From Insight to Action: The Evolution of Our 4-Step Chronic Pain Program

Chronic pain affects millions of Australians and has a profound impact on daily life, healthcare systems, and the economy. Our journey to develop a community-based, multidisciplinary chronic pain program began with a personal experience that highlighted both the challenges and possibilities of managing chronic pain outside specialist, inpatient settings.

The Spark: Personal Experience

In 2004, my wife experienced a car accident that led to the development of chronic pain. Over the following decade, she navigated a complex journey of treatments, including medications and procedures, and participated in two specialist pain management programs. A significant turning point came through a neurostimulator implant, which, once adjusted to high-frequency stimulation, provided meaningful relief. Alongside this, participation in a multidisciplinary pain program demonstrated the powerful impact of coordinated care, education, and patient engagement.

While these specialist services were life-changing, they also raised a question that shaped the next chapter of our work: why could this model of multidisciplinary pain care not be delivered in the community?

From Pilot to Program: Iterations of Learning

The first iteration of our program included an initial clinical assessment, followed by workshop-based group education, with patients guided to access community-based allied health support according to their individualised pain plan. This pilot allowed us to test the structure and materials, gather essential feedback from both patients and clinicians, and evaluate clinical outcomes.

In the second iteration, funded by health, we were able to include a budget to purchase allied health support for patients in the community. While clinical outcomes remained consistent with the pilot, this approach enabled us to engage with and build a network of allied health providers who were willing to adopt an active self-management ethos.

The next evolution, driven by the needs of patients unable to attend workshops in person and the challenges faced by rural and remote communities, led to the creation of the 4-step model. This approach ensures that patients can access timely, flexible, and individualised support without compromising the multidisciplinary principles demonstrated to be effective, while retaining the elements most valued by both patients and clinicians.

The 4-Step Model

The 4-step model combines the lessons learned from previous iterations and feedback:

1. Self-Directed Education – Free, online, and accessible to all patients with a GP referral, using proven material from previous programs.

2. Clinician-Guided Learning – Retains small group workshops supported by allied health professionals, while adding the individual pathway, allowing patients to commence anytime with seven one-on-one consults with members of the multidisciplinary team.

3. Multidisciplinary Assessment & Planning – Collaborative care planning with GPs, physiotherapists, pharmacists, and psychologists, unchanged from prior iterations.

4. Ongoing Support & Monitoring – Introduces a coaching option for follow-up and goal tracking, maintaining progress and adapting care via periodic GP case conferences. Expansion of allied health support options via the directory continues to grow as the network of allied health providers expands.

   
   

Throughout this journey, my background in education (vocational and adult learning) and my wife’s experience as a trained nurse helped shape the program’s structure, pedagogy, and clinical grounding. We also benefited from guidance from an experienced pain specialist, a broad group of GPs, researchers, and allied health providers, ensuring the program reflects evidence, clinical insight, and lived experience.

In 2024, this program was recognised with the award for Best Multidisciplinary Care Program, validating the impact of our approach and the collaborative effort behind it. At every subsequent iteration, we have ensured that the elements valued by both patients and clinicians, which contributed to this award-winning outcome, have been preserved, even as we adapted the program to increase access, flexibility, and reach.

Working with Primary Care

From the start, our aim has been to ensure the program works seamlessly with GPs in primary care, providing an early option for multidisciplinary care. This approach complements specialist interventions rather than challenging them, recognising that specialist services can take time to access. Our solution provides a useful stepping stone, enabling patients to receive timely, coordinated support while waiting for or alongside specialist care.

Looking Ahead: Accessibility, Collaboration, and Innovation

Our mission is to bring effective, patient-centred chronic pain care closer to home, removing barriers to timely access, providing solutions that complement GP care, and empowering patients to manage their pain in partnership with clinicians.

Ahead of International Pain Awareness Month this September, we have updated our website to reflect the new 4-step model of care, including a pathway for free access to our online “Pathways to Pain Management” program.

Chronic pain affects millions of Australians, and the economic cost is estimated at $139 billion per year, including healthcare costs, lost productivity, and reduced quality of life. With the prevalence of chronic pain continuing to rise across all age groups, these costs are projected to exceed $200 billion by 2050. Meeting this growing need requires innovative solutions that work alongside existing services, contributing to a cohesive national pain management ecosystem.

We believe that community-based programs like ours can help address this growing need, but system-wide collaboration will be crucial to making a meaningful impact.

We invite patients and clinicians alike to explore the new 4-step model, designed to provide accessible, evidence-based support and to integrate smoothly with existing care pathways, in particular the new GP Chronic Condition Management Plan (GPCCMP).

Learn more about the 4-step model in this quick video overview, see how it works for patients and clinicians alike

Access Free Online Program