Rx16 presummit 200_empower_veteransprogram

Empower Veterans Program:
Innovative Functional Restoration
for High Impact Chronic Pain

Disclosures
• The following presenters each have disclosed no relevant, real, or
apparent personal or professional financial relationships with proprietary
entities that produce health care goods and services.
– Michael Saenger, MD, FACP
– Ushvani Persaud, LCSW, MSW
– Paul Burholt, LCSW
– Beth Hammons, PhD
– Jennifer Gansen, DPT
– Lindsay Ballengee, DPT
• All content represents the personal views of each presenter and does not
necessarily reflect the views of the Atlanta VA nor of VHA

Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

Learning Objectives
1. Describe how the Empower Veterans Program
provides intensive, integrated self-care coaching for
veterans with chronic pain.
2. Identify each of the bio-psycho-social-spiritual
dimensions of real chronic pain.
3. Advocate the value of integrated, multidisciplinary
coaching for functional restoration and wellness in
chronic pain.
4. Explain how to implement similar intensive whole
health interventions through clinical and business
cases.

Overview
Michael Saenger, MD, FACP
Lead Physician, Pain Management, VISN 7
Director, Empower Veterans, Atlanta VA Medical Center

EVP Workshop Overview
• Overview of
– Need for large scale functional restoration
– Empower Veterans Program (EVP)
• Perspectives from
– Social Worker (then Q&A and Break)
– Whole Health facilitator
– ACT facilitator
– Mindful Movement facilitators
• Q&A

The Goal
•Safe and thriving Veterans

Step 3
Multi-
Disciplinary
Step 2
Subspecialty
Consults
Step 1
Patient–Primary Care
(Self Care desired)
Opioids
Current State of Pain Management

No Change in Chronic Low Back Pain
From 73mg MEDD vs NSAID or Placebo
9

Evidence in Chronic Pain
for Long Term Opioid Therapy
• No strong evidence for effectiveness
• Possible functional “Sweet Spot” with small infrequent doses
• Strong evidence of harm
– Worsening of Migraines and Fibromyalgia
– Association with worsened
• Mood
• Sleep
– Association with increased deaths
10
Chou, AHRQ, 2014

Risk of Accidental Overdose
Death in Veterans
11

More Effective Pain Medicine
• Duloxetine (SNRI)
– Of clients with Diabetic Peripheral Neuropathy
30% may have 30% less pain
– I.e. not all helped, and no pain “cured”
Griebeler et al, Annals Int Med, 2014

Some Common Injections Questioned
• Epidural Spinal Injections for
Central Canal Stenosis
– After 2 weeks to 2 months
– No difference in pain or function for
• Steroids + temporary numbing medicine, versus
• Numbing medicine by itself
Friedly et al, NEJM, 2014

Common Surgery for Back Questioned
• Laminectomy when done not for radicular
pain but primarily for Low Back Pain
– 3 studies, after 2-5 years after surgery,
– No difference in pain in those with surgery versus
those who were randomized to wait
E.g.: Chou et al, Spine, 2009

Towards therapies:
Safe and
Moderately effective and
Active / Self-efficacious:
Away from therapies:
Dangerous or
Ineffective or
Passive:
Saenger, APA PCSS-O Webinar Series, Evidence CAM LBP, 2013

Towards therapies:
Safe and
Deep Breathing
Progressive Relaxation
Self Massage
TENS self care
“Mindful Movement”:
- Alexander Technique
- Yoga / Tai Chi
- PT Neuro-Muscular
Rehabilitation
Mindfulness Training
CBT or ACT for Pain
Dangerous or
Ineffective or
Passive:
High Dose Opioids
Benzodiazepines
Chronic “Muscle Relaxants”
Chronic “Sleep Medications”
Some Injections
Some Surgery

