Reaching rural veterans: applying mind-body skills for pain using a whole health telehealth intervention (ramp-WH) - 1 this project addresses the significant challenge of implementing effective,…

Reaching rural veterans: applying mind-body skills for pain using a whole health telehealth intervention (ramp-WH) - 1 this project addresses the significant challenge of implementing effective, non-opioid interventions for chronic pain 2 management in rural and remote dwelling veteran populations. Pain is a complex biophysical, psychological, and social 3 (BPS) condition and there is a growing evidence base to support several complementary and integrative health (CIH) 4 approaches, which can address pain in a more holistic way. While the VA has become a leader in advancing CIH through 5 its whole health initiative, there remain many barriers, especially for rural patients. Our team has CO-developed, with 6 multiple-levels of VA stakeholders (including rural patients), an innovative telehealth evidence-based intervention that 7 builds upon our team's previous research. The reaching rural veterans: applying mind-body skills for pain using a 8 whole health telehealth intervention (ramp-WH) project strategically coalesces multiple evidence based CIH self- 9 management strategies to address veterans' BPS needs and overcome existing barriers. Comprised of pain education, 10 mindfulness, pain specific exercises, and cognitive behavioral strategies, the program is cohesive and scalable. Designed 11 to be implemented within the VA through its nationwide whole health system initiative, IT uses VA whole health (WH) 12 coaches as program facilitators. Ramp-WH is a 12-week program including a 1-to-1 session with a WH coach, followed 13 by 11 group sessions including pre-recorded expert led education videos, mind-body skill training and practice, and 14 facilitated discussions. For the preparatory phase (UG3) we will conduct 1) stakeholder engagement activities including 15 identifying and developing new community partnerships and using mixed methods data collection from multiple levels of 16 stakeholders (n=35-50 patients, community partners, VA healthcare system leaders and staff), guided by the established 17 RE-aim/prism framework, to learn about key factors that can affect long-term adoption; and 2) conduct a pilot study of 18 40 rural VA patients with chronic pain to assess the feasibility of delivering ramp-WH (experimental intervention for 19 the UH3 trial) in terms of recruitment and engagement, intervention fidelity and adherence, data collection, and other key 20 metrics. For the UH3 phase, we will conduct a randomized hybrid type 2 effectiveness-implementation multi-site 21 pragmatic clinical trial of ramp-WH compared to usual care, among rural patients (n=500) in the VA healthcare 22 system. UH3 aim 1 will assess the relative effectiveness of ramp-WH in terms of the primary effectiveness outcome 23 of pain interference at 13 and 26 weeks and secondary outcomes including opioid use and other heal recommended 24 outcomes. In UH3 aim 2 we will work iteratively with multiple levels of stakeholders (from UG3) to evaluate 25 intervention implementation strategies used in the trial and adapt these strategies to scale up ramp-WH within the 26 national VA healthcare system. This will include: a) conducting mixed-methods assessments of stakeholder and 27 randomized trial participant views of implementation-related barriers and facilitators, resource needs, and other RE- 28 aim/prism domains; b) working with stakeholders to CO-create additional plausible strategies for overcoming barriers to 29 implementation of ramp-WH; and c) conducting budget impact analyses using models informed by stakeholder views to 30 inform future decision making. 31