The 3Cs Framework for Pain and Unhealthy Substance Use: Minimum Core Competencies for Interprofessional Education and Practice

 

Background

In 2018, the National Academy of Medicine’s (NAM’s) Action Collaborative on Countering the U.S. Opioid Epidemic was established to catalyze public, private, and nonprofit stakeholders to develop, curate, and implement multi-sector solutions designed to reduce opioid misuse and improve outcomes for individuals, families, and communities affected by the opioid crisis (NAM, n.d.). The Action Collaborative’s diverse members work together to advance initiatives organized into the following priority areas, which are also the focus of its work groups: health professional education and training; pain management guidelines and evidence standards; prevention, treatment, and recovery services; and research, data, and metrics needs.

Specifically, the Health Professional Education and Training Work Group authored a Special Publication in 2021 titled Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic (Chappell et al., 2021). This Special Publication analyzed professional practice gaps (PPGs) across five professions and the current requirements landscape pertaining to pain management and substance use disorder (SUD) care. The results of the analysis elucidated highly variable education needs and requirements and an underlying urgency for harmonization across the broader health system. To address unwarranted variation and accelerate action around shared goals, the Special Publication highlights five priorities for health education and training stakeholders to catalyze substantive and lasting change in the opioid crisis response. The first of these five priorities is to establish minimum core competencies in pain management and SUD for all health professionals and support evaluation and tracking of health professionals’ competence. Minimum core competencies aim to set a standard for the minimum level of competence expected from all health care professionals and should help systemize tracking and evaluation of appropriate competence in pain management and SUD care.

To advance this priority, the Education and Training Work Group developed a core competency framework for pain management and unhealthy substance use care, including SUD care. The core competency framework describes the knowledge, skills, attitudes, qualifications, and behaviors that are needed to address PPGs across pain management and unhealthy substance use care and can strengthen the delivery of coordinated, high-quality, and person-centered care. Additionally, the framework acknowledges commonalities shared between pain and SUD while recognizing both as separate and multifaceted conditions with potential intersections. Given that affected individuals often have complex health and social needs, the competency framework is designed to help health care professionals and the broader health system understand the interrelation and aspects of both conditions independently, collectively, and contextually (Gatchel et al., 2014; Saitz et al., 2008).

The core competency framework aims to improve pain and unhealthy substance use care by building upon previous frameworks, emphasizing interprofessional team-based care, and supporting the advancement of innovations across the health professions. For the purpose of this work, the framework’s reliance on context is adapted from the Interprofessional Consensus Summit’s work on advancing pain curricula, specifically the need to reduce emphasis on learners acquiring factual knowledge and increase emphasis on learners’ “capacity to act effectively in complex, diverse, and variable situations” (Interprofessional Education Collaborative, 2016).

 

Framework Scope and Overview

The core competency framework is comprehensive and interprofessional in its construction and aims to inform a standard that can be adapted to different professions, settings, and contexts. The content of the framework includes distinct foundational concepts that apply to pain, unhealthy substance use, relevant mental health conditions, and any potential intersections. To address PPGs and ensure health care professionals demonstrate competence in these domains, concepts included in the framework should be incorporated into education, training, and evaluation across the continuum of a health professional’s career. While the implementation of the competency framework will help to close PPGs, it may also serve as a foundation for health care professional practice and lead to improved patient- and family-centered care and community partnerships, strengthened interprofessional coordination and collaboration, and enhanced readiness and responsiveness of the health care system (Interprofessional Education Collaborative Expert Panel, 2011). Notably, the framework outlines domains, general competencies, and supporting sub-competencies, not specific or prescriptive competencies. This is intentional, as the framework should serve as a tool for strengthening existing competencies or developing new competencies as needed and can guide updates to current requirements and standards.

