VHA N ATIONAL PAIN M ANAGEMENT STRATEGY Implementa8on o f a stepped care m odel o f pain m anagement ROBERT D. KERNS, PH.D, NATIONAL PROGRAM DIRECTOR FOR PAIN MANAGEMENT February 2012
Learning Objec8ves 1. Tell an overview of Pain Management Task Force. 2. Outline similari8es and diﬀerences with pain management challenges facing Department of Defense and Veterans Health Administra8on. 3. Iden8fy best prac8ces of pain management alterna8ves from the Pain Management Task Force.
Disclosure Statement • Robert Kerns has no ﬁnancial rela8onships with proprietary en88es that produce health care goods and services. • Kevin Galloway has no ﬁnancial rela8onships with proprietary en88es that produce health care goods and services.
Pain Management is a priority • As many as 50% of male VHA pa8ents 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 se]ngs; total es8mated cost a^ributable to Veterans with low back pain was $2.2 billion in FY99 (Yu et al., 2003) • Number of Veterans with chronic low back pain is growing steadily (Sinno^ & Wagner, 2009) 4
Frequency of Diagnoses1 among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans Diagnosis (Broad ICD-‐9 Categories)a Frequency Percentb Infec8ous and Parasi8c Diseases (001-‐139) 144,167 16.0 Malignant Neoplasms (140-‐209) 13,016 1.4 Benign Neoplasms (210-‐239) 64,424 7.2 Diseases of Endocrine/Nutri8onal/ Metabolic Systems (240-‐279) 302,719 33.6 Diseases of Blood and Blood Forming Organs (280-‐289) 36,899 4.1 Mental Disorders (290-‐319) 486,015 54.0 Diseases of Nervous System/ Sense Organs (320-‐389) 415,543 46.2 Diseases of Circulatory System (390-‐459) 198,140 22.0 Disease of Respiratory System (460-‐519) 241,229 26.8 Disease of Diges8ve System (520-‐579) 326,338 36.3 Diseases of Genitourinary System (580-‐629) 142,687 15.9 Diseases of Skin (680-‐709) 199,803 22.2 Diseases of Musculoskeletal System/ConnecBve System (710-‐739) 519,721 57.8 Symptoms, Signs and Ill Deﬁned Condi8ons (780-‐799) 478,267 53.2 Injury/Poisonings (800-‐999) 267,407 29.7 1Includes both provisional and conﬁrmed diagnoses. aThese are cumula8ve data since FY 2002, with data on hospitaliza8ons and outpa8ent visits as of September 30, 2011; Veterans can have mul8ple diagnoses with each health care encounter. The total may be higher than 899,752 unique Veterans because a Veteran can have more than one diagnosis and each is entered separately in this table. bPercentages reported are approximate due to rounding. 5 Cumulative from 1st Quarter FY 2002 through 1st Quarter FY 2013
Prevalence of Chronic Pain, PTSD and TBI: sample of 340 OEF/OIF veterans Chronic Pain PTSD N=277 N=232 81.5% 16.5% 68.2% 2.9% 10.3% 42.1% 6.8% 12.6% TBI 5.3% N=227 66.8%Lew et al., (2009). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. Journal of Rehabilitation Research and Development, 46, 697-702.
