Transcript Document 7205635

VHA National Pain Management Strategy:
Update and Future Directions
Robert D. Kerns, Ph.D.
Chief, Psychology Service
VA Connecticut Healthcare System
And
Professor of Psychiatry, Neurology and Psychology
Yale University
Pain management is a national
priority for VHA



As many as 50% of male VA 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 frequent presenting
complaints of returning OEF/OIF soldiers;
particularly in patients with polytrauma (Clark, 2004;
Gironda 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)
Concomitants of persistent pain

Pain is associated with:







poorer self-rating of health status,
greater use of healthcare resources,
more tobacco use, alcohol use, diet/weight
concerns,
decreased social and physical activities,
lower social support,
higher levels of emotional distress, and
among women, high rates of military sexual
trauma. (Haskell et al, in press; Kerns et al., 2003; Mantyselka et al., 2003)
VHA National Pain Management
Strategy



Informed by study demonstrating
inconsistencies in VHA pain care
Strategy initiated by the Undersecretary
for Health in 1998
Pain Management Directive published in
2003
VHA Directive 2003-021:
Pain Management
Provides policy and implementation guidance for the
improvement of pain management consistent with the
VHA National Pain Management Strategy and compliance
with generally accepted Pain Management Standards of
Care.
Overall objective of the national strategy 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.
Goals of the VHA National Pain
Management Strategy




Provide a system-wide VHA standard of care for
pain management that will reduce suffering from
preventable pain
Assure that pain assessment is performed in a
consistent manner.
Assure that pain treatment is prompt and
appropriate.
Include patients and families as active
participants in pain management.
Goals of the VHA National Pain
Management Strategy



Provide for continual monitoring and
improvement in outcomes of pain treatment.
Provide for an interdisciplinary, multi-modal
approach to pain management.
Assure that clinicians practicing in the VA
healthcare system are adequately prepared to
assess and manage pain effectively.
Organization of National Strategy





National Program Director
Pain Strategy Coordinating Committee
Coordinating Committee Working Groups
VISN Points-of-Contact/VISN Pain
Committees
Local Facility Oversight Committees
Coordinating Committee Members











Bob Kerns – VACO/VACHS (Psychology)
Matthew Bair – Indianapolis (Primary Care)
Martha Bryan – VACO (ORD)
Michael Clark – Tampa (Psychology)
Audrey Drake – VACO (Nursing)
Rollin “Mac” Gallagher – Philadelphia (Pain Medicine/
Psychiatry)
Francine Goodman – VACO (PBM)
Mitchell Nazario – West Palm Beach (Pharmacy)
Beverly Green-Rashad – Houston (Nursing)
Jack Rosenberg – Ann Arbor (Pain Medicine/
Anesthesiology)
Anne Turner – Birmingham (EES)
Working Groups










Acute Pain Management (Rosenberg)
Education (Turner)
Guidelines (Rosenberg)
Nursing (Rashad)
Outcomes Measurement (Lawler)
Performance Improvement (Czarnecki)
Pharmacy (Goodman/Nazario)
Polytrauma (Clark)
Primary Care (Bair/Gallagher)
Research (Kerns/Bryan)
Coordinating Committee
Responsibilities








Coordinating system-wide implementation of
Strategy
Disseminating state-of-the-art treatment
protocols
Assure access to pain care throughout VHA
Assure employee education
Assure pain-relevant research agenda
Integrate pain education into professional
training curricula
Assure performance improvement
Assure internal and external communication
VISN Responsibilities

Identify VISN Pain Point of Contact


VISN 4 Pain POC – Nancy Wiedemer, CRNP
Oversight and monitoring of facility
performance
Facility Responsibilities

Provider and staff competencies assured



Assessment and treatment standards met






Orientation regarding pain assessment and management
Annual education
Pain as the 5th Vital Sign
Comprehensive pain assessment
Patient and family education
Pain management protocols established and implemented
Pain management is integral component of palliative and end-oflife care
Ongoing evaluation of outcomes and quality




Pain management committee established
Processes for continuous improvement are in place
Monitoring of outcomes
Assure adequate documentation
VISN 4 Facility Pain POCs

Altoona – Rodolpho Medina, MD

Butler – Timothy McNulty, MD

Clarksburg – Tracy Oldaker, RN, MSN

Coatesville – Pat O’Rourke, RN, CHPN

Erie – Harry Haus, MD

Lebanon - Jean Royal, RN

Philadelphia - Nancy Wiedemer, CRNP

Pittsburgh - Michael Mangione MD; Mary Lou Bossio CRNP

Wilkes-Barre -Joseph Casagrande, Ph.D., Nabeela Mian, M.D.

