development and implementation of an interdisciplinary ...€¦ · development and implementation...
Post on 05-Jun-2020
2 Views
Preview:
TRANSCRIPT
Development and Implementation of an Interdisciplinary Group Medical Visit for Chronic Pain in a Rural Health Clinic
• Maxwell Moholy, PhD, Behavioral Health Consultant, Cascade Medical Center
• David Bauman, PhD, Behavioral Health Education Director, Central Washington Family Medicine
Session # H5b
CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York
Faculty DisclosureThe presenters of this session currently have or have had the
following relevant financial relationships (in any amount)
during the past 12 months.
David Bauman is a consultant for Beachy Bauman Consulting
Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
Learning Objectives
At the conclusion of this session, we hope that will be able to:
▪Discuss the need for an interdisciplinary approach to pain management in a rural primary care setting.
▪Describe the process, including successes and ongoing challenges, of developing and implementing an interdisciplinary chronic pain group medical visit in a rural primary care clinic.
▪Evaluate the feasibility and effectiveness of a chronic pain group medical visit for improving patient care and provider satisfaction.
About us❖Maxwell Moholy, PhD❖Behavioral Health Consultant for Cascade Medical Center
❖Roles include: PCBH Clinical, QI committee
❖David Bauman, PsyD◦ Behavioral Health Education Director for Central Washington Family Medicine
◦ Roles include: PCBH clinical, core faculty for FM residency, RTD of PCBH psychology internship
Outline❖Background❖Chronic Pain
❖Group Medical Visits
❖Implementation at Cascade Medical Center
❖Discussion
Who’s here?Physicians?
Nurses?
Behavioral Health Clinicians?
Administrators?
Other?
Who’s here?Who has helped run a group medical visit?
What challenges/barriers have people faced in trying developing/implementing a group visit?
What successes have people seen?
What is Chronic Pain?1
Acute vs Chronic Pain◦ Pain lasting longer than 3 – 6 months
Chronic pain◦ Usually no clear etiology
◦ Musculoskeletal disorders◦ Muscles, ligaments/tendons, bones and nerves
◦ Localized or generalized
◦ Low back pain◦ Most common disability
◦ Lumbar degenerative disc disease
◦ 30% of people (30-50 y/o)
◦ May or may not cause discomfort
◦ W/o structural abnormality, can still have pain
What is Chronic Pain?Chronic Pain◦ Joint disease
◦ Arthritis
◦ Rheumatoid arthritis – immune system attacks own cells
◦ Other forms of chronic pain◦ Chronic fatigue syndrome
◦ Endometriosis
◦ Fibromyalgia
◦ Lupus
◦ Inflammatory bowl disease
◦ Interstitial cystitis
◦ Temporomandibular joint dysfunction
◦ Headaches
◦ Migraines
What is Chronic Pain?1,2
Influence of CP on the PC system:◦ CP is the most common reason for seeking medical attention
◦ Estimated 20-50% of patients seen in PC◦ Think about that… 20-50%
Current treatments: only about 30% reduction in pain levels3
◦ However, partial reduction in pain can significantly improve patient’s QOL
Demand for opioid intervention◦ Lacking of long-term benefit and sx/QOL improvement; increase in serious risk of harm5,6
Recommended CP tx by multidisciplinary team◦ Medications should NOT be sole focus of treatment
◦ We will come back to this ☺
Lifestyle factors associated w/ Chronic Pain1-
3
Tobacco use◦ Higher levels of smoking = higher level of pain & less physical involvement9
Depression (similar pathways – emotion & pain)
◦ 4x’s higher rate of having disabling pain
◦ Greater pain intensity
Overweight or Obese
What came first?
Behavioral interventions for chronic pain1-7
Research on behavioral techniques◦ Eh… could be better
◦ CBT recommended for general chronic pain and chronic low back pain◦ In addition to CBT, relaxation techniques, exercise, self-care , education have been shown to be somewhat effective
◦ Self-care → Pacing, returning to functioning, helpful in pain reduction and functionality
◦ Exercise therapy → helpful in pain reduction and functioning
◦ Mind body interventions (mediation and mindfulness) → budding research but not clear regarding effectiveness
◦ Education → budding research, not conclusive, focus on neurophysiology education vs biomechanical may be more beneficial
In addition to the above, we like to promote the NEEDS approach◦ N – Nutrition; E – Enjoyable activities; E – Exercise; D – Don’t smoke or drink; S – Sleep
Population based efforts1-8
Limitations of one on one visits
Need to have population based approaches to get the message/interventions out to the masses
Say hello to chronic pain groups◦ Most of the affirmation behavioral interventions have been adapted and applied in group
formats◦ Similar results to individual
◦ Encouraged to include multidisciplinary team members, which could include medical providers, behavioral health providers, nutritionists, physical therapists, etc. (emphasizes the team approach)
◦ Research:◦ Not well defined but showing evidence of improvement in both pain reduction and functioning
Last few thoughts…Anecdotally from our experience at CWFM◦ Include a BHC, resident and PA
◦ 10-15 patients per group (two monthly groups)
◦ Best part of the group?◦ Love isn’t everything, it’s the only thing
Chronic pain pathways◦ Great ideas!
