Innovati0ns in pain management The VHA National Pain Management Strategy

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Innovati0ns in pain management The VHA National Pain Management Strategy

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1. Innovati0ns in pain management The VHA National Pain Management Strategy Robert D. Kerns, Ph.D. Director, PRIME Center, VA Connecticut Healthcare System National Program Director for Pain Management, VA Central Office Professor of Psychiatry, Neurology and Psychology, Yale University

2. Disclosures Nothing to disclose No potential conflicts of interest

3. Pain Management is a priority As many as 50% of male VHA patients in primary care report chronic pain (Kerns et al., 2003; Clark, 2002) The prevalence may be as high as 75% in female Veterans (Haskell et al., 2006) Pain is among the most costly disorders treated in VHA settings; total estimated costs attributable to low back pain was $2.2 billion in FY99 (Yu et al., 2003) Number of Veterans with clbp is growing steadily (Sinnott & Wagner, 2009)

6. Pain Assessment and Pain Characteristics by Sex

8. National Pain Management Strategy Objective is to develop a comprehensive, multicultural, integrated, system-wide approach to pain management that reduces pain and suffering for Veterans experiencing acute and chronic pain associated with a wide range of illnesses, including terminal illness.

9. VHA Pain Management Directive Objectives of National Pain Management Strategy Pain Management Infrastructure Roles and responsibilities Stepped pain care model Pain Management Standards Pain assessment and treatment Evaluation of outcomes and quality Clinician competence and expertise

10. VHA National Pain Management Strategy Infrastructure Pain Management Program Office Specialty Care Services; Patient Care Services; DUSH for Policy and Services National Pain Management Strategy Coordinating Committee (Two representatives from ONS) Coordinating Committee Working Groups Nursing Pain Management Working Group VISN Pain Points of Contact Facility Pain Points of Contact Primary Care Pain Champions Pain Resource Nurses VISN and Facility Pain Management Committees

11. Nursing Pain Management Working Group BCMA Qualifiers-Maximize technology Pain Documentation: Assessment/Reassessment Patient/Staff Pain Education Pain Resource Nurses Nursing Clinical Indicators Patient and Nurse Satisfaction Identify specialty nursing groups and roles in pain management

12. Stepped pain care model Single standard of pain care for VHA Population based approach Timely access to pain assessment State of the art treatment and follow-up Reliable communication and case management Patient and family participation Empirically supported model Von Korff et al. Stepped care for back pain: Activating approaches for primary care. Ann Int Med 2001;134:911-917. Dobscha et al. Collaborative care for chronic pain in primary care. JAMA 2009;301:1242-1252. Kroenke et al., Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial. JAMA 2009;301:2099-2110.

14. Implementation of the stepped care model OEF/OIF Pain Care Enhancement funding Education for primary care providers Externship at Tampa for building Pain Centers Incentive for increased staffing of secondary and tertiary programs National pain management leadership conferences Pain and Primary Care Task Force Primary Care Rural Health Initiative Mental Health-Primary Care Integration Project SCAN (Specialty Care Access Networks)

15. Other national initiatives Communication/education infrastructure VA Pain List Serve National Pain Management Website ( Monthly Pain Management Leadership teleconferences Monthly pain management educational teleconferences Guidelines Chronic Opioid Therapy Acute, post-operative pain management Dissemination of APS/AAPM guidelines Web-based education General, opioid therapy, polytrauma Pain and OEF/OIF Pain and polytrauma initiatives PTSD-TBI-Pain Practice Recommendations Consensus Conference “A Team Approach to Veterans with Comorbid Conditions” Conference Nursing VANOD Nursing Assessment and Reassessment Initiative Pain Resource Nursing (PRN) Initiative

16. Promoting safe and effective use of opioids Opioid – High Alert Medication Initiative Opioid Renewal Clinic Collaborative Addiction and Pain (CAP) Program Opioid Decision Support System Chronic Opioid Therapy – Clinical Practice Guideline Opioid Therapy Web Course Pharmacy Benefits Management Initiatives Directive and Clinical Considerations regarding state-authorized use of marijuana programs Partnership with ONDCP in development and implementation of National Prescription Drug Control Policy

17. The Opioid Renewal Clinic Concept In 2001 a Nurse Practitioner developed what became known generically as an Opioid Renewal Clinic or ORC to support Primary Care Providers in managing high risk patients on Chronic Opioid Therapy The Model has grown to include multiple clinical specialties and various models of care Examples: Opioid Pain Care Clinics Pharmacy Pain Management Clinic Primary Care/Opioid Case Management Programs “PRN” taking over routine renewals in PACT

18. Health Analysis & Information Group (HAIG) Pain Management Survey Completed in October 2009 100% facility response rate Components Adherence to Directive requirements Clinical care characteristics Implementation of stepped care model Focused review (e.g., opioid safety practices)

19. HAIG Survey Results 100% of facilities have pain management policies 100% of VISNs and 95% of facilities have identified Pain Points of Contact (POCs) All but eight facilities report at least beginning implementation of stepped care approach 54% of facilities identified a primary care pain champion All but five facilities have multidisciplinary pain committees

