INTRODUCTION: The opioid crisis has highlighted the needs for more effective pain management. Integrative|multidisciplinary pain programs are effective, but are not widely available. A native Alaskan primary care (PC) group had successfully implemented an opioid reduction and MAT programs, but were unsuccessful sustaining an integrated pain program. A new approach was piloted by addressing three issues: 1) patient reluctance to go behavioral health due stigmatization; 2) the need for a care paradigm whose language helped integrate PCs, rehabilitation services (RS), behavioral health (BH) and nurse providers around the patient and their care ROADMAP; 3) the limitations in teaching and care-coordination resources to support patient self-management.
PRACTICE CHANGE: Three strategies addressed the above issues: 1) BH came to the RS department where they joined a pain specialist, nurse, and physical therapist for a team history, clinical evaluation and patient collaborative decision-making; 2) a Patient Perspective Pain Paradigm (PPPP) was developed and unified providers with their patient in their joint assessment of pain’s five components (PFC) and in the development of a care plan balanced between active and passive therapies; 3) BH offered care management and education to helped patients follow their care ROADMAP through the phases of illness to living well.
AIM & THEORY: Our aim was to change care from a provider-centered|episode-based process, to a patient-driven|performance-based process that looked at five components of pain and taught self-management.
POPULATION & TARGET: Patients and representatives, PC providers, BH directors and therapists, RS director and therapists, a specialty consultant and board director contributed to the pilot program development serving one clinic.
TIMELINE: Tasks accomplished between May 2018 to May 2019 were: setting goals based on the system’s strategic plan; assessing needs; delivering BH pain-care in the RS department; creating care ROADMAP templates for patients; modifying scheduling, documentation and billing templates; selecting screening questionnaires; scaling the care management service.
HIGHLIGHTS: Referred patients were hesitant, but afterwards they: 1) felt heard and became engaged in their own care; 2) gained new insights about the components to their pain; 3) agreed to participate in the BH groups; 4) care management became financially viable and scalable because of BH involvement.
SUSTAINABILITY & TRANSFERABILITY: Important factors for sustainability will be: 1) Access to TeleMed pain care in remote villages; 2) Centralization and standardization of BH care management to support patients and care teams; 3) Standardization of post-acute and chronic pain evaluations allowing personalized care ROADMAPS.
CONCLUSIONS: Integrated care teams helped patients feel heard, appreciate the comprehensive evaluation framework, and engage with their self-management opportunities around: movement-function, inflammation, nervous system sensitization, autonomic visceral activation, and cognition patterns. They committed to an active greater than passive care plan and a ROADMAP to lead them through illness phases: crisis to self-confidence; acceptance to living well.
DISCUSSION: Problem areas implementing an integrated pain evaluation program included: scheduling, billing, interprofessional communication, patient reluctance and care-management discontinuity. Nearly all chronic pain patients meet BH diagnostic criteria necessary for CM services.
LESSONS LEARNED: Collaborative development needs to fit within the organization’s structure and payor regulations.

Knee and hip osteoarthritis is linked to hip and knee pain, but this is only part of the picture. Excessive weight, weakness, stress and environmental factors are modifiable factors that also play a role. Substantial evidence exists for non-operative management of the osteoarthritis hip and knee prior to considering surgery. However, limited access to health and lifestyle assessment and services for non-operative management of joint pain means this chronic condition is often poorly managed by pharmaceutics and long waiting periods for specialist review and surgery.

The Tweed Community Health Knee and Hip Arthritis Service was developed in partnership with North Coast Primary Health Network, Orthopaedic Specialists, General Practitioners and the local Community Health services. Also supported by the Agency for Clinical Innovation (ACI). It provides seamless, person centred care through partnership across primary and public service providers. Timely and evidence based assessment and intervention, is provided to reduce pain and reverse functional decline, and where appropriate, avoid joint surgery. Emphasis is on patient empowerment through better understanding of their condition and support for self-management. GP’s and surgeons are provided with a holistic-health report and recommendations to better manage their clients joint pain. This includes standardised Patient Related Measures for physical fitness and function, quality of life, weight and other findings early in the disease process. Ongoing monitoring and progression of patients over a 6-9 month period facilitates sustained improvement and ‘hard-wiring’ of health and lifestyle changes.

Key determinants of a patients need for joint replacement surgery are pain and function. After 3 interventions over 3 months outcomes were as follows. (n=131)
Function Score (Oxford):
• 73% improved, average improvement of 6 points from moderate-severe (24/40) to mild-moderate impairment (30/40)
Pain score (out of 10):
• 69% improved, average pain changed from high-moderate (5.8/10) to low-moderate (3.9/10) range.
At completion of the program at 6months (n=93):
• 2 out of 3 patients said their walking on flat ground had improved
• 2 out of 3 patients said their hip or knee had in general had improved
A review of patients at 6 to 18 months after leaving the program (n=130):
• 4 out of 5 remained NOT on a waiting list for joint surgery
A mail out survey for patient 6 month after completing the program (n=37)
• 78% said their ‘day to day’ activities were easier now than before attending the SOS Clinic
The Knee and Hip Arthritis Service is based on the ACI Osteoarthritis Chronic Care Program Model of Care which targets patient waiting for joint replacement surgery. Our service demonstrates this this model of care can be successfully implemented and sustained from a Primary Health referral base and not rely on a service entry point at placement on a public health joint replacement waiting list. It has been operating for over 2 years with consistent flow of Specialist and General Practice referrals. We have learned collaborative engagement, and using Redesign methodology can be successful in implementing change to clinical referral and practice management in the Primary Health setting.

