Managing Pain Management


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This lecture was given by Dr Cathy Price, Consultant in Pain Management for the Southampton University Hospitals NHS Trust, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".

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  • Managing Pain Management

    1. 1. Managing Pain Management Cathy Price Consultant in Pain Management
    2. 2. Where we are now
    3. 3. Aims: <ul><li>Introduce Southampton’s Pain service’s model of care </li></ul><ul><li>Detail on tiered approach </li></ul><ul><li>Impact on secondary care service </li></ul><ul><li>Impact on outcomes </li></ul>
    4. 4. Challenges and Opportunities for Pain management – the frameworks <ul><li>Challenges </li></ul><ul><ul><li>Not in QOF </li></ul></ul><ul><li>Opportunities </li></ul><ul><ul><li>MSF </li></ul></ul><ul><ul><li>Care Closer to Home </li></ul></ul>
    5. 5. The Problem 50,000 care population-endless waiting list for specialist medical care pain cannot be managed Dodgy thinking had lead to dodgy expectations
    6. 6. What are the PCT’s expectations? <ul><li>end the scatter gun effect for MSK referrals and doctor shopping </li></ul><ul><li>Pain patients are high demand- clog other services </li></ul><ul><li>Local access </li></ul><ul><li>Patients to increase own responsibility for health </li></ul>
    7. 7. Southampton’s Solution (took 3 months to come up with it, 6 months to implement it)
    8. 8. Solution <ul><li>To provide & develop a pain management service encouraging self-management based largely outside hospital </li></ul><ul><li>Empower primary care physicians to provide the majority of care for people with long term pain in a systematic fashion </li></ul><ul><li>Mantra: Manage expectations, provide clear pathway in and out of specialist care </li></ul>
    9. 9. The Service Structure (pain is a long term condition) Kaiser Permanente NW Pain care model 2000 Von Korff- Stepped care BMJ 2002 DH LTC 2003 Increasing complexity of biopsychosocial factors
    10. 10. What could we do about Primary Care? <ul><li>Educational programme for GP’s- pain, aetiology, psychosocial risk factors </li></ul><ul><li>Prescribing guidelines- support of DPC – pharmacy driven </li></ul><ul><li>Pharmacy teaching of community pharmacists </li></ul><ul><li>Clear pathways of care </li></ul><ul><li>Practices nurses jealously guarded! </li></ul>Allows 30% of paper triage discharges
    11. 11. Specialist team What can happen when pain patients exit primary care? Keeps wait to a minimum as triage generally accurate
    12. 12. Psychosocial Risk Factors <ul><li>Screening designed to detect these “Yellow and Orange” flags from the outset (Main) </li></ul><ul><ul><li>7 domains for yellow flags </li></ul></ul><ul><ul><li>(Main/Kendrick/Linton 1997) </li></ul></ul><ul><ul><li>Orange Flags require psychiatric assessment </li></ul></ul><ul><ul><li>More complex patients would require specialist services </li></ul></ul><ul><ul><li>Relatively successful in spinal care, much less successful in shoulders/knees </li></ul></ul>
    13. 13. Pain Management – community interventions Complex individual case management- Self management programmes- varying levels of intensity Usual Care with Support- primary care doctor medicines, explanations of pain within a biopsychosocial framework , musculoskeletal practitioners, community pharmacists Level 1 70-80% of a CCM pop Level 2 High risk members Level 3 Highly complex members Short secondary prevention groups Some individual care Operational policy for the community screening teams Expert patient Programme Interdisciplinary CBT-based pain management Programmes Council run leisure centre schemes Link with MIND Patient support groups 20% OF REFERRALS
    14. 14. What did it take? <ul><li>Consultants to move out to do community clinics </li></ul><ul><li>PMP’s to be based in community centres – allowed accessibility of psychologist </li></ul><ul><li>Some secondary care staff volunteered to take part in pilot- allowed development of competencies </li></ul><ul><li>Developed systematic way of identifying risk </li></ul>
    15. 15. What results won hearts and minds? (still need to do it)…..
    16. 16. Overall Outcomes of Assessment for Level of Need 47% other pathway 34% Complex individual care management 19% pain management programme
    17. 17. User Surveys <ul><li>Triage </li></ul><ul><ul><li>88% felt the assessment process was about right </li></ul></ul><ul><ul><li>75% were satisfied with the outcome of assessment </li></ul></ul><ul><ul><li>A small number were unclear as to the next step </li></ul></ul><ul><li>Secondary Care: </li></ul><ul><li>95% highly satisfied with care in RSH </li></ul><ul><li>Pain management programme: </li></ul><ul><li>90% patient satisfaction </li></ul>
    18. 18. Case Mix 80 25 47 27 80 Alliance PCT 80 85 Duration > 2 years ? 29 depression score (Beck) 44 47 Pain impact scale 23 25 Pain Intensity 70 89 Musculoskeletal pain National City PCT
    19. 19. What’s been the impact on secondary care pain services?
    20. 20. Decreased medical follow-ups Increased emphasis on coping and self management skills Decreased short term solutions Waiting times: steady at 6 weeks 8% do not opt in from assessment Budget decreased
    21. 21. Impact on specialist team…tricky patients…wide range of needs <ul><li>Needed to redesign team </li></ul><ul><ul><li>to provide self management skills training to patients </li></ul></ul><ul><ul><li>Ability to motivate, negotiate </li></ul></ul><ul><ul><li>Function as MDT </li></ul></ul><ul><ul><li>Range of skills </li></ul></ul><ul><li>Redesign process of care- patients struggle with group programmes </li></ul>
    22. 22. Process to rebuild team <ul><li>Mapping patient journey </li></ul><ul><li>Functional skills analysis </li></ul><ul><li>Skills matrix done as team </li></ul><ul><li>Regular business meeting </li></ul><ul><li>Regular team meeting </li></ul>Opt in from triage “taster” Team member Complete needs assessment Stuck team meeting Intervention Discharge
    23. 23. Now… <ul><li>Psychologists offer regular supervision- nearly all staff have this </li></ul><ul><li>Core team = medic/physiotherapist/nurse </li></ul><ul><li>Plus: </li></ul><ul><ul><li>Strong Mental health support- psychology/psychiatry </li></ul></ul><ul><ul><li>Pharmacist input </li></ul></ul><ul><ul><li>Vocational rehabilitation specialists </li></ul></ul>
    24. 24. Activity <ul><li>25% need mental health needs formally assessed </li></ul><ul><li>25% highly complex (see > 3 team members) </li></ul>28% doctor only Nurses 68% Doctors 70% Physios 48% Psychologists 6% but consultancy offered Pharmacist
    25. 25. Challenges <ul><li>Interaction between community and secondary care team </li></ul><ul><li>Single vision across multiple organisations </li></ul><ul><li>Many staff very part time ? Sufficient to learn </li></ul><ul><li>Clinical governance structures different with each organisation </li></ul><ul><li>Strong community service- secondary care cases costly – not adequately reimbursed </li></ul>
    26. 26. Summary Pain Management - The solution…
    27. 27. The Pain Framework <ul><li>The right patient is in the right place at the right time </li></ul>Complex individual case management- Self management programmes Usual Care with Support- primary care doctor medicines, explanations of pain within a biopsychosocial framework , musculoskeletal practitioners, community pharmacists Level 1 70-80% of a CCM pop Level 2 High risk members Level 3 Highly complex members Increasing complexity of biopsychosocial factors Re-referral rate is 10% at present- needs to be closely monitored
    28. 28. What you can see by working in the community! Southampton