20. Pain Committee Roles

21. Use of CPRS templates for documentation

22. HAIG Survey Results

23. Opioid Safety Practices Inpatient Settings

24. Trends in pain care settings

25. Implementation of Stepped Care Model

26. Specific areas for improvement 54% of facilities report having a “Primary Care Pain Champion” Eight VISNs reported no facilities with specialty headache clinics 19 facilities with surgical programs report absence of peri-operative epidural analgesia 32% of facilities report having a pain relevant patient/family education program 61% of facilities require pain education for medical staff


28. Step One: PACT

29. Pain and Primary Care Toolkit Links VHA Pain website ( LMS training VA-DoD Clinical Practice Guidelines Local Resources Contacts for specialty care Contacts for alternative care (e.g., acupuncture) Contacts for aberrancy (e.g., Mental Health, Substance Use Disorders) Patient Education resources Documents Pain management competencies How to develop a pain service agreement Sample pain service agreements How to set up an Opioid Renewal Clinic Urine drug screening guidelines National Opioid Pain Care Agreement Back pain guidelines

31. PC Rural Health Series

32. SCAMP Trial Kroenke K, Bair MJ, Damush TM et al. Optimized antidepressant treatment and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial. JAMA 2009;301:2099-2110.

33. Industry Innovations Project “VA Technology Infrastructure for Patient Centered Collaborative Management of Chronic Pain and Depression in Primary Care” Partnership between Interactive Performance Technologies and VA Connecticut Healthcare System and Roudebush VA Medical Center (Indianapolis) Introduction of automated system for facilitating patient communication, especially patient reporting of outcomes and other key variables Nurse care manager as facilitator Complementary programs for delivery of cognitive-behavior therapy and for monitoring opioid therapy

34. Improving access using technologies Videoconferencing (Sellinger) National Telemental Health Center Interactive Voice Response (Heapy) Entirely therapist-less intervention Self-management emphasizing self-monitoring, self-evaluation, and self-reinforcement Funded HSR&D Investigator Initiated Research (IIR) Project Non-inferiority trial Web-based (Kerns) Veterans Pain Management Resource Center Veteran preferences Pain coping skill module approach

35. PROJECT SCAN (Secondary Care Access Networks) University of New Mexico developed Project ECHO (Extension for Community Healthcare Outcomes) Allows specialists to electronically connect with Primary Care Providers in rural areas Uses Telehealth and allows for specialists at a regional site to provide expert advice to Primary Care Providers Model based on case-based learning Providers in underserved areas present patient’s case to specialists and discuss treatment options Individual treatment plans are developed for each patient and are adjusted as needed

36. Qualitative analysis of other nurses and other team members’ experiences Roles Patient centered care Team based care Primary of medications Barriers System barriers Personal barriers Patient barriers Positive aspects Personally gratifying Benefits of team Negative aspects Challenging interpersonal aspects Clinical quandaries Hopelessness of staff

37. Implementation: Lessons Learned Education and Training Nursing education Systems Redesign Optimize nursing roles Comprehensive pain assessment Patient education Patient self-management Treatment monitoring Care management Support Engage nursing in team building efforts Implement PRN Program Peer support

38. Step Two: Specialty Care

39. Pain Specialty Care Capacity Building 100% of VISNs have specialized pain clinic services 89% of facilities have specialized pain clinics 10.3% increase since FY09 in physician FTE providing pain care services Of those facilities with pain clinics, 80% have dedicated physician staff Of those with pain clinics staffed by physicians, 75% have physicians specializing in Pain Medicine 15% increase in Pain Medicine physician FTE since FY09 Steady increases since FY05

40. Specialty Pain Care Capacity One hundred percent of VISNs are providing dedicated PAIN Clinic Services. Eighty-nine percent (124/140) of facilities have dedicated PAIN Clinics established.

41. Nursing actions in Specialty Care Education and Training Nursing education Systems Redesign Optimize nursing roles Comprehensive pain assessment Patient education Patient self-management Treatment monitoring Care management Support Engage nursing in team building efforts Implement PRN Program Peer support

42. Step Three: Tertiary, Interdisciplinary Pain Centers

43. USH Chartered Interdisciplinary Pain Management Center Work Group Work Group Responsibilities: Programmatic analysis of existing programs Development of specific guidance: Scope and objectives Core services Admission criteria Plans for care coordination Educational mission Staffing patterns Oversight of the development and implementation

44. HAIG Survey Results All but eight facilities have at least begun to implement the stepped pain care model Three facilities have CARF accredited pain rehabilitation programs 36 facilities intend to pursue CARF accreditation Only two VISNs do not have at least one facility intending to pursue CARF accreditation

45. Summary: Nursing roles in pain management Development of nurse leaders in quality improvement, administration, clinical care, education, and research. Enhanced roles in PACTs and other teams, especially roles in clinical assessment, patient education, and monitoring of interventions Nurse care management; delivery of pain self-management interventions. Development of Pain Resources Nurses to help support pain management across the continuum of care.

47. Discussion

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