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CDA 19-075 – HSR&D Study

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CDA 19-075
Building Better Interdisciplinary Pain Teams Across Disciplines
Karleen F Giannitrapani PhD MA MPH
Palo Alto, CA
Funding Period: January 2022 - December 2026


Background: Chronic pain disproportionately affects Veterans and is often managed in VA primary care. Because chronic pain may exhibit physical, emotional, social, and existential dimensions, individualized, interdisciplinary approaches are clinically important. Various pain team models have been implemented in diverse clinical settings, and some are effective. However, to meet the complex needs of specific patients, pain teams often benefit from dynamic membership and different providers (e.g., pharmacist) fulfilling specific roles or tasks (e.g., opioid tapering). The providers who come together around one patient may or may not work together regularly or in the same combinations on other patients. In fact, dynamic teams and bounded teams often overlap. Compared with bounded teams, dynamic teaming, which I refer to hereafter as “teaming”, is a more complex process with a smaller empiric research base. Whether teams are bounded or dynamic (and often they have elements of both), they need to coordinate/negotiate and understand their mutual roles and role boundaries to serve patients effectively. Facilitating “teaming”, through establishing scaffolds, represents a strategy for organizing providers with dynamic membership around shared patient care goals. Significance/Impact: Developing a “teaming” intervention to facilitate collaboration around the numerous tasks involved in providing good and safe pain management is particularly timely as it aligns with the VA ORD clinical priorities. This work will be done in partnership with Veterans, providers, and operational leaders from the national pain program office to ensure alignment with VA pain and opioid initiatives. Innovation: The proposed intervention will create team scaffolds and a teaming facilitation process for interdisciplinary providers that participate in pain care tasks. The integration of organizational theory and co- design principals and strategies to produce and test a teaming intervention represents a novel approach for improving processes of pain care in the VA. Specific Aims: This proposal seeks to address scientific gaps through three projects. AIM1: Identify roles, structures and processes of interdisciplinary providers involved in primary care based chronic pain management. AIM2: Co-design an intervention to improve interdisciplinary “teaming” with VA providers and Veterans. AIM3: Pilot test the feasibility and acceptability of a teaming intervention for improved pain management at one site. Methodology: To yield insights on teams, teamwork and teaming and AIM3 study features for trial design, AIM1a will complete a systematic review of randomized controlled trials of chronic pain care in primary care settings. To characterize the concept of dynamic teaming and garner insights on teaming for chronic pain in PACTs, 1b will use semi-structured interviews to explore experiences and perceptions of PACT providers, pharmacists, pain specialists, non-pharmacologic providers, and supervisors/leadership (n=45). Building on AIM1 insights and principles and processes of co-design, I will build a logic model 1) of the problem and 2) for the desired change. I will conduct 3) theory-based design and 4) intervention production with providers and Veterans, followed by 5) implementation planning with the practical, robust implementation and sustainability Model (PRISM), and 6) evaluation planning. Patients (n=30) and interdisciplinary PACT teams (n=10) involved in “teaming” around chronic pain management at the VA Palo Alto will be recruited for the pilot of an intervention arm to inform feasibility and acceptably of a subsequent randomized trial. Following this pilot work, I will apply for an HSR&D IIR to conduct a two-arm cluster randomized trial (usual pain processes vs. “teaming” intervention). Implementation/Next Steps: Through the successful execution of this work, we will be prepared to submit a VA HSR&D merit award application for a fully powered trial of the “teaming” intervention in comparison to usual care. The co-design process and resultant teaming intervention will serve as a model to develop strategies to support clinicians teaming in a diverse array of VA settings.

NIH Reporter Project Information:


Journal Articles

  1. Maheta BJ, Singh NK, Lorenz KA, Fereydooni S, Dy SM, Wong HN, Bergman J, Leppert JT, Giannitrapani KF. Interdisciplinary interventions that improve patient-reported outcomes in perioperative cancer care: A systematic review of randomized control trials. PLoS ONE. 2023 Nov 20; 18(11):e0294599.
  2. Giannitrapani KF. Teaming Up With Palliative Care to Improve Perioperative Goals of Care Communication. JAMA Network Open. 2023 Nov 1; 6(11):e2341892.
  3. Giannitrapani KF, Sasnal M, McCaa M, Wu A, Morris AM, Connell NB, Aslakson RA, Schenker Y, Shreve S, Lorenz KA. Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. Journal of pain and symptom management. 2023 Dec 1; 66(6):621-629.e5.
  4. Singh N, Giannitrapani KF, Gamboa RC, O'Hanlon CE, Fereydooni S, Holdsworth LM, Lindvall C, Walling AM, Lorenz KA. What Patients Facing Cancer and Caregivers Want From Communication in Times of Crisis: A Qualitative Study in the Early Months of the COVID-19 Pandemic. The American journal of hospice & palliative care. 2023 Jun 30; 10499091231187351.
  5. Giannitrapani KF, McCaa MD, Maheta BJ, Raspi IG, Shreve ST, Lorenz KA. Serious illness care quality during COVID-19: Identifying improvement opportunities in narrative reports from a National Bereaved Family Survey. Palliative Medicine. 2023 Jul 1; 37(7):1025-1033.
  6. Connell NB, Zupanc SN, Lorenz KA, Bhatnagar S, Fereydooni S, Gamboa RC, Ganesh A, Satija A, Singh N, Spruijt O, Giannitrapani KF. Facilitators of palliative care quality improvement team cohesion: Lessons from a seven-site implementation project in India. Health care management review. 2023 Jul 1; 48(3):219-228.
  7. Garcia R, Brown-Johnson C, Teuteberg W, Seevaratnam B, Giannitrapani K. The Team-Based Serious Illness Care Program, A Qualitative Evaluation of Implementation and Teaming. Journal of pain and symptom management. 2023 Jun 1; 65(6):521-531.
  8. Sasnal M, Lorenz KA, McCaa M, Wu A, Morris AM, Schenker Y, Shreve ST, Giannitrapani KF. "It's Not Us Versus Them": Building Cross-Disciplinary Relationships in the Perioperative Period. Journal of pain and symptom management. 2023 Apr 1; 65(4):263-272.
  9. O'Hanlon CE, Giannitrapani KF, Gamboa RC, Walling AM, Lindvall C, Garrido M, Asch SM, Lorenz KA. Integrating Patient and Expert Perspectives to Conceptualize High-Quality Palliative Cancer Care for Symptoms in the US Veterans Health Administration: A Qualitative Study. Inquiry : A Journal of Medical Care Organization, Provision and Financing. 2023 Jan 1; 60:469580231160374.
  10. Clark JD, Bair MJ, Belitskaya-Lévy I, Fitzsimmons C, Zehm LM, Dougherty PE, Giannitrapani KF, Groessl EJ, Higgins DM, Murphy JL, Riddle DL, Huang GD, Shih MC. Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER), a pragmatic trial for conservative chronic low back pain treatment. Contemporary clinical trials. 2023 Feb 1; 125:107041.
  11. Satija A, Lorenz KA, Spruijt O, Ganesh A, Singh N, Connell NB, Gamboa RC, Fereydooni S, Chandrashekaran S, Hennings T, Giannitrapani KF, Bhatnagar S. : Lessons From Disseminating Quality Improvement Methods Through a Multisite International Collaborative Palliative Care Project in India. JCO global oncology. 2022 Oct 1; 8:e2200147.
  12. Singh N, Giannitrapani KF, Satija A, Ganesh A, Gamboa R, Fereydooni S, Hennings T, Chandrashekaran S, Spruijt O, Bhatnagar S, Lorenz KA. Considerations for Fostering Palliative Care Awareness in Developing Contexts: Strategies From Locally Initiated Projects in India. Journal of pain and symptom management. 2022 Oct 1; 64(4):370-376.
  13. Giannitrapani KF, Holliday JR, Dawson AW, Huynh AK, Hamilton AB, Timko C, Hoggatt KJ. Provider perceptions of challenges to identifying women Veterans with hazardous substance use. BMC health services research. 2022 Mar 4; 22(1):300.
  14. Connell NB, Prathivadi P, Lorenz KA, Zupanc SN, Singer SJ, Krebs EE, Yano EM, Wong HN, Giannitrapani KF. Teaming in Interdisciplinary Chronic Pain Management Interventions in Primary Care: a Systematic Review of Randomized Controlled Trials. Journal of general internal medicine. 2022 May 1; 37(6):1501-1512.
  15. Haverfield MC, Garcia A, Giannitrapani KF, Walling A, Rigdon J, Bekelman DB, Lo N, Lehmann LS, Jacobs J, Festa N, Lorenz KA. Goals of Care Documentation: Insights from A Pilot Implementation Study. Journal of pain and symptom management. 2022 Apr 1; 63(4):485-494.

DRA: Health Systems
DRE: Prevention, Technology Development and Assessment, TRL - Applied/Translational
Keywords: Career Development
MeSH Terms: None at this time.

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