The framework incorporates key components of the knowledge, skills, and attitudes needed to define qualifications and behaviors that will better prepare all health professionals across the continuum to address pain and unhealthy substance use (Baker et al., 2003; Salas and Cannon-Bowers, 1997; Cannon-Bowers et al., 1995; AHRQ, n.d.). These baseline components are summarized into a core list of three broad, interprofessional performance domains, with general competencies and sub-competencies under each that can be used to support or develop profession- or specialty-specific competencies as needed. In addition to seeking to address PPGs and improve quality care, the domains and competencies also serve as a bridge for disciplines that lack sub-specialization in pain management, such as dentistry and orofacial pain, or disciplines with emerging specialties, such as pain psychology. The framework is designed to be simple, practical, and widely applicable across health professions and the continuum of education and training.

 

Development Process

Developing the core competency framework was an iterative process that started with a broad environmental scan of existing competency frameworks and curricula on pain- and SUD-related topics. Action Collaborative members and their respective networks provided a diverse sample of 25 curricular formats (guidelines, standards, recommendations, educational blueprints, and systemic reviews) intended for a range of professions and disciplines across the pre-licensure and post-licensure education and training levels. These disciplines included allopathic, osteopathic, dental, pharmacy, nursing, social work, psychology, psychiatry, and physical therapy. The main focus areas of the existing curricular formats included acute and chronic pain management, SUD treatment, opioid prescribing, mental/behavioral health, prevention, and a range of other topics that were profession- or specialty-specific or interdisciplinary topics within the realm of pain and SUD care.

Core content, domain categories, and structural organization from the sample frameworks were summarized into a table (see Appendix A) and further analyzed for overlapping themes, gaps, and key takeaways (see Appendix B). The content of the frameworks was then mapped to the PPG findings from the Special Publication to identify cross-cutting themes. Members of the Education and Training Work Group developed an initial list of domain areas that were then expanded, using the results from the environmental scan and the subsequent thematic analysis. The resulting content was organized into domains, general competencies, and sub-competencies. The domains and general competencies were largely chosen based on their relevance to and inclusion in existing frameworks (AHRQ, 2019; Interprofessional Education Collaborative, 2016). Sub-competencies were developed to address educational needs across pain management and unhealthy substance use care. The development of the domains, general competencies, and sub-competencies was an iterative process, as over 10 drafts were reviewed by members of the Education and Training Work Group and further refined and reorganized based on their input. Once the content of the general competencies and sub-competencies was determined, the domains were further refined into interprofessional performance domains. The general competencies were then mapped to the domains, which collectively indicate competence. These components, along with foundational concepts of partnership, learning, collaboration, and continuous improvement were assembled to create a framework.

The draft core competency framework was then presented and discussed during a series of closed listening sessions hosted by the Action Collaborative. The purpose of the listening sessions was to gather feedback from a range of end-users and health care stakeholders on the clarity, content, and usability of the framework. Each listening session included a broad and diverse set of practicing health care professionals and health system stakeholders involved in developing, implementing, and measuring clinical competencies, as well as clinicians currently in training and individuals with pain and SUD lived experience. Feedback from the listening sessions was summarized and used to further refine the framework. The updated framework was again presented to members of the Education and Training Work Group, who helped further refine and finalize the subcompetencies and core elements of the framework.

 

 

Framework Structure and Content

The resulting framework is centered on partnering with patients, families, and communities, which includes but is not limited to engaging in shared decision making, learning with and from patients and families, and including lived experience perspectives in education and continuous improvement (Dokken et al., 2021; SAMHSA, 2021; Dardess et al., 2018; Baker et al., 2003). A key aspect of partnership in pain and unhealthy substance use care requires clinicians to recognize their patients’ unique circumstances and foster solidarity in overcoming challenges to “meet patients where they are” (Fishman et al., 2013; Sartorius, 2002; Cannon-Bowers et al., 1995). An inclusive definition of “family” is central to ensuring functional and fruitful partnerships and should be based on patients’ preferred definition of family. This concept of partnership is built on the importance of patient and family involvement in ensuring and maintaining safety and high-quality care, as well as improving health outcomes (Dokken et al., 2021; Dardess et al., 2018). Similarly, in this context, community engagement embraces an expansive definition of community. Community should include feelings of association due to shared attitudes, interests, goals, or geographical space, which can create or facilitate systems of support for information or resource exchange (Simona Kwon et al., 2017). Recognition of patients and families as part of broader communities is critical to effective engagement and partnership.