Wilmington - Mary Mackenzie CRNP
National Pain Management Strategy
Accomplishments

Implementation of “Pain as the 5th Vital
Sign” initiative




Pain as the 5th Vital Sign Toolkit
EPRP supportive measures
Successful VHA/IHI Pain Management
Collaborative
Development of web-based opioid training
Accomplishments

Provider education









Four national leadership conferences
“Evolving Paradigms” conference
Participation in multiple other conferences (primary
care, polytrauma)
Several satellite broadcasts
National pain management website
(www.va.gov/pain_management)
Monthly provider education teleconferences
VA Pain List Serve
VISN library resources
Patient education


Patient infomercial
MyHealtheVet information, self-assessment, and links
Accomplishments


Pain medicine fellowship training
established
Pain management guideline development



Low back pain
Acute post-operative pain
Chronic opioid therapy
Accomplishments

Outcome Measures




CPRS Clinical Reminders/Pain assessment and
treatment planning template
Outcomes Measures Toolkit
Consensus statement on assessment of pain
in the cognitively impaired person
Review of opioid use data
Accomplishments

Research



Rehabilitation R&D solicitation
Collaboration with HSRD QuERI programs
Special issue of Journal of Rehabilitation Research
and Development


Working group established


JRRD, Volume 44, Number 2, 2007
Over 50 VA pain-relevant investigators identified
Cluster groups developed






Pain in the cognitively-impaired
Pain, opioids, and substance abuse
Diversity and health disparities
Chronic pain and comorbid psychiatric disorders
Health services
Post-deployment health
Accomplishments

Performance measures



EPRP
ORYX
SHEP
Current Projects

Performance Measures

Cancer pain management pilot project
Documented pain plan of care
 If opioid therapy, is there constipation prophylaxis


Evidence Synthesis Projects (ESP)
Management of pain in inpatient medical settings
 Pain and polytrauma


Outcomes measures


Revised CPRS pain assessment and treatment
planning template/reminder system
Revised Outcomes Measures Toolkit
Current Projects

Guidelines



Revise post-operative pain guideline
More broadly disseminate guidelines, including
guidelines developed by other groups (e.g., APS)
Education





Revise opioid web-based course
Publish Information Letters on spinal cord stimulators
and intrathecal pumps
Continued collaboration with MyHealtheVet initiatives
Identify and disseminate model web-based training
Continuing update of national pain management
website
Current Projects

Pharmacy





National opioid data “dashboard” project
PBM publications related to opioids
Development and dissemination of model “opioid
agreement”
Evaluation of regulations related to C-II prescriptions
Pain and Polytrauma



HSRD/QuERI pain assessment formative evaluation
and implementation project
PT/BrI QuERI Executive Committee
Representation at National Polytrauma Conference
and upcoming TBI SOTA
Current Projects

Pain and primary care




Identify and disseminate best practices
Cyberseminar on pain and primary care
Recently established pain and primary care task force
within Primary Care SHG
Research





Developing proposal for multisite Cooperative Studies
TBI State-of-the-Art Conference
Continued advocacy within ORD for increased pain
relevant research funding
Special issue of Pain Medicine on pain and OEF/OIF
veterans
Advocating for establishment of Pain Research and
Education Center
Current Projects

Nursing Working Group






Support Coordinating Committee
Encourage collaboration
Develop specific nursing initiatives
Promote involvement of nurses in existing projects
Foster nursing initiated research and dissemination of
evidence-based practices
Increased acknowledgement of nursing contributions
Current Projects

Proposal for enhanced funding for
musculoskeletal disorders among OEF/OIF
veterans

Objective: Improved access to care
Increased medical and psychological providers
 Provider education
 Telehealth technologies
 Creation of additional multidisciplinary pain centers

Current Projects

Opioid – High Alert Medications Project


Objective: Enhance safe and effective use of opioids
Aims:






Increased use of CPRS pain assessment and reassessment
templates
Increased use of opioid agreements
Increased percent of prescribers who have completed opioid
web-based course
Increased percent of facilities that have successfully
implemented accepted protocols/guidelines for opioid use
(oral and PCA) in inpatient settings
Reduction in opioid related AEs
Increased availability of pain specialists, including pain
medicine specialists, pain resource nurses, clinical
pharmacists, and pain psychologists
Opioid – High Alert Medications