During Tapering
or beginning
Active Self-Care
with temporary
Bridging
Therapies
(Passive,
Evidence-Based):
Acupuncture or
Spinal Manipulation or
Massage or
Hypnosis
Towards therapies:
Safe and
Deep Breathing
Progressive Relaxation
Self Massage
TENS self care
“Mindful Movement”:
- Alexander Technique
- Yoga / Tai Chi
- PT Neuro-Muscular
Rehabilitation
Mindfulness Training
CBT or ACT for Pain
Dangerous or
Ineffective or
Passive:
High Dose Opioids
Benzodiazepines
Chronic “Muscle Relaxants”
Chronic “Sleep Medications”
Some Injections
Some Surgery

Traditional Multi-Disciplinary
Pain Management Programs
• 100 hours in 3-4 weeks
• Effective
• Costly, but cost effective in earlier age
• Limited access
Aetna, Chronic Pain Programs, accessed 3/1/2016

Back or Pain Schools
• “A little bit of this…”
– Often 60 min of weekly or monthly drop in
didactic
• Not enough and mixed results
Brox et al, Spine, 2008

CBT for Chronic Pain
• 8+ weeks of 50 minute individual or group
• Mild to moderate effect size for pain
interference, QoL, catastrophizing…
Stewart et al, Clin J Pain, 2015

3
2
Step 1
Veteran Client &
Primary Care
Self-Care
Empower
Veterans Program
Accessible
Functional
Restoration
Intensive, Integrated Self-Care Coaching

Why Groups?
• Effective
• Efficient

WheelofHealth
VHAOfficeofPatientCenteredCareandCulturalTransformation

EVP Transdisciplinary Coaching
• 10 weeks of self-care training for Wellness
• Group Coaching (30 hours)
– Whole Health and Well-Being
– ACT
• Based on what is most important to you
• Learning to mindfully not let thoughts, feelings nor
circumstances derail one from their valued direction
– Mindful Movement
• Feeling safe in and aware of one’s own body
• Using movement to retrain the brain

Weekly Individualized Coaching
• Whole Health and ACT – weekly check-in call
• Mindful Movement – in person

Break-even Modeled in <3 years
Modeled Running Costs
Empower Veterans Program
Modeled Running Costs
Without EVP;
Using only Emergency Dept.,
Medication, and UDT costs

Graduates since Summer 2015
• > 20 Veteran groups
• > 140 Veteran graduates (and some spouses)

Changes in Scheduling:
8 Concurrent Training Cohorts
time Monday Tues Wedn Thurs Friday Saturday
7:30
8 Check In Check In Check In Check In Check In
8:30 Meet & WH WH WH iMove
9 Greet once
9:30 ACT ACT ACT annual
10 Check In Check In Saturday
10:30 WH MM MM MM WH Series
11 (in place
11:30 ACT ACT of Monday
12 Check In Check In Check In Midday)
12:30 MM WH WH WH MM
1
1:30 ACT ACT ACT
2 Check In
2:30 iMove MM MM MM
3
3:30

Going Forward
with iterative
improvements:
Model for
Improvement

EVP for Training ONLY
• Distinction of training and assessment of
pharmacological pain management

Feedback from Facilitators
• “Learning from one another”
– Integrating training
– Transdisciplinary

Stories from Veterans
• Mr. S1
• Before: “to relieve stress,”
• “I get on my computer and shoot up things”
• After: “I’m not angry anymore”
• “I’m using my breathing… [skills]”
• “Now I appreciate my wife”
• “Every Veteran should come to this program”

• Ms. S
• Burdened by stress and alcohol
• “The pain is not in control anymore”
• “Reconnected with my church family”

• Mr. W
• 23 years in misery from Chronic Pain with care
– MANY Inside VHA and outside providers
• “EVP is the best thing the VA has given me”
• Wrote letter to forgive man
who killed his family in car accident

• Mr. S2
– Very depressed and isolated
– Suicidal Ideations daily
– Came twice to 10 week EVP
• “I don’t need you all anymore.
I’m doing better.”
• “But can you help me quit smoking,”
because, “I want to live!”