In addition to partnership, the framework incorporates two important facilitating factors that are needed to translate the identified domains and competencies to achieve expected outcomes. One of these facilitating factors is continuous learning and improvement, and the other is interprofessional collaboration and learning (Interprofessional Education Collaborative, 2016; AHRQ, 2015).

Continuous learning and improvement are connected concepts that should be embedded across the continuum of education and are relevant to systems, individuals, and their interactions. This mutual responsibility at the macrosystem and microsystem levels is built on the principles of learning and coproduction (Elwyn et al., 2020). Learning health systems recognize individuals, teams, and systems as having distinct yet interdependent roles, and places value on working together across levels to transform health care delivery (IOM, 2011). At the macro level, systems must ensure that health care professionals receive effective, timely continuing education that is sensitive to setting and patient population needs. Individual health care professionals should be oriented toward lifelong learning and continuous improvement in clinical practice (IOM, 2010). At the micro-level, health care professionals are responsible for translating scientific knowledge, best practices, and policy applications into health care delivery while engaging in co-learning and co-production with patients. It is critical for health care professionals to engage in continuous learning and improvement practices to stay informed and learn the skills needed to ensure safe, effective, person-centered, and equitable care delivery across diverse settings (IOM, 2010).

Continuous learning and improvement require individuals and systems to work synergistically to improve performance and patient outcomes (Wilcock et al., 2009). One of the foundational components of this process is assessment and evaluation. Assessment and evaluation provide the infrastructure to reinforce and strengthen continuous improvement in practice. Performance-based assessments, specifically, emphasize optimizing learning, prioritizing feedback and formative processes, and evaluating what a learner does in practice (Moore et al., 2009). In this process, both the individual and the system learn from each other to uphold the principles of continuous learning and improvement.

Interprofessional collaboration and learning rely on foundational respect, which includes equal recognition of all members of the care team and an understanding of environmental context. When thinking of the care team, it is important to note that individual patients, family members, and their communities serve as key team members. Fostering trust and using codesign principles is essential to collaborating with patients (Boyd et al., 2012; Bechtel and Ness, 2010). For successful collaboration to occur within and across all professions in the care delivery process, stakeholders must strengthen coalitions throughout the health care system (Interprofessional Education Collaborative, 2016; AHRQ, 2015; AHRQ, n.d.). Learning through collaboration enhances care delivery to better meet the complex, individual needs of patients and families (IOM, 2003). By understanding how the care team collectively and individually functions within the health care system, interprofessional collaboration can improve access to comprehensive, coordinated, and high-quality care, whether through hands-on care or referrals.

Of note, these facilitating factors apply to clinical and non-clinical stakeholders. In addition to patients, their families and communities, clinicians, and health systems, groups such as payers, licensees, regulators, and educators are a critical part of the broader health care ecosystem and play a fundamental role in the framework’s implementation and long-term sustainability.

Building on the central components described above, the framework is further organized into three broad domains of performance that encompass needed knowledge, skills, and attitudes and reflect competence for all health professionals: Core Knowledge, Collaboration, and Clinical Practice (Dokken et al., 2021; Dardess et al., 2018). These three overarching performance domains map to six general competency areas (and their associated sub-competencies) describing core competency and termed the “3Cs Core Competency Framework for Pain Management and Unhealthy Substance Use Care” (see Table 1).

