PAIN ASSESSMENT • TWO TYPES OF PAIN. • PHYSICAL • PSYCHOLOGICAL.
PHYSICAL • Real pain from a physical injury or medical condition.
PSYCHOLOGICAL • A condition where pain is felt when no actual physical or medical condition exists.
QUESTION He/she is a pain in the _______ (You fill in the blank) Is this physical or psychological?
MEDICAL PRACTIONER’S PROBLEM • DETERMINING IF PAIN IS PSYCHOLOGICAL OR PHYSICAL.
ANSWER TO PROBLEM • It’s both. • Psychological distress can cause headache, stomach cramps and nausea which is physical. • The medical practitioner has to determine the psychological impact on the physical pain
DETERMINING TREATMENT • In determining treatment a medical practitioner must use a comprehensive tool that address both the physical and psychological.
HOW TO DO THIS • By documenting medical outcomes thru Pain Assessment
PAIN ASSESSMENT • A Pain Assessment must addresses both the physical and psychological aspect of the patients condition.
PROCEEDURE • Outcome Assessment • Collection and recording of information relative to health processes • Outcome Management • Using information in a way that enhances patient care (Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)
OUTCOME ASSESSMENTS/MANAGEMENT • Outcomes in clinical practice provide the mechanism by which the health care provider, the patient, the public, and the payer are able to assess the end results of care and its effect upon the health of the patient and society. (Anderson & Weinstein, 1994).
HEALTH POLICY • With the dawning, of the “era of accountability,” there are new social mandates directed toward health care providers and health-related facilities. Measurements of quality, satisfaction, efficacy, and effectiveness now serve as essential elements for health care decisions and matters of health policy. (Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)
SURVIVAL • To survive, in fact to flourish, in this era of accountability health care providers must be prepared to maintain and be able to provide appropriate documentation and patient records in a clinically efficient and economical manner. (Hansen, 1994).
OUTCOMES CRITERIA • Utility Is it useful? • Reliability Is it dependable? • Validity Does it do what it is supposed to? • Sensitivity Can it identify patients with a condition? • Specificity Can it identify those that do not have the condition? • Responsiveness Can it measure differences over time?
APPROPRIATE FOR CLINICAL USE • Questionnaires • General health status • Pain • Functional status • Patient satisfaction • Physiological outcomes • Utilization measures • Cost measures
APPROPRIATELY USED • When outcome measures are appropriately used and integrated into an evidence-based, patient-centered model of practice, there is accountability and quality assurance. (Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)
OUTCOME MEANINGS • Health Care Customer - Meaning of Outcomes • Payers-purchasers Cost containment • Regulators HCP compliance • Administrators Efficiency-low utilization • Clinical Researchers Proof of a premise • Outcomes Experts Patient’s benefit • Health Care Providers Clinical-Health Status (Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)
SUBJECTIVE QUESTIONNAIRES • Subjective outcomes assessment information is gathered by the patient in self-administered questionnaires and scored by either the: • Health care provider • Staff members or • By a computer.
SUBJECTIVE QUESTIONNAIRES • In spite of the definition associated with the term “subjective,” these “pen-and-paper tools” have been described as very valid and reliable – in many cases more so than many of the “objective’ tests that health care providers have relied upon for years. (Chapman-Smith, 1992; Hansen, 1994; Mootz, 1994).
SUBJECTIVE VS OBJECTIVE • It must be emphasized that although the term “subjective” carries negative connotations, the reliability/validity data published regarding these methods of collecting outcomes is exceptional, typically out-performing the test-retest reliability and validity of most “objective” physical performance tests. (Chapman-Smith, 1992).
Subjective (Patient Driven) General Health Pain Perception Condition or Disease Specific Psychometric Disability Prediction Patient Satisfaction Objective (HCP Driven) Range of Motion Strength - Endurance Non organic Proprioception Cardiopulmonary Developmental OUTCOME CLASSIFICATION
ASSESSMENT TOOLS • It is important to remember to utilize the same outcome assessment tool through the course of case management with each patient.