VHA Pain Management Direc8ve (2009-‐053) • Objec8ves of Na8onal Pain Management Strategy • Pain Management Infrastructure – Roles and responsibili8es • Stepped Pain Care Model • Pain Management Standards – Pain assessment and treatment – Evalua8on of outcomes and quality – Clinician competence and exper8se 7
Na8onal Pain Management Strategy Objec8ve is to develop a comprehensive, mul8cultural, 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. 8
VHA Na8onal Pain Management Strategy Infrastructure • Pain Management Program Oﬃce – Specialty Care Services; Pa8ent Care Services; DUSH for Policy and Services • Na8onal Pain Management Strategy Coordina8ng Commi^ee – Coordina8ng Commi^ee Working Groups • VISN Pain Points of Contact • Facility Pain Points of Contact • Primary Care Pain Champions • Pain Resource Nurses • VISN and Facility Pain Management Commi^ees 9
VHA Stepped Care Model for Pain Management • Single standard of pain care for VHA – Popula8on based approach – Timely access to pain assessment – State of the art treatment and follow-‐up – Reliable communica8on and care management – Pa8ent and family par8cipa8on • Empirically supported model – Von Korﬀ et al. (2001). Stepped care for back pain: Ac8va8ng approaches for primary care. Annals of Internal Medicine, 134, 911-‐917. – Dobscha et al. (2009). Collabora8ve care for chronic pain in primary care. Journal of the American Medical Associa9on, 301, 1242-‐1252. – Kroenke et al. (2009). Op8mized an8depressant therapy and pain self-‐ management in primary care pa8ents with depression and musculoskeletal pain: A randomized controlled trial. Journal of the American Medical Associa9on, 301, 2099-‐2110. 10
Veteran-‐Centered Pain Management • Informed by chronic illness model • Empowering Veterans through reassurance, encouragement and educa8on • Conserva8ve use of analgesics and adjuvant medica8ons • Promo8on of regular exercise and healthy and ac8ve lifestyle • Development of adap8ve strategies for managing pain 11
Stepped Care Model for Pain Management Ter8ary Interdisciplinary Pain Centers Advanced diagnos8cs & interven8ons RISK Commission on Accredita8on of Rehabilita8on Facili8es accredited pain rehabilita8on Integrated chronic pain and Substance Use STEP ComorbidiBes Disorder treatment 3 Treatment Refractory STEP 2 Primary Care/Pa8ent Aligned Care Teams (PACTs) Rou8ne screening for presence & intensity of pain Comprehensive pain assessment STEP Complexity Management of common acute and chronic pain condi8ons 1 Primary Care-‐Mental Health Integra8on, Health Behavior Coordinators, OEF/OIF/OND & Post-‐Deployment Teams Expanded nurse care management Clinical Pharmacy Pain Medica8on Management 13 Opioid Pain Care and Renewal Clinics
Implementa8on ini8a8ves • OEF/OIF Pain Care Enhancement Ini8a8ve • Communica8on/educa8on infrastructure – VA Pain List Serve, – Na8onal Pain Management Website (www.va.gov/painmanagement) – Monthly Pain Management Leadership Teleconference – Monthly “Spotlight on Pain Management” webinar (collabora8on with HSR&D Center for Informa8on Dissemina8on and Educa8onal Resources [CIDER] – Na8onal Pain Management Leadership Conferences – VA Pharmacy Pain Management Mentors (VAPPMM) Outlook exchange • Clinical Prac8ce Guidelines – Opioid Therapy for Management of Chronic Pain – Peri-‐opera8ve pain management – Dissemina8on of American Pain Society/American Academy of Pain Management guidelines 14
Implementa8on Ini8a8ves • Web-‐based educa8on – General, opioid therapy for acute and chronic pain, polytrauma – Primary Care Rural Health Ini8a8ve pain management courses • Post-‐Deployment and Integrated Care Ini8a8ves – Pos^rauma8c Stress Disorder-‐Trauma8c Brain Injury-‐Pain Prac8ce Recommenda8ons Consensus Conference – PC-‐MHI/HBC ini8a8ves • Nursing – Veteran Aﬀairs Nursing Outcome Database Nursing Assessment and Reassessment Ini8a8ve (ini8al focus on management of acute pain in inpa8ent se]ngs) – Pain Resource Nursing (PRN) Ini8a8ve • Pharmacy – Na8onal Clinical Pharmacy Pain Management Training – Opioid Pain Care Clinics Central Repository 15
Implementa8on Ini8a8ves • Telehealth – Telebehavioral Pain Management – Mobile Pain App • Pain Medicine – Capacity for specialty pain medicine diagnos8cs and interven8ons • Mental Health – Evidence-‐Based Psychotherapy – Capacity for pain management in Substance Use Disorders programs – Capacity for pain management in PTSD treatment se]ngs • Externship training at James Haley Veterans Hospital – Interdisciplinary pain management – CARF accredited pain rehabilita8on 16