 

 

Each of the general competencies contains several sub-competencies. The sub-competencies are interconnected both within and across all domains of the framework. For example, stigma is particularly salient for those who experience pain or unhealthy substance use. Concepts related to stigma are represented in several sub-competencies and integrated across all domains. The learning concepts reflected in the subcompetencies and general competencies are interdependent and serve to reinforce each other to provide safe, effective, patient- and family-centered, equitable, timely, and efficient care. To comprehensively achieve the desired education outcomes for health professionals, the minimum core competencies, or abilities, should reflect competence across all aspects of the framework.

 

Performance Domain: Core Knowledge

The core knowledge domain describes the foundational concepts of pain and unhealthy substance use and the knowledge, skills, attitudes, and behaviors needed to effectively apply this knowledge. General competencies and sub-competencies focus on foundational clinical knowledge of pain and SUD; relevant aspects of mental health and related intersections; clinical guidelines and treatment options; baseline skills for recognizing and assessing signs of pain, SUD, risky substance use; and ability to translate evidence and data into practice. Competencies and associated sub-competencies include the following:

 

General Competency 1: Foundational Knowledge

Sub-competencies:

• Acquire knowledge of pain, unhealthy substance use, including SUD, their intersections, discrete concepts, and comorbidities (common comorbidities could include but are not limited to depression, anxiety, PTSD, and insomnia).
• Acquire knowledge of emotional, mental, and behavioral health and their intersections with pain and unhealthy substance use.
• Recognize the range of and differences among conditions relating to SUD and pain.
• Acquire knowledge of stigma, mistrust, and fear related to pain and unhealthy substance use (refers to stigma experienced by patients and understanding the role of self-stigma, societal stigma, and clinician stigma).
• Acquire knowledge of clinical practice guidelines, evidence-based resources, expert guidance, and understand the difference in evidence between these resources.
• Acquire knowledge of treatment options for pain and prevention of SUD.
• Acquire knowledge of treatment options for SUD.

 

General Competency 2: Applied Knowledge

Sub-competencies:

• Develop and apply baseline skills for recognizing and assessing signs of pain, risky substance use, and SUD.
• Develop and apply baseline skills for determining risks associated with mismanaged or undermanaged pain and SUD.
• Develop the ability to translate evidence, expert recommendations, and data into practice.
• Develop and apply baseline skills to develop realistic individualized treatment goals.
• Develop and apply baseline skills to monitor patients for benefits (e.g., function, quality of life) and harms (e.g., adverse effects, substance misuse).
• Develop and apply baseline skills to effectively counsel patients toward more healthy behaviors.
• Develop and apply baseline skills to modify treatment based on clinical outcomes.
• Understand the relationship between stigma and biases, as they pertain to disparities and inequities in pain and unhealthy substance use care (disparities refer to treatment, prevention, and recovery outcomes; inequities refer to care access and delivery).

 

Performance Domain: Collaboration

The collaboration domain describes the core principles of patient- and family-centered practices and team-based care. The competency domains and subdomains focus on knowledge, skills, attitudes, and behaviors needed to successfully collaborate with patients, families, and interprofessional teams, including respect and appreciation for individual- and family-level needs and autonomy; knowledge of individual roles and responsibilities within care teams; and ability to provide appropriate referrals for pain and SUD. Competencies and associated sub-competencies include the following:

 

General Competency 3: Patient- and Family-Centered Practices

Sub-competencies:

• Respect and appreciate individual- and family-level needs and autonomy.
• Recognize and eliminate stigma experienced by patients and families (refers to stigma experienced by patients and understanding the role of self-stigma, societal stigma, and clinician stigma).
• Encourage patient and family discussions and expectations for functional care goals.
• Demonstrate attitudes and behaviors reflecting cultural competency and centering on health equity.
• Practice effective and evidence-based communication strategies with patients and families, including the use of non-biased, nonjudgmental, non-stigmatizing, nondiscriminatory language without use of microaggressions.
• Use person-centered, collaborative approaches and decision making, using techniques such as motivational interviewing, conflict resolution, and redirection to address anchoring (refers to anchoring on initial information, which may prevent receptivity of subsequent information) (Riva et al., 2011; Searight, 2009).
• Develop awareness of trauma-informed care practices and implementation skills for these practices when needed (refers to a care approach that acknowledges the patient’s past and present life situation and the widespread impact of trauma; recognizes signs and symptoms of trauma in patients, families, and staff; and understands the diverse pathways to recovery) (Trauma-Informed Care Implementation Resource Center, 2021; SAMHSA, 2014).
• Select and prepare individuals with lived experience to share their experiences and perspectives in educational sessions for clinicians, staff, students, trainees, and faculty.

