionally, delays to clinic builds meant that some encounters were incorrectly classified as in-person rather than telehealth, and likely underestimated the true utilization of Pain Telehealth. Additionally, expansion of the program within the local pilot area was necessarily limited by local capacity at both the hub and spoke sites. Because of the existing Pain Clinic organizational structure upon which the pilot program was overlaid, all patients needed to present at least once for in-person care with an interdisciplinary pain team to be enrolled in the Pain Clinic. So, although they could complete some aspects of their care by telehealth, in-person intakes were capped based upon clinic availability, and thus limited the reach of telehealth services. Therefore, the project cannot be construed as estimating how well a program that is fully telehealth-based could serve new populations.

Without additional funding for evaluation, we were only able to describe the demographic and clinical characteristics of a limited subset of patients who received Pain Telehealth (i.e., those with musculoskeletal chronic pain), which might not apply to patients with neuropathic, facial, pelvic, or other pain. Another limitation is that although the inclusion/exclusion criteria for the program were consistent with criteria used within other outpatient telehealth programs, they might limit the utility of the program for patients with greater psychiatric complexity. Finally, the pilot was conducted within the VA system only. The literature suggests that barriers to accessing the psychosocial components of comprehensive pain care are at least as problematic outside VA (e.g., Schatman, 2018), but our approach and recommendations might require further adaptation within other public-sector settings.

Program staff based their QI strategy upon the advice of local leaders and VA best-practices guidance, but did not apply explicit implementation strategies such as external facilitation. Support for evidence-based implementation would likely catalyze the expansion of the program. Many of these barriers have since been highlighted by other VA telehealth programs (e.g., Chen et al., 2019; Interian, King, St. Hill, Robinson, & Damschroder, 2018; Perry, Gold, & Shearer, 2019).

Finally, although the program aimed to serve rural patients, half of the participating CBOCs were classified as urban, which likely reflected their presence in a relatively populous state. This is not representative of CBOCs within the rest of the region, and thus we will need to consider implications for more highly rural areas—for example, seasonal road closures, inaccessibility of sites by car, or lack of 4G Internet connectivity. Nevertheless, on an informal satisfaction distributed to psychotherapy group participants in the local service area, several patients indicated that they would not have been able to attend if not for the telehealth option.

Lessons Learned and Recommendations

We outline several lessons learned through the Pain Telehealth pilot and recommendations to other public sector health care teams that might seek to implement a Pain Telehealth program at their sites. First, converting services from in-person to telehealth modalities unfortunately is not as simple as the flip of a switch. A complex set of administrative processes is required to sufficiently address the safety, legal, ethical, technical, and logistical nuances of the telehealth modality. Often, one administrative step is dependent upon previous ones, so delays at any stage can significantly slow the rollout of clinical services. Second, within VA, no single, coordinated route exists for developing a telehealth program, at least at the initiation of our program. Each step had to be completed separately through independent consultation with different departments and regional contacts. The program also needed to adapt frequently and suddenly in response to legal or policy shifts—such as updated guidance about the Ryan Haight Act (Drug Enforcement Administration, Department of Justice, 2009; Veterans Health Administration, 2016), and local hardware and software transitions—which often were not disseminated reliably to the pilot team because there was not an oversight structure in place for doing so.

Third, referring providers might be unfamiliar with the nuances of telehealth or specific program criteria, so should receive additional guidance placing consults. In addition, keeping the consult form straightforward and automating determination of eligibility (if possible) could assist both referring providers and triage staff in making rapid decisions. Fourth, telehealth requires the development of strong relationships with stakeholders at the spoke sites, and referrals truly depend upon the support of local champions. Finally, a coordinated administrative system is needed to better capture need and program utilization. For example, no-shows and cancellations should be included in utilization counts to ensure all patient interest is captured, and the number of consults placed to Pain Telehealth could be tracked to include patients who were referred but not eligible. Associated triage and scheduling hours are often greater for telehealth than in-person services within VA because of multiple documentation currently required by policy, but are not captured through clinical productivity metrics. Stream-lining telehealth documentation through the electronic medical record offers an opportunity to standardize the process for all modalities of care.

