Can an integrated care service (ED PainPATH) improve the value of care for people with chronic pain frequently attending NSW Emergency Departments?

Participants enrolled in the study will be randomly allocated to either the care coordination intervention group or the usual care control group. When a participant is allocated to the intervention group, a referral will be made to the Care Coordination Service, for a Care Coordinator to be assigned and to contact the patient to offer care coordination support. The established care coordination services of the LHD will be used to provide this intervention. The established model of care will be used for the study, with the addition of specific Pain Management Skills Training being provided to the Care Coordinators to enable them to more effectively provide support to study participants. The care coordination intervention is a clinical service provided by Registered Nurses (CNS2) for people with complex care needs requiring integration of their care. It enables integration of the care team (the patient, their carer and their health and social care providers) in the delivery of required care and support. It is a time-limited service, requiring review at 3 months to confirm that needed integrated care and supports are in place, and that the patient and their carer are able to effectively self-manage, prior to discharge from the care coordination service intervention. If further care integration is required the patient can receive an additional 3-month intervention period. Key components of the Care Coordination intervention include: 1. Face-to face baseline consultation at the participant's home, involving completion of a comprehensive clinical assessment. This is anticipated to take between 60-120 minutes in addition to travel time and time for documentation and liaison. 2. Regular (initially weekly then progressing to 'when required') face-to face or telephone consultations aimed at identifying the patients’ care needs and developing a care management plan in consultation with the patient, carer and their healthcare providers. The plan is provided to the patient, uploaded into the patient’s eMR and shared with the patient's General Practitioner (GP). This is anticipated to take between 30-60 minutes but would reduce over time. 3. Care navigation support to assist patients in the identification of health and social care providers, booking of appointments and if required attending key consultations (either face-to-face or via telehealth). Time duration will depend upon the need for travel plus the time in preparation and attendance at the consultation. This would normally reduce as the plan is established but for some patients may need to continue to enable maintenance of their situation. 4. Assisting liaison between GP, hospital, specialists and relevant health/non-health providers. The time spent on this will vary from week to week and the number of healthcare providers involved. The time spent on this is likely to be higher earlier on and may initially require up to 120 minutes. This will reduce once the plan is established. 5. Supporting patients to identify goals and encouraging chronic pain self-management. This would be undertaken during the initial and subsequent sessions. 6. Providing health coaching with the aim to empower patients to feel more confident managing their chronic pain as they work towards achieving their health care goals. This would be provided during the initial and subsequent sessions. 7. Referral to chronic pain specific Multidisciplinary Team services and other services as needed. This would be provided during the initial and subsequent sessions. Fidelity of the intervention will be monitored and evaluated by the research team using the Patient Assessment of Chronic Illness Care (PACIC) tool aimed at assessing the extent to which participants received care coordination and self-management support (implementation fidelity). In addition, qualitative data / narratives will assess whether contextual (patient, clinician or organisational) factors influenced implementation of the care coordination pathway for people with chronic pain.