Table 1 Overview of Training Sessions for Primary Care Providers (PCPs) in Intervention Clinics

Session 1

Introduction

Physician leader of the back pain care quality improvement project introduced the researchers, the rationale and importance of reorganizing care for back pain and overview of the project aims and activities. Focused on getting clinicians to support the project and excited about the opportunity to improve back pain care in their clinics. Introduced the STarT Back tool and risk stratification strategy.

Session 2

Using the STarT Back Tool

Focused on getting PCPs and staff comfortable with administering the STarT Back approach, including use in the EHR (EPIC), scoring of tool, and understanding matched treatment recommendations for each risk level. Discussions of how to find and use the GH Back Pain Guidelines, attach the STarT Back tool in secure messages to patients, enter patient responses into the EHR, view results, use tools within the EHR to enhance visits for back pain such as patient instructions and ordering patient centered back pain (acute and chronic) DVDs.

Session 3

Improving Diagnosis and Ruling out Red Flags

Check-in on clinic’s use of the STarT Back tool. Used patient case examples to provide a “refresher” on how to conduct differential diagnoses of common back pain problems (focused on lower back, L2-L4, L5, S1). Reviews included how to conduct an efficient exam, common errors in examinations, appropriate use and interpretation of diagnostic imaging, red flags for serious conditions, how to communicate to patients during the examination.

Session 4

Talking with Patients about Chronic Pain

Training focused on ways to communicate more effectively with patients about chronic pain including: 1) preferred language in discussing pain, 2) ways to better communicate anatomical links to pain, 3) explaining what chronic pain is (pain centralization, gate theory, reoccurrence of pain – having continued pain with no injury), 4) talking about red flags and when to return to primary care, 5) focusing on improving function rather than reducing pain, and 6) how to discuss outcomes from the STarT Back tool and shared decision making around treatment options.

Session 5

Improving Partnership between PCPs and PTs

This session brought together PCPs and PTs for an interactive discussion on how to improve team based care for patients. Topics included: how PT was providing improved care based on training, shared responsibility and roles of providers, how to integrate the STarT Back tool across the departments, and how to collaboratively work together to help patients not showing improvement.

Session 6

Complementary and Alternative Medicine Treatments for Chronic Back Pain

Focused on building an understanding of the role that CAM providers (acupuncturists, chiropractors, massage therapists) and yoga classes can play for back pain patients. Emphasized practical information: brief description of each CAM modality, scientific evidence for their effectiveness, contraindications, dosing. CAM therapies referrals were linked to STarT Back tool risk category, emphasized the use of active over passive therapies, and how to conduct referrals within the healthcare system.