 

General Competency 4: Team-Based Care

Sub-competencies:

• Acquire knowledge of individual roles and responsibilities within the care team.
• Develop the ability to work effectively and collaborate within and across different professions and settings.
• Recognize and eliminate stigma against care teams.
• Practice effective and evidence-based communication strategies with team members.
• Recognize patients, families, caregivers, and communities as members of the interdisciplinary team.
• Provide appropriate referral and follow-up for pain and SUD.

 

Performance Domain: Clinical Practice

The clinical practice domain describes the baseline awareness needed to understand health systems, health environments, and professionalism. The competency domains and sub-domains focus on the knowledge, skills, attitudes, and behaviors that facilitate successful integration with practice, such as the ability to recognize social determinants of health and political determinants of health, awareness of current regulations and policies and their relationship to practice, and commitment to lifelong learning and professional development in pain and SUD care. Competencies and sub-competencies include the following:

 

General Competency 5: Health Systems and Environment

Sub-competencies:

• Recognize the social determinants of health, high-risk populations, and structural barriers that may be affecting pain and SUD care.
• Acquire knowledge about clinician-level stigma and impact (refers to stigma experienced by practicing and emerging health professionals in pain/addiction care and underserved areas, and understanding the role of self-stigma, societal stigma, and provider stigma) (HHS, 2019; Scutti, 2019; Blevins et al., 2018; Ostrow et al., 2014).
• Recognize and appreciate the role of health care professionals and the responsibility of providing complex care.
• Understand health systems and strategies for navigating practice setting challenges by learning from colleagues.
• Develop awareness and appropriate use of current data, evidence, guidelines, tools, and resources.
• Develop awareness of current regulations and policies (at local, state, and federal levels) and their relationship to practice.
• Develop an understanding of harm reduction and prevention strategies at individual and population levels (refers to a strategy or behavior that helps reduce harm or risk from substance use or undermanaged/mismanaged pain. For the purpose of this work, the U.S. Centers for Disease Control and Prevention’s (n.d.) definition of harm reduction is adapted to pain as well as substance use).

 

General Competency 6: Professionalism

Sub-competencies:

• Acquire knowledge and use of ethical practices and mediation strategies.
• Exercise self-care skills.
• Engage in interprofessional continuing education that supports lifelong learning and professional development related to pain and unhealthy substance use care and addresses attitudes and behaviors related to treatment.
• Continually assess and address one’s own implicit attitudes and biases (AHRQ, 2015; Sartorius, 2002).
• Exercise resourcefulness and adaptability across practice settings.
• Demonstrate compassion, empathy, and support throughout all stages of care (including treatment and recovery), and exercise the ability to “meet patients where they are.”

 

A complete visual of the core competency framework (see Figure 2) follows.

 

 

Figure 2 displays a snapshot of how the framework’s three broad performance domains (the “Cs”) relate to the six competency domains and how all of the domains are interrelated and connect to one another. Figure 2 also demonstrates how the framework integrates the two facilitating factors (interprofessional collaboration and learning; and continuous learning and improvement) and is collectively centered around a focus on partnering with patients, families, and communities.