• Mr. E
• “I helped my family with
what I learned in EVP”
– “[in family argument] I sent my daughter to her
room and I talked with my wife
• [about not screaming in anger or saying
that their daughter was stupid]”
• “That’s the way I used to treat you”

Feedback from Spouses
• “My husband’s a new man”
• [not isolating anymore]
– “My husband went to church for the first time in two
years, and now is spending time with family again”
– “Now he get dressed, has breakfast with me and goes
to the park every day”
• “His anxieties are so much better”
[had been attending weekly PTSD support group
without change for years]

Clinical Outcome Assessments
(Preliminary Details to Come)
• Chronic Pain Acceptance Questionnaire
• Acceptance Action Questionnaire II
• NRS
• Multidimensional Pain Inventory - Interference
• PHQ9
• WHOQOL-BREF
• PROMIS 29 paper v2.0
• Pain Catastrophizing Scale

Next Steps
• Analysis of
– Clinical outcomes (with sensitivity to change)
– Utilization outcomes
– Staff satisfaction

“Empower Veterans” Value Compass
Costs
• Utilization of Emergency,
Walk-in and PM&R
Satisfaction
• Long Term Veteran
Satisfaction
Biological
Status
• High Dose Opioids
• Benzodiazepine Use
• Urine Drug Screen
• Anxiety / PTSD
• Depression
• Self-efficacy
Function Health Status
• Quality of Life
• Attainment of Personalized Functional Goals
• Disruptive Behavior

“Empower Veterans” Balanced Scorecard
Financial
• Utilization of Emergency, Walk-Ins, PM&R
• Utilization of PACT routine appointments
• Other Personnel Costs
• Pharmacy Costs
Satisfaction vs Need
• Veteran Accidental Overdose
Deaths from Opioids
• Veteran Function
• Long Term Veteran Satisfaction
• Long Term Congressional Office
Satisfaction
Innovation
and Learning
• Staff Satisfaction and
Retention
• Operating at “top of
their license”
• Increased Efficiency
• Group Visits
• Secure
Messaging
• TeleHealth
Encounters
Key Processes
• Identification of Veterans at Risk
• Training Veterans in Self-Management

Social Worker Perspective
Ushvani Persaud, LCSW

– Bio-Psychosocial & Financial assessment
– Planning & Intervention
– Crisis Intervention
– Pt & Family Education
– Counseling & Advocacy
– Resource Brokering & Referrals
– Quality Improvement & Systems Integration
– Case Facilitation
Social Work Services:

Homeless Veteran in tears,
“I want to leave…I thought I could do this program,
but I can’t!”
Social Worker provided immediate crisis
intervention/counseling & advocacy
She completed EVP training,
empowered to make a change in her life
Stories of Veteran success with Social Work
Intervention (Part 1 of 4)

Veteran with whole life dysfunction,
Frustrated with traditional medical care, with life….
Social Worker helped with:
Sleep Study and CPAP
Care Coordination
Financial Issues
Now with better mood and sleep
And better and safer care

Veteran with daily suicidal thoughts, PTSD,
poor ability to communicate with others …
With weekly Social Work intervention he received:
Sleep Medicine treatment;
PTSD and other specialized Mental Health care including
coaching in social skills …
He successfully completed EVP Training
(showed up in cap & gown at Graduation)

Veteran with PTSD, two suicidal attempts & substance abuse,
Was afraid to sleep without TV on,
Was non-adherent to attending appointments
Weekly Social Work intervention, case management
Pt successfully completed EVP training & said
he loves EVP!

Understanding Pain video link:
http://www.dvcipm.org/clinical-resources/joint-pain-
education-project-jpep

EVP WHOLE HEALTH
NEW PERSPECTIVES AND SKILLS FOR VETERANS
LIVING WITH CHRONIC PAIN
Paul Burholt, LCSW

Personal Health Inventory
Fuller Life
Well-Being
Values

BASIC PREMISE:
I can create a fuller life for myself,
in spite of my pain and limitations !