◦ “Hell is paved with good intentions.” - Samuel Johnson
◦ Often, difficult to implement
◦ Need:
◦ Provider support
◦ Administration support
◦ Support staff support
◦ Etc., etc.,
◦ We are going to give an overview of an initiative and be REAL about it
Implementation efforts at a clinic in Leavenworth, WA
The Setting
The Setting
Medicare40.00%
Medicaid, 14.00%
Other 46.00%
Patients with chronic pain❖515 patients on long-term opioid therapy
❖140 patients with a long-term opioid therapy treatment agreement
❖83 patients with concurrent opioids + benzos
Long-term opioid therapy treatment agreements❖84-day refill appointments
❖Annual urine drug screens + provider discretion
❖Prescription monitoring program
❖How to involve BHC?
Early Development of Group❖Realistic expectations/goals for the group
❖Group Medical Visit vs. Traditional Behavioral Health Group
❖How to conduct the “medical” part of the visit
The Group❖Who❖Provider, BHC, two support staff
❖Guest speakers:❖Dietician, PT, Clinical Pharmacist, others?
❖When❖Monthly
❖2-hour schedule block, 90-minutes for the group
Recruitment❖Letter + follow-up phone calls
❖Identifying patient’s at refill visits
❖Patient buy-in?❖Counts as an office visit for pain med refills
❖Become more proactive in management of your pain
Group Agenda❖Check-in / Vitals / Complete Pain Tracker
❖Brief individual visit with provider
❖20-30 minute presentation/discussion❖Pathophysiology of pain
❖Mindfulness
❖Exercise/Pacing
❖Sleep
❖Nutrition
Measurements❖University of Washington Pain Tracker❖PEG
❖Sleep
❖PHQ-4
❖Satisfaction w/ Tx
https://depts.washington.edu/anesth/education/pain/index.shtml
PEG
Participants❖26 patients across 5 groups to date❖Our target? 8-12
❖Patient feedback❖8 patients have been to 2+ groups
Pain Tracker Data
0
2
4
6
8
PEG Sleep PHQ-4 Satisfaction
Comments from our provider❖Recruitment efforts
❖Clinic initiative
❖Nuts and bolts
Discussion/Questions
Final Thoughts❖Different way of engaging patients and providers
❖Shifting perspective clinic-wide
❖Ongoing evaluation and improvement
Handouts/Tools available for you❖Sample group visit planning checklist
❖Sample group visit flyer
❖Sample group visit recruitment letter
❖UW Pain Tracker (https://depts.washington.edu/anesth/education/pain/index.shtml)
References1. Rosenquist, E. W. (2018). Overview of the treatment of chronic non-cancer pain. In UpToDate. Retrieved September 30, 2018, from https://www-
uptodate-com.offcampus.lib.washington.edu/contents/overview-of-the-treatment-of-chronic-non-cancer-pain?search=chronic%20pain&source=search_result&selectedTitle=1~150&usage_type=default&di
2. Chou, R. (2018). Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment. In UpToDate. Retrieved September 30, 2018, from https://www-uptodate-com.offcampus.lib.washington.edu/contents/subacute-and-chronic-low-back-pain-nonpharmacologic-and-pharmacologic-treatment?sectionName=Cognitive%20beh avioral%20therapy&topicRef=278
3. Janke, EA, Collins, A, Kozak, AT. Overview of the relationship between pain and obesity: What do we know? Where do we go next? Journal of Rehabilitation Research and Development 2007; 44(2): 245-262
4. Geneen, L. J., Moore, R., Clarke, C., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane database of systematic reviews. doi:10.1002/14651858.CD011279.pub3
5. Robinson, P., Bauman, D., & Beachy, B. (2016). Promoting healthy lifestyle behaviors in patients with persistent pain. In J. Mechanick, & R. F. Kushner (Eds), Lifestyle medicine: Manual for clinical practice. New York, NY: Springer Science, Business Media, LLC.
6. Monticone, M., Cedraschi, C., Ambrosini, E., Rocca, B., Fiorentini, R., Restelli, M. … Moja, L.(2015). Cognitive-behavioural treatment for neck pain. Cochrane database of systematic reviews. doi:10.1002/14651858.CD010664.pub2
7. Williams, A. C., Eccleston, C., & Morley, S. (2012). Psychological therapy for adults with longstanding distressing pain and disability. Cochrane database of systematic reviews. doi:10