Promo8ng safe and eﬀec8ve use of opioids • Opioid – High Alert Medica8on Ini8a8ve • CPG on Management of Opioid Therapy for Chronic Pain • TMS: Opioid Therapy for Acute and Chronic Pain • Pharmacy Beneﬁts Management Ini8a8ves and Clinical Guidances • Direc8ve and Clinical Considera8ons regarding state-‐authorized use of marijuana • Implementa8on of Na8onal Prescrip8on Drug Control Policy • Opioid Safety Ini8a8ve • Par8cipa8on in State Prescrip8on Drug Monitoring Programs • Signature Informed Consent 17
VA Specialty Care Access Network – Extension of Community Healthcare Outcomes (VA SCAN-‐ ECHO) The mission of VA SCAN-‐ECHO is to: • Meet the needs of primary care providers and PACT teams for access to specialist consulta8on services and support • Provide case-‐based learning modules to improve core competencies and provider sa8sfac8on • Facilitate referrals to ter8ary care centers when indicated • Ul8mately to improve veteran access to specialty care and treatment outcomes 18
HEC PMWG: Objec8ves/Ini8a8ves • DoD/VHA Core Pain Curriculum / • PASTOR/PROMIS Training • DVPRS• Collaboration with NiH CoEPES • CREATE• ECHO / SCAN-ECHO• Phone Apps for patient & for provider Standardize Deliver• Tiered acupuncture training Education and Measurement and treatment Training Based Care Function Readiness• Opioid Risk Strategy • COT – CPG Ensure Patient Establish • Stepped Care Model • Opioid Risk Tools Consistent • Interdisciplinary PC / PACT Safety • Urine Drug Screening / Model of Care Pain Champions & Teams Reporting • Pain Medicine Specialty• Integration of non-medication support for Primary Care modalities (PCMH)• Patient Safety Videos • Pain Rehabilitation• Joint Suicide Prevention Initiative
Joint Educa8on/Training Program (JPEP) VA/DoD HEC Pain Management Working Group VHA Pain Management (PACT) VHA/DOD DOD Pain Strategic Oversight CommiTee HEC Management JIF Joint VA/ Pain EducaBon DOD Pain Advisory Team EducaBon Community of PracBce Pain Management CoordinaBng EducaBon and Workgroup Training Facility Pain Workgroup Champions CoordinaBng Workgroup Training Program Community of Facility Pain PracBce Champions i.e. PCP/RNCM Facility/VISN Monthly Calls Team, facility SME Pain Team PACT
Healthcare Analysis Informa8on Group 2010 VHA Pain Management Survey Results • 100% of facili8es have pain management policies • 100% of Veterans Integrated Service Network (VISN) and 95% of facili8es have iden8ﬁed Pain Points of Contacts (POCs) • 54% of facili8es iden8ﬁed a primary care pain champion • 96% of facili8es have mul8disciplinary pain commi^ees 21
Building Capacity for Ter8ary, Interdisciplinary Pain Centers • VHA Pain Direc8ve requires every VISN to have a ter8ary interdisciplinary pain center by September 2014 • VISN Directors survey in December 2011 – 19 VISNS report mee8ng standard for advanced pain medicine diagnos8cs and interven8ons; 2 have yet to iden8fy site • Most recent data on Commission for Accredita8on of Rehabilita8on Facili8es (CARF) – 7 VISNs report having CARF-‐accredited pain rehabilita8on programs; 10 have applica8ons pending 24
Pain Research – FY 2012 • 61 pain-‐related Oﬃce of Research • Basic mechanisms underlying pain and Development funded research • Pain diagnosis projects • Preclinical studies • $11.9 million for pain-‐relevant • Pain management (medica8ons; research psychosocial interven8ons) • Pain Research Working Group • Co-‐morbidi8es • Health Services Research and • Quality of Life (QOL), compara8ve Development Pain Research Center eﬀec8veness; bioinforma8cs; funded (PRIME Center) dispari8es • Partnerships with Na8onal Ins8tute • Training (career development) of Health/Department of Defense 25
FY 2013 Priori8es • Opioid Safety Ini8a8ve, and other opioid therapy ini8a8ves • Pain and Primary Care ini8a8ves; Joint Incen8ve Fund Ini8a8ve • Specialty Care Services Transforma8on Ini8a8ves, especially SCAN-‐ECHO • Guidance for Ter8ary, Interdisciplinary Pain Centers • Publica8on of acute, peri-‐opera8ve pain management guideline • Capacity for behavioral services in PACT • Pa8ent Educa8on Ini8a8ves • Provider Educa8on Ini8a8ves • Nursing ini8a8ves • Health Execu8ve Council Pain Management and VA-‐DoD ini8a8ves 26