PSYCHOLOGICAL AND GENERAL HEALTH QUESTIONNAIRES (GHQ) • One can benefit from the use of a Psychological and GHQ because it is not condition-specific and, therefore, can be applied to virtually any complaint. Yeomans SG: The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000
APPLICATION OF PAIN ASSESSMENT QUESTIONNAIRES (PAQ) • The application of a PAQ should, at minimum, be used at the following intervals: • At the time of the initial presentation for baseline establishment of outcomes assessment. • To identify problems for prompt management. • At 4 to 6 week plateau in care or discharge for outcomes assessment of the treatment benefits or lack thereof. • Six months after discharge in order to evaluate the long-term benefits of treatment.
SYMPTOM INVENTORY QUESTIONNAIRE • This can serve as a very practical reference tool to use for patient report of findings, to insurers to justify “medical necessity” for additional care, and to the health care provider to facilitate the decision making process of case management (referral, discharge).
PAIN WORD INVENTORY • Established as the standard by which other psychological instruments for pain measurement are compared • Consists of 86 descriptor words divided into twenty-one categories • Categories divided into 4 Classifications.
PAIN DRAWING • Developed by Danard Lilly Corporation to show the front and back body drawing with numbers to map the nature and distribution of pain.
OUTCOME-BASED PRACTICE • Correlating this information to the patient’s specific clinical data and then making a clinical decision based on the results represents a difficult but important step in making a “paradigm shift” into becoming an “outcome-based” practice. • Yeomans SG: The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000
PAIN PERCEPTION • Visual Scales • Reliable and valid • Advantages of measurement methods • Pain Word Inventory • Pain Drawing (Scott and Huskisson 1976, Price et al 1994).
PAIN ASSESSMENT OFFERS: • Four specific factors - Von Korff et al, 1992 • CURRENT Pain Level • AVERAGE or TYPICAL Pain Level • Pain level at its BEST • Pain level at its WORST • Final Assessment
GUIDELINES • Chronic Patient • Average Pain = Last 6 months • Frequency • Every 4 to 6 weeks since a patient’s failure to progress may indicate a need for a change in management approaches (Haldeman et al, 1993).
QUESTIONNAIRE MEASURES • Outcome measures for the upper and lower extremities. “this dispels the myth that so-called soft (subjective) outcomes are less valuable when compared to objective measures when, in fact, the subjective measures are often more sensitive, specific, and responsive than many objective measures.” (Koran, 1975)
Assessment Validity An assessment and traditional physical examination measures of median nerve function capture different but complementary outcome information. Therefore, symptom severity and functional status cannot be reliably compared to sensibility or nerve conduction testing.” (Levine et al, 1993)
Psychometric Assessment Tool • Distress and Risk Assessment • Pain perception questionnaire that incorporates both physical and psychological conditions.
4 STEPS TO BECOME OUTCOMES BASED • Utilize subjective/objective tools • Score the tools at the initial visit to establish baseline measures • Repeat the instrument after 4-6 week intervals to track the effects of treatment changes • Base clinical decisions on the outcome results
“Medical Necessity” • The fully developed clinical record defines the “medical necessity” of the case in the eyes of the insurer.
“MEDICAL NECESSITY” DOCUMENTATION • Provider must document • Etiology of complaint (onset, severity, frequency , duration • Patient’s health history • Current subjective complaints • Current objective clinical findings • Diagnosis • Treatment plan • Measurements of patient improvement (outcome assessment)
HELPS TO EXPOSE FRAUDULENT CLAIMS • Continued use of Pain Assessments could expose inconsistencies in claims limiting insurance liability. • Verifies insurers proof for needed care.
Increase Revenues by Utilizing Pain Assessments • There is potential for increased billing utilizing Pain Assessments. • Insurance billing codes cover Pain Assessments and Doctor’s consultations
Danard-Lilly, Corporation • Clinical analysis and innovative technology has produced the only complete advanced Pain Assessment Tool in the industry that covers both the physical and psychological. • Provides complete, consistent and efficient patient care. • Reduces patient recovery time by 20% - 30%. • Helps to expose fraudulent claims. • Breaks the language barrier between doctors and patients.
Danard-Lilly, Corporation P.O. Box 512 Sunset Beach, CA 90742 (714) 385 1131 Email: Danardlilly@Yahoo.com Web Site: www.danardlilly.com