Standardize pain management protocols
Use appropriate monitoring for side effects
Increase use of non-pharmacologic
interventions
Double checks on pumps
Reversal protocols
Opioid agreements/treatment goals
Medication reconciliation
Availability of pain specialty consult
%
% PAIN POLICY/PAIN COMMITTEES
100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
90.0
72.3
PM Policy
PM Committee
Ot
he
r
Ph
M
ar
DmNe
D
u
ro
M
Dlog
Ps
is t
yc
hia
tri
st
DAn
es
th
iol
og
Ps
ist
yc
ho
log
ist
M
DPM
R
AP
RN
/N
P
M
DPa
RN
in
M
ed
ici
ne
M
%
PAIN STAFF
60.0 51.5 46.9
50.0
35.4 34.6 34.6 33.9 33.9
40.0
25.4 22.3
30.0
15.4
20.0
10.0
0.0
M
ed
Ps i ca
y tio
Ps c ho n m
yc l og a
ho ic na
l o al ge
Pa
g c m
t ie Bl ic al ons en
nt oc tre ult t
ed k s/ at ...
Su
uc i nj m e
pp
a e n
Co or PC ti on cti o t
gn tiv e A pr ns
i tiv p - i n o.
Be e sy c pa ..
G h a Beh ho ti en
ro vi a th t
u p or vi ...
ps a l t or T
Re y re ..
l a cho atm .
xa th e
ti o er n t
Bi n tr apy
Se ofe ain
l f- ed ing
O
Sp pio PC hyp ba c
in id A n o k
al re - s
Co ne c a i s
rd wa nc e
PC Stiml cli r
A u nic
Pa
l
i n Int Ac - Ho ator
Re ra up s p s
s o the un i ce
ur c a c tu
ce l p re
N um
PC urs ps
A e.
- H ..
BP
C
%
PAIN SERVICES
100
90
80
70
60
50
40
30
20
10
0
% SERVICES/SPECIALISTS
70.0
63.9
60.0
%
50.0
40.0
30.0
25.4
24.6
Pain Specialist in
PCS
Post-OP Epidural
20.0
10.0
0.0
Palliative Care Svc
(PCS)
%
PAIN TREATMENT FACILITIES
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
33.9
30.8
17.7
9.2
Pain clinic
Multidisciplinary
Modality
pain clinic
oriented clinic
Multidisciplinary
pain center
OPIOID SAFETY INPATIENT
Routine medication reconcilliation
72.3
Pain specialty consultation available
72.3
Performance improvement program
47.7
Routine double checks for PCAs
Protocol/algorithms for opioid
initiation/continuation
Protocols for AE monitoring
Protocols and reversal agents available
w ithout MD order
46.9
37.7
30.8
21.5
0
10
20
30
40
%
50
60
70
80
OPIOID SAFETY OUTPATIENT
Routine use of opioid agreements
80.8
Routine use of random uring drug
screens
68.5
Performance improvement program
37.7
0
20
40
60
%
80
100
Recommendations for enhanced
pain care at the facility level

Pain Management Committee




Assure provider competence
Promote patient/family education
Promote safe and effective use of analgesics,
particularly opioids
Promote access to effective pain care



Emphasize optimal pain care in primary care
Expand interdisciplinary focus
Assure access to cost-effective care
Pain Management Committee


Facility pain management policy
“The Pain Management Committee provides
oversight, coordination, and organization-wide
monitoring of pain management activities and
processes to ensure consistency with the VHA
National Pain Management Strategy”

Report to Chief of Staff and Medical Staff
Executive Committee

Reports to VISN Pain Committee
Pain Management Committee

Active performance improvement effort
 Ongoing monitoring of performance in all
settings of care





Establish minimal competencies and provide
ongoing provider education




Collaboration in establishing pain-relevant policies and procedures
Pain report card
Setting specific performance improvement projects
IHI type projects
Orientation of new employees
Annual mandatory training
Case based and setting/specialty specific provider training
Provide ongoing patient/family education



Pain fairs
Promote access to MyHealtheVet
“Living with pain class”
Highlights from VISN 4

Philadelphia



Opioid Renewal Clinic
Chronic Pain School
Pittsburgh


Successful Pain Resource Nurse (PRN)
Program
Upcoming two day training program
Summary

Support VISN Pain POC


Establish high functioning facility Pain Committee




Performance improvement
Provider competence
Educated consumers
Use existing resources




Develop mechanisms to assure bidirectional
communication with National Pain Management Strategy
Coordinating Committee
Pain Management website –
www.va.gov/pain_management
VA Pain List Serve
Monthly national teleconferences
Identify and nurture “painiacs”; get involved
Thanks!
[email protected]