Next Steps

Since the initiation of the pilot, the team has already taken several steps toward expansion of the Pain Telehealth program to the rest of the four-state region, to meet the rapidly growing need for comprehensive care for rural patients with chronic pain. After submitting a grant that was awarded but later discontinued, pilot staff sought replacement funding from regional leadership. Their decision to support the clinical expansion of the program has allowed for hiring of 15.2 new FTE, including administrative support, dedicated clinicians, and technical staff. Telehealth clinical technicians, medical administration specialists, and medical services assistants are needed to schedule patients, operate telehealth equipment, document encounters, create new clinic grids, and assist rural sites in establishing telehealth service agreements. Similarly, dedicated time from IT professionals is required to maintain the continuity of clinical services over telehealth, including addressing equipment failures, setting up new equipment, or instructing patients in the use of home telehealth equipment. The regional funding also includes an equipment budget to purchase equipment for all sites in need and travel to facilitate program development at new sites. This support is expected to promote long-term program sustainability by reducing medical costs associated with opioid risk and untreated chronic pain.

Most recently, pilot staff partnered with research stakeholders to apply for and secure a partnered implementation grant in collaboration with regional leadership. This now supports efforts to formally implement Pain Telehealth using external facilitation as an implementation strategy (Kirchner et al., 2014) and to evaluate clinical and implementation effectiveness. Program success will be measured in two ways: (a) clinical effectiveness, which includes process of care outcomes (e.g., number of sessions and types of specialty pain care received per patient) and patient-reported outcomes that are gathered as part of routine care (e.g., the PEG pain scale [Krebs et al., 2009]), and (b) implementation success, including measures of reach (proportion of patient population served by the program) and adoption (proportion of providers utilizing referrals to Pain Telehealth). Formal support for evidence-based implementation is likely to improve rollout pace, and perhaps also clinical outcomes.

Future Directions

Going forward, the program will consider how Pain Telehealth services may better meet the needs of patients and providers. Program evaluation will be essential in guiding program modifications, including continual reassessment of barriers to care. Addressing questions of which patients choose and benefit most from telehealth versus in-person care and noting any disparities that can be addressed through focused outreach will be important. Interviews and satisfaction surveys are planned as part of the implementation grant, and will inform an implementation manual that can be used by other VA sites. The program is already considering partnerships with other regions to assist with their own program development, which could also inform research collaborations, policy recommendations, and a more coordinated system for developing new chronic-pain telehealth programs. Similarly, partnerships with other telehealth providers and researchers—especially within the Department of Defense and the Indian Health Service—hold promise in solving complex telehealth problems at the Federal level, which could benefit patients within many health care systems (e.g., Tuckson et al. [2017] and Elliott [2019] provide compelling recommendations for telehealth research and policy).

Conclusions

Pain Telehealth services can provide tremendous benefit to patients, clinicians, and health care systems, but funding, infrastructure, and institutional support are crucial in initiating an efficient and sustainable clinical program. New funding obtained since the pilot began will expand access to comprehensive chronic-pain services throughout the VA’s Northwest Region, which is expected to improve the safety and functioning of high-risk rural patients with chronic pain. Going forward, we seek to partner with other VA regions that would benefit from support in implementing their own pain telehealth services, and collaborate with other health care agencies with a goal of improving delivery of chronic-pain care to rural patients, wherever they might be located.

Impact Statement.

A pilot project was created to bring chronic-pain care by telehealth to rural patients at Veterans Affairs (VA) clinics in their local communities. The program increased access to safer alternatives to opioid medications, including pain education and psychotherapy. New funding will expand the program to the rest of VA’s Northwest Region.