 

Conclusion

The 3Cs Framework was created to address PPGs across pain and SUD, catalyze system-level change in the health care environment, and improve health outcomes at the individual and population levels. Although various accredited educational institutions, committees, and task forces have developed their own comprehensive frameworks with similar objectives, the existing curricula are either limited in scope (only focusing on pain or SUD care) or limited in applicability and audience (only intended for specific health fields or specialties or education or training level). Using a public health lens, this framework builds from previous works and integrates core concepts relevant to learners and educators of all health professional backgrounds and education and training levels. The competency domains and sub-domains describe a minimum level of ability and are intentionally broad and comprehensive in scope to enable a wide range of applicability and use.

The 3Cs Framework is intended to inform minimum core competencies and describe baseline knowledge, skills, behaviors, performance, and attitudinal expectations across health professions. The framework would benefit from broad dissemination to education systems and stakeholders to facilitate far-reaching and collaborative implementation. This framework is not intended to detract from existing or emerging evidence-based, interprofessional competencies for pain management and SUDs but rather to ensure flexibility (Fishman et al., 2013).

The framework’s usability and impact rely on support from stakeholders representing clinical, educational, regulatory, and financial systems across health care. A coordinated effort is needed across health professions to incorporate the 3Cs Framework into existing curricula. This should be supported by effective teaching and learning approaches and assessed by accreditation and licensing bodies. Specialty societies, associations, and other accredited continuing education providers can develop training content to address the needs of certain professions and special populations. In addition, competencies developed from the framework will need to be reinforced through accreditation assessments. Certifying and licensing examination criteria across states should reflect concepts included in the framework. Quality metrics can be updated and mapped to support implementation of the framework. Additionally, health systems and reimbursement structures should incentivize clinical practices that build on the core principles ingrained in the framework, particularly interprofessional collaboration and patient- and
family-centered approaches to care.

To support uptake, the framework should be accompanied by a suite of implementation tools, including implementation science principles, implementation guidance for different stakeholder groups, and clinical resources mapped to the framework’s sub-competencies. While these resources may not be exhaustive, they may help accelerate the framework and the development of additional tools, resources, and educational materials needed to facilitate implementation of core competencies across professions, settings, and contexts. Tracking and evaluation will be critical to assess implementation eff orts. Specifically, continuing education accreditors, regulators, and educational leaders across the health care continuum should collaborate to enable national tracking of core competencies for pain management and unhealthy substance use care. Tracking continuing education activities that are designed to address specific competencies paired with evaluation of learning outcomes will help education providers and health professionals to collaborate around targeting setting- and patient population-specific PPGs and underlying educational needs. This tracking should be supported by evaluation frameworks, which will further center accountability for adaptive interprofessional continuing education and care delivery across the health care professional workforce (Chappell et al., 2021).

The 3Cs framework can help shape a health care environment that values an improved state of care for pain and unhealthy substance use by fostering interprofessional coordination and collaboration and supporting continuous improvement and learning, across prevention and care. Health care processes focused on partnership and co-production are integral to sustain effective and comprehensive patient-centered care. In addition to transforming structures and processes, successful implementation of the 3Cs Framework will catalyze adaptive, interprofessional practice that will better prepare health care professionals with the knowledge, skills, and abilities needed to proactively address the complex needs of patients and families with pain and unhealthy substance use and close persistent PPGs.

 

 

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Join the conversation!

  Tweet this! The new 3Cs Framework from the #OpioidCollaborative was developed to close professional practice gaps in treating pain and unhealthy substance use and serve as a foundation for overall improved care. Read more: https://doi.org/10.31478/202206a #NAMPerspectives

  Tweet this! A new framework from the #OpioidCollaborative aims to help close persisting professional practice gaps in treating pain and unhealthy substance use by outlining minimum core competencies for all. Read more: https://doi.org/10.31478/202206a #NAMPerspectives

  Tweet this! The 3Cs Framework from the #OpioidCollaborative centers on partnering with patients, families, and communities to co-produce pain management and unhealthy substance use care. Read more about the framework: https://doi.org/10.31478/202206a #NAMPerspectives

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