Introduction
Implementation and spread of health coaching is a priority of the South Eastern Sydney Local Health District (SESLHD) Integrated Care Strategy. Health coaching is supported by literature showing improvements to lifestyle behaviours, physical and mental health.
SESLHD initially implemented health coaching throughout the District by providing externally delivered training programs for healthcare professionals. Program evaluation showed 44% of training recipients were unable to implement or provide regular coaching, resulting in lost opportunity to improve patient care.

Practice change implemented
Surveys, interviews, workshops and focus groups were conducted with healthcare providers and consumers. This identified issues and root causes, allowing for generation of the following solutions:
1. Develop and spread a standardised definition of health coaching
2. Enhance training and support models
3. Provide access to online resources
4. Develop and implement an ongoing evaluation framework

Aim and theory of change
A project team was established to improve the translation of health coaching training into every-day clinical practice. Improvement methodology was used to develop and implement sustainable change processes.

Targeted population and stakeholders
The health coaching program is available to all care providers within SESLHD and local Primary Care.

Timeline
The project commenced in April 2017, with solutions implemented in February 2018. Evaluation will be completed in 2019. Results will be used to refine solutions and enhance the program through to June 2022.

Highlights
The health coaching program has been redesigned in response to identified issues and participant needs. The redesigned program is delivered by SESLHD subject matter experts over a four month period, with a significant increase in practice opportunities. This enables all participants to embed skills whilst receiving support, significantly increasing implementation of health coaching into clinical practice.

Sustainability
The sustainability of the previously commissioned model is equal to the redesigned model which provides significantly improved outcomes. Phase 2 of the project is due to commence in July 2019 which will focus on sustainability.

Transferability
With local adaptations, solutions developed throughout this project are likely to be highly transferable.

Conclusions
A generic training program is insufficient to achieve wide-spread implementation of health coaching into clinical practice. Reasons for this need to be understood within the local context and requires solutions to be co-designed with participants.

Discussions
The majority of healthcare providers recognise the benefits of health coaching and support its use. Coaching recipients value the effect of coaching, stating it needs to occur throughout the continuum of care. In order to implement health coaching into practice, many organisations commission the delivery of externally provided training programs. This project has shown that such training is not always effective in allowing the successful translation of training into practice.

Lessons learned
Implementation and sustainable delivery of health coaching is complex. It is influenced by many factors which are not adequately addressed by the mere prevision of health coaching training. Significant investment should be made in planning and supporting the translation of health coaching training into practice.

Introduction: A way of re-orienting the model of care is needed to provide efficient and effective healthcare services using the primary and community care services. Strategies for coordinating services focus on ways of reducing the fragmentation of care delivery through improving continuity of care and relationships with people. The Nursing Centre (NC) was initiated as a continuity of care model to improve self-management of hypertensive patients. The aim of this study was to analyse the effectiveness of intervention in the NC to improve self-management of hypertensive patients in Indonesia.
Methods: This research used a pre and post-test with control group design. The treatment provided was a package of intervention within one of the nursing centre in Bandung, Indonesia. The sample was 35 people in the intervention group and 33 people in the control group. Data collection was conducted from May to June 2018 using Hypertension Self-Management Behaviour Questionnaire (HSMBQ). Treatment group was given intervention in the NC in accordance with self-management of hypertension protocol. Intervention in the first week was conducted in the NC, followed by home visits once a week for three weeks. The data were analysed using RASCH model, paired t test, and independent t test.
Results: The RASCH model analysis showed the mean “logit” of pre-test in treatment group increased from -0.46 (SD=0.45) to +2.56 (SD=1.04) after receiving intervention in nursing centre model. Mean person measure (logit) of control group increased from -0.41 (SD=0.36) in the pre-test to -0.30 (0.38) in the post-test. The mean of self-management scores for intervention and control group were 62.71 (SD=19.831) and 61.27 (SD=16.457) respectively, which both included as a low level of self-management. The mean score of hypertension self-management after treatment in the intervention group was 131.26 (SD=12.106) which is in a very good level, while the mean of post-test score of self-management in the control group was 65.42 (SD=14.078). There was a significant difference of hypertension self-management among patients who received intervention within the nursing centre compared to those who in the control group (p=0.000).
Discussion: the increased of hypertension self-management behaviour in the intervention group occurred because the NC was designed according to framework of 4Cs (completeness, collaboration, coordination, and continuity). We argue that this 4 Cs intervention led by nurses in the NC is more effective to improve hypertension self-management rather than in a regular treatment. In this way, patients and their families would become active participants in their own care planning and implementation.
Conclusion: The intervention in the NC is effective to improve self-management of hypertensive patients in Indonesia
Lesson Learned: Completeness, collaboration, coordination, and continuity of care are important to improve self-management of patients with hypertension as the most common chronic disease in the world.
Limitations: This study was conducted in one area in Indonesia so even though the results could not be generalised, the findings are likely to be applicable within similar settings.
Suggestions for Future Research: Research is needed to examine the effectiveness of the intervention in the NC for other chronic disease self-management.