Reducing the Transition From Acute to Chronic Musculoskeletal Pain Among Older Adults
Reducing the Transition From Acute to Chronic Musculoskeletal Pain Among Older Adults
The investigators have developed a three component intervention to support shared
 decision-making during the early recovery phase for older adults who present to the emergency
 department (ED) or orthopedic urgent care with acute musculoskeletal pain. The first
 component is a brief interactive video to enhance patient knowledge and self-efficacy
 regarding treatment options with the intent of facilitating conversations between patients
 and emergency providers. The second component is a protocol-guided phone conversation
 (telecare) between a nurse care manager and the patient at 48-72 hours following discharge to
 assess pain severity and interference with daily activities, review analgesic use and side
 effects and recovery-promoting behaviors, and discuss adjustments to the patients treatment.
 The third component is communication with the patient's primary care provider following the
 telecare call to inform them of the patient's condition and treatment plan and encourage
 primary care followup. The short-term objective of this project is to test the efficacy of
 this intervention to reduce the transition from acute to chronic musculoskeletal pain among
 older adults and obtain data to inform implementation. The investigators will conduct a
 three-arm randomized controlled trial with adults aged 50 years and older who present to the
 ED or orthopedic urgent care with acute musculoskeletal pain. Patients will be randomized to
 (1) the full intervention (video + telecare + communication with primary provider), (2) video
 alone, or (3) usual care. The primary outcome will be pain, measured longitudinally over the
 course of the year following the acute care visit. Secondary outcomes will include physical
 function, analgesic side effects and adverse events, opioid use, depression and anxiety
 symptoms, sleep duration and quality, and healthcare utilization at one, three, six, and
 twelve months. Secondary analyses will (1) examine whether the intervention has its effect by
 promoting shared decision-making, and (2) estimate the cost-effectiveness of the
 intervention. The long-term goal of this work is to develop, test, and implement
 interventions that improve long-term health outcomes for older adults with acute
 musculoskeletal pain.
Patients will be assigned to one of the three treatment arms using 1:1:1 randomization,
 stratified by access to a primary care provider, using randomly permuted blocks with random
 block sizes. (Primary care access will be determined using Source of Care questions from the
 Primary Care Assessment tool.) Randomization will be based on computer generated lists and
 allocated within subgroups based on access to a PCP using REDCap's integrated randomization
 module. One arm will receive the full intervention (educational video, telecare call,
 transmission of clinical information to the PCP), one will view the educational video only,
 and one will receive usual care. The investigators decided against a 2x2 factorial design,
 which would add a telecare only arm, because our team' s collective understanding is that a
 basic understanding of pain management (as provided by the educational video) is essential
 for effective SDM (shared decision-making) and often missing among older patients. Screening,
 consent, randomization, and assessments will be completed by the study coordinator.
 Interventions

 Educational Video:Development of the original video was funded by the John A. Hartford
 Foundation and used a systematic approach that included a review of literature and current
 pain management guidelines and input from emergency physicians, geriatricians, and experts in
 pharmacology, physical therapy, and risk communication. The video offers information about
 the pharmacologic management of acute musculoskeletal pain (MSP) and recovery-promoting
 behaviors. Each video section is followed by a multiple-choice question to promote
 interaction and reinforce learning. The actress for the 13-minute video is a 56-year-old
 mixed-race woman who presents herself as a healthcare provider. The video script was
 developed for a grade level 5.5 and will be shown to the patient within 24 hours of the acute
 care visit. A link to the video is emailed or texted to the patient.

 Telecare: Telecare will be provided via a protocol-guided phone call from a nurse care
 manager 48-72 hours after discharge. The call is designed to support patient decision-making
 regarding analgesics and behaviors following the content presented in the video. Before the
 call, the nurse will review the note from the index visit to obtain information about
 comorbidities,medications, allergies, and the patient's evaluation and treatment in the ED.
 Topics covered in the call will include discussion of pain management goals and priorities,
 current analgesic use, non-pharmacologic methods of pain management, warnings about potential
 side effects, and open-ended questions to address additional patient care needs.
 Conversations will be guided by an SDM framework in which the nurse elicits information from
 the patient, then discusses with the patient alternative strategies, and actively elicits
 feedback from the patient. Patients will be encouraged to follow-up with their PCP; uninsured
 patients will be referred to local free or low-cost medical clinics. The telecare call is
 designed to last 15 minutes and the nurse will be trained to complete the call in 15 minutes.

 Correspondence with PCP: Following the telecare conversation, the nurse will enter a note in
 the EHR (Electronic Health Record) documenting the patient's current clinical status,
 information reviewed, and any recommendations or referrals made. The nurse will then share
 this note directly with the patient's PCP using a secure e-mail or an electronic message
 within the EHR if the PCP is a University of North Carolina (UNC)-affiliated provider. (If
 the PCP's email address is not available, the research staff will contact the PCP or their
 office by phone to obtain an email address or fax number.) This communication with also
 include: (1) The date, time, location and reason for the initial visit; (2) Results of
 diagnostics studies; (3) Discharge prescriptions/recommendations; (4) A summary of and link
 to the video, explaining the emphasis on patient knowledge and SDM; (5) summary of the
 telecare conversation; and (6) encouragement for follow-up. PCPs will be asked to confirm
 receipt of this message.
Inclusion Criteria:

 -  Age 50 years and older

 -  Present to UNC ED patient with primary complaint of acute musculoskeletal pain

 -  Average pain score >/= 4 on 0-10 scale

 -  Expected discharge from the ED

 Exclusion Criteria:

 -  patient does not speak English

 -  primary pain located in the head, chest, or abdomen

 -  pain due to ischemia, infection, or some other cause not due to MSP (blood clot,
 kidney stone, etc.)

 -  primary pain due to self-injury

 -  patient is critically ill determined by an acuity score of 1 in the tracking board

 -  diagnosis of somatoform disorder, schizophrenia, dementia, or bipolar disorder

 -  patient is a prisoner or in police custody

 -  self-reported daily opioid use for more than 2 weeks

 -  resides in a nursing home or is homeless

 -  at-risk alcohol use

 -  speech, hearing, vision problems

 -  cognitively impaired (6-item Brief Screener)

 -  nonworking phone number (follow-up occurs via phone calls)