The goal posts have been moved--
but that does not mean
I am out of the game

Whole Life Issues
• Poor Diet
• Poor Sleep
• Spirituality—loss of meaning and purpose
• Isolation
• Anger and resentment
• The challenge of suffering

“I can’t have a fuller life until I
am pain-free!”
Paradigm Shift is always hard…

Question this!
Someone with chronic pain and disability
is of no value and has nothing to offer

And this!
You are only of value if you are young, healthy
and pain-free

Week 2: Foundational
• Can someone with chronic pain and
disability have a life which is
fulfilling and meaningful?
• Can I live a fuller life, in spite of my pain
and the tendency toward an ever more
constricted life which my pain
seems to imply?

Week 2 (Contd.)
• Viktor Frankl’s witness

Week 3: Foundational
• Empowerment by Values
• Personal Values clarification and
Goal setting
• Reinforces ACT

Weeks 4-6
• Food and Drink
• Sleep
• Spirit and Soul

Weeks 7-9
More Personally Challenging and Existential Themes
• Re-building Relationships
• Forgiveness
• Meaning in our Suffering

Because many Veterans
are in Crisis…

Don’t believe
everything you think!

Empowered to Live a Fuller Life

Acceptance and Commitment
Therapy (ACT)
Beth Hammons, Ph.D.
Clinical Psychologist

ACT Overview: Values
• Goal of ACT is to create a rich, meaningful life
• Personal Values
– What you want to be doing with your life
– What you want to stand for
– Choices you make about what you want your life
to be about

ACT Overview: Action
• Emphasis on taking effective action
• Action is directed by personal values
• Acceptance is an essential part of committed
action

ACT Overview: Mindfulness
• Mindfulness is an essential facet of ACT
• Completed mindfulness practice during Whole
Health presentation

ACT Overview: Empirical Data
• Based on empirical data supporting its
effectiveness
• Overview of EVP ACT program evaluation data
– Increased activity engagement regardless of pain
– Increased psychological flexibility
– No changes in pain willingness

ACT Overview
• Not about getting rid of unpleasant feelings
– About living a meaningful life
• Use of metaphor and experiential exercises
– “What is your experience telling you?”

The Passengers on a Bus:
An ACT metaphor

EVP-Mindful Movement
Jennifer Gansen, DPT
Lindsay Ballengee, DPT, RYT

Jennifer Gansen, DPT
• EVP-MM developer and trainer
• Relevant background/experience:
– Hospital-based multi-disciplinary Chronic Pain
Program (1993-95)
– Research Physical Therapist in Neurorehabilitation
to improve walking and use of arm after stroke.
– Awareness Through Movement instructor
(Feldenkrais Method)
– 6 years VA Outpatient clinic and Pain School

EVP-MM: Important role of the Nervous System
• Pain is a protective output of the brain that reflects a
“best guess” perceptual inference of threat/danger.
• Objectives:
– Relate Activity to values & goals
– Minimize nociceptive input from tissues
– Promote feeling safe, competent, and in control
– Promote enriched learning environment

Need to design structured approach to rehab that
reconciles Tissues AND Nervous System
Structural Pathology Paradigm
(Tissues)
Learning/Neuroplasticity
(Nervous System)
Content Aerobic Exercise
guidelines
Emphasize mindfulness &
variety of movement
Content Overload Principle
(“no pain, no gain!”)
Weber-Fechner Law and
ability to perceive change
Content Stretch tight tissues &
Strengthen weak tissues
Dynamic systems and
“Re-set button”
Content Whole Body Movement
systems
Learning principles like
“chunking”

Need to design structured approach to rehab that
reconciles Tissues AND Nervous System
Structural Pathology Paradigm
(Tissues)
Learning/Neuroplasticity
(Nervous System)
Style SMART or FITT goals Goals reflect Values
Style Role as “Expert” Role as “Coach”
Style Avoid Diagnostic
Uncertainty
Minimize perceived
“threat value” of
diagnosis
Style Hurt ≠ Harm Minimize perceived
“threat value” of stimulus

