Event 3: Patient-Centered Medical Homes

Patient is at the Center

Patient is at the center of an comprehensive and integrated healthcare delivery system

Patient-centered home medical care
Patient-centered home medical care

Accessible Information Hub

There is an accessible information hub that aids providers in delivering effective care

Accessible information hub
Accessible information hub

Coordination with Family and Other Supports

System works effectively in coordination with family and other supports.

Family and other support
Family and other support

Patient is Always at the Center

Patient is always at the center
Patient is always at the center

Primary Care Provider

The primary care provider outlines and follows up on comprehensive care plan.

Primary care provider outlines and follows up
Primary care provider outlines and follows up

Benefits of Comprehensive Care

  • Less sedation and cognitive impairment
  • Improved long-term health
  • Fewer adverse effects of medication
  • Less reliance on opioids
  • Higher patient satisfaction
  • Higher levels of good functional outcomes

Pain Treatments

Pain treatments: active utilization of specific non-pharmacological therapies as appropriate.

Non-pharmacologic treatments
Non-pharmacologic treatments

Patients Should Take an Active Role

Encourage patients to take an active role in pain management: document and follow up on recommendations.

The Spectrum of Care

Treatments for pain vary with the situation: Sometimes dominated by the patient’s symptoms and sometimes by the specific diagnosis.

Spectrum of care
Spectrum of care

Mechanism-Based Classification of Pain

Mechanism-Based Classification of Pain
Mechanism Nociceptive Inflammatory Neuropathic
Non-pharmacologic treatments

Ice and cooling




Moderate exercise




Pleasant activities

Pharmacologic choices for mild-moderate pain Standard anagelsics NSAIDs Neuromodulating
Pharmacologic choices for moderate-severe pain Opioids, local anesthetics, nerve blocks

Disease modifying


Multi-drug regimens


Parallel Path Model of Pain Intervention

‘Parallel path’ model of pain intervention: diagnosis and treat in parallel.

Parallel path model of pain intervention
Parallel path model of pain intervention

The Four ‘A’s of Follow-Up

For the patient with chronic pain, it is very important to balance analgesia with other goals of treatment.

Four As of follow-up
Four As of follow-up

Chronic and Persistent Pain

Motivational interviewing for Behavior Change

  • Readiness for change
    • stages of change model
    • tailoring actions to stage of change
  • Commitment
    • ascertain values, talk values
  • Confidence
    • foster confidence, talk small steps
  • Strategies for difficult moments
    • Express empathy
    • Develop discrepancy
    • Roll with resistance
    • Support self-efficacy

Stages of Change Model

Enduring value

Stages of Change Model
Stage in Model Patient Characteristics Other Models

Not considering change

Resignation (no control)

Denial (not relevant)

Concern - low

'locus of control'

'health beliefs'

Motivational interview

Contemplation Weighing benefits/costs Motivational interview
Preparation Experimenting with change


Motivational interview

Action Taking steps to change 12-step
Maintenance Maintaining behavior 12-step

Normal part of process

Feels demoralization

Motivational interview

Core of Motivational Interviewing

Assess readiness to change.

  • Pre-contemplative 
  • Contemplative 
  • Preparation
  • Action 
  • Maintenance 
  • Relapse

Provide support and counsel that is stage appropriate.

If pre-contemplative

  • talk about what patient values to discover what’s important to them
  • frame the risks and benefits of potential change in terms of the values expressed by the patient

If contemplative

  • Ask about the commitment to change
  • Ask about their confidence to change
  • Use information about patients values to boost commitment
  • emphasize negatives that are most worrisome
  • emphasize benefits that are most valuable
    • e.g. teens typically worry about white teeth, middle-aged adults worry more about cancer
  • Use brainstorming to find small steps would boost confidence
  • Ask about what ideas the patient has or has tried
  • Propose some small steps that you think might work well
  • Make sure to check back on progress

If in preparation stage:

  • Provide support with specific therapies, e.g. PT, CBT
  • Provide ideas for substantive positive changes 
    • (e.g. a new program of moderate exercise)
  • Continue to support motivation: commitment, confidence
  • Use affirmation and encouragement

If in action stage:

  • Ask about how the change is going
  • Support the patient by addressing side effects, problems
  • Suggest ways to avoid challenging situations
    • (e.g. ask for help with lifting heavy objects)

If in maintenance stage:

  • Ask about the behavior briefly
  • Determine if challenges are present and aid if possible.

If in relapse:

  • Express empathy- ‘Change is difficult but it is really important that you’ve already started’
  • Develop discrepancy – ‘How is this different from your goals?’ ‘Is this what you really want?’
  • Roll with resistance – stop pushing and reflect on patient’s standpoint (‘It sounds like this is really difficult’)
  • Support self-efficacy - Encourage the patient to take up change once more, e.g. ‘I really believe you can…’


Miller WR, Rollnick S. Motivational interviewing: preparing people for change (2nd ed.) Guilford Press, 2002.


  • The patient-centered medical home model is well-suited to providing comprehensive care to patients with pain.
  • Physicians have a very important role in caring for patients with pain in the context of the medical home model: anticipating pharmacological and non-pharmacological treatment needs, adapting treatment to respond to patient and diagnosis, and employing an parallel pathway approach to commence pain-relieving treatments while diagnostic testing is underway are essential components.
  • Motivational interviewing is an valuable skill for physicians to develop in order to promote positive changes in patient behaviors in the context of a chronic illness model.
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