Project STEP-ing Out

Study Name: 
Project STEP-ing Out
Study Period: 
October 1, 2010 to September 30, 2013
Mayday Foundation; Cox Foundation (1 year support for Project ECHO®); Wallace Fund (1 year support for Project ECHO®)
Principal Investigators: 
Daren Anderson, MD

The objective of this study was to conduct a comprehensive formative assessment of chronic pain management in a large, multisite community health center and use the results to design a quality improvement initiative based on an evidence-based practice model developed by the Veterans Health Administration. Improving quality and safety by incorporating evidence-based practices (EBP) is challenging, particularly in busy clinical practices such as Federally Qualified Health Centers (FQHCs). FQHCs grapple with financial constraints, lack of resources and complex patient populations.

The Promoting Action on Research Implementation in Health Services (PARIHS) Framework served as a basis for the comprehensive assessment. We used a range of measures and tools to examine pain care from a variety of perspectives. Patients with chronic pain were identified using self-reported pain scores and opioid prescription records. We employed multiple data collection strategies, including querying our electronic health records system, manual chart reviews and staff surveys.

We found that patients with chronic pain had extremely high primary care utilization rates while referral rates to pain-related specialties were low for these patients. Large gaps existed in primary care provider adherence to standards for pain care documentation and practice. There was wide provider variability in the prescription of opioids to treat pain. Staff surveys found substantial variation in both pain care knowledge and readiness to change, as well as low confidence in providers’ ability to manage pain, and dissatisfaction with the resources available to support chronic pain care.

Improving chronic pain management at this Community Health Center requires a multifaceted intervention aimed at addressing many of the problems identified during the assessment phase. During the intervention we will put a greater emphasis on increasing options for behavioral health and complementary medicine support, increasing access to specialty consultation, providing pain-specific CME for providers, and improving documentation of pain care in the electronic health records.


With this model, we hope to improve provider knowledge about pain management and adherence to standards of care, and improve primary care team adherence to pain management standards of care.


Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary Care: A First Phase of a Quality Improvement Initiative at a Multisite Community Health Center. Quality in Primary Care. 2012;20:421-433.

Tian et al 2013 - Refined ICD9 Code List

Sub-Project: Validated Algorithm to Identify Patients with Chronic Pain

Sub-Project: Integration of Chiropractic Services to Improve Treatment of Chronic Pain in a Community Health Center