EVP Mindful Movement (EVP-MM) Overview:
Content Understanding Pain and natural tendencies of the
nervous system
Content 5 Minute walking (movement) break/ 3x per day
Content Neuromuscular Reeducation (NMR) or “Movement
Awareness Lesson”
Content Motion is Lotion Exercises (MILEs): Functional
progression of movement patterns with emphasis on
mindfulness & context variety
Content Neutral Spine and Re-set Button: Experiential and
problem-solving approach emphasizes guidelines
applied to daily activities

EVP Mindful Movement (EVP-MM) Overview:
Style Active Listening: Non-judgmental, empathic, convey a
positive regard
Style Promote Autonomy
Style Promote Self-Efficacy
Style Promote Social-Relatedness/ Values

POWER TOOL: MINDFULNESS when EXERCISING
If you notice increased pain with exercise, ask
yourself 2 questions:
1)Am I safe?
2)If I continue, will I pay for it later?
1) Is my breath calm?
2) Is my body calm?
3) Am I staying in touch with my body?
Source: 6 minute video on YouTube
NEIL PEARSON: EXERCISE GUIDELINES
http://youtu.be/gN-WwxfPIZo

Lindsay Ballengee, DPT, RYT: Mindful Movement Experience

Spread
• Manualized EVP is coming!

Cheers for GREAT EVP Team:
• “Paul” Burholt, LCSW
• Chaplain Curtis Williams, D Min
• Chaplain “Drew” Tomberlin, D Min
• “Beth” Hammons, PhD
• Jenna DelVentura, PhD
• Jennifer Gansen, DPT
• Lindsay Ballengee, DPT, RYT
• George Shaw, PT
• Ushvani Persaud, LCSW
• Natasha Ewell, MSA; Bevelyn Porter, MSA
• Faye King, Administrative Officer

3
2
Step 1
Veteran Client &
Primary Care
Self-Care
Empower
Veterans Program
Accessible
Functional
Restoration
EVP for a Fuller Life!

Special Thanks to:
Atlanta VA Healthcare System
• Leslie Wiggins; Director (now Director, VISN 7)
• David Bower, MD; Chief Medical Officer (now Acting Director of ATL VA)
• Sandy Leake, MSN, RN; Associate Director, Nursing/Patient Care Services
• Tom Grace; Associate Director; “Bob” Evans; Assistant Director
• Anne Tomolo, MD, MPH; Quality Scholars Program
• David Fishman, MD; Chief of Anesthesia Service Line
• Cedrella Jones-Taylor, MD; Deputy Chief of Primary Care Service Line
• “Kathy” Davari, Pharm D, Supervisor Pharmacy Specialists
VHA Pain Management
• “Mac” Gallagher, MD; Director and team
VHA Office of Patient Centered Care and Cultural Transformation
• Tracy Gaudet, MD; Executive Director and team
VHA PACT Pain CoP (Community of Practice); PDICI CoP; Ilene Robeck, MD
92

Key References
ACT Manual:
1Vowles, K.E., Sorrell, J.T. (2007). Life with Chronic Pain: An acceptance-based
approach.
EVP-Mindful Movement:
1Lotze, M., Moseley, G.L. (2015). Theoretical considerations for chronic pain
rehabilitation. Phys Ther (95):1316-1320.
2Pelletier, R., Higgins, J., Bourbonnais, D. (2015). Is neuroplasticity in the central
nervous system the missing link to our understanding of chronic musculoskeletal
disorders? BMC Musculoskeletal Disorders 16:25. DOI 10.1186/s12891-015-
0480-y.
3Zaman, J., Vlaeyen, J.W.S., Van Ourdenhove, L., Weich, K., Van Diest, I. (2015).
Associative fear learning and perceptual discrimination: A perceptual pathway in
the development of chronic pain. Neuroscience and Biobehavioral Reviews 51:
118-125.

Rx16 presummit 200_empower_veteransprogram

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