Since early this year, the Bree Collaborative has been looking at ways to best organize care to support people with chronic pain. One of the systems with the best evidence is through collaborative care. Collaborative care is based in primary care and uses a team-based care model with a care coordination or care management function, often supported by health information technology infrastructure, and involves the patient often through self-management.

These types of organized care are based on models of managing chronic illness, one of the first, the chronic care model, developed right here in Seattle at the Group Health Research Institute. The Advancing Integrated Mental Health Solutions (AIMS) Center defines five principles of Collaborative Care including a patient-centered care team, population-based care like tracking patients in a registry, measurement-based treatment to target such as measuring clinical outcomes and patient goals, evidence-based care, and accountable care or providers being reimbursed for quality not volume. We used many of these elements when we looked at the best ways to integrate behavioral health into primary care – you can see those recommendations here.

Literature reviews such as those done by the Veterans Administration find that many of the elements identified as being helpful to integrate behavioral health into primary care are also important to support patients with chronic pain in primary care. These include having decision support to help providers, supporting care coordination resources like a care manager, involving the patient in care through education and activation, and access to multi-modal care.

Do you have experience with chronic pain in primary care? What do you want to see from your providers? Let us know at

Ginny Weir, MPH
Program Director, Bree Collaborative