Supporting Veterans With Chronic Pain: Using 5As Framework to Improve Self-Care

Introduction: Active-duty military personnel and veterans are disproportionately affected by chronic pain. More than 50% of veterans’ report pain in primary care. Human Rights Watch, 2014 states that conventional pain management includes prescription opioids and lack emphasis on self-care management. A multimodal approach is needed to support self-management, improve quality of life, and decrease pain. Glasgow, Emont, & Miller, 2006's the 5A’s is an evidence-based approach shown to improve self-care management, consisting of “Ask, Assess, Advise, Assist, Arrange”. Development of a patient-centered care plan and goal for follow-up allows for continued monitoring of treatment effectiveness and compliance.

Objectives: To implement a Nurse Practitioner (NP) telephone follow-up guided by the 5A’s framework among veterans with chronic pain in a primary care setting. This pilot evidence-based project aimed to improve follow-up of self-care management in order to decrease pain, increase quality of life, and decrease pain medication use.

Methodology: The Iowa Model of evidence-based practice guided this project. Baseline data was retrieved from 26 medical records of veterans with chronic musculoskeletal pain from September 2015 to June 2016. The pilot project was implemented from June 2016 to November 2016 among a total of 14 veterans. A monthly telephone follow-up using the 5A’s framework was made by NP, which reinforced self-care, developed patient-centered goals, and established a follow-up plan. Outcome data was collected monthly including pain scores (Numeric Pain Rating Scale), quality of life scores (American Chronic Pain Association Scale), and number of pain medications. After 3 months, average pre/post intervention data was analyzed to evaluate project effectiveness.

Results/Outcomes: Evaluation of pre/post project implementation data among 14 veterans revealed a decrease in average pain scores from baseline, an increase in average quality of life scores, and no significant change in average pain medication use. Average pain scores decreased 1.44 from baseline (95% confidence interval, .605, 2.27) and was statistically significant at p < .003. Averagē quality of life scores increased 2.08 (95% confidence interval, 1.0, 3.15) and was statistically significant at p < .001. 13 out of 14 veterans (93%) completed all 3 telephone follow-ups.

Conclusions:This pilot evidence-based project revealed a monthly NP telephone intervention may improve overall quality of care among chronic pain veterans. Results illustrated a decrease in average pain scores, increase in average quality of life scores, and no significant change in average pain medication use compared to baseline. The intervention also improved follow-up compliance. Limitations include length of study and timing of project implementation due to variable schedules of veterans and provider. Future research is warranted and may consider using scheduled telephone follow-up appointments that are incorporated into the schedule in order to improve project plan process.

Implications for Clinical Practice:

5A’s is an evidence-based framework that may be adapted to promote self-care of chronic pain and establish goals for follow-up in a primary care setting. The use of telephone intervention may potentially serve as a substitute for routine chronic pain follow-up visits or as a supplement to improve quality of care for veterans. The results aim to provide further insight and new knowledge on ways to continuously improve pain management among the veteran population, allowing them to return to their baseline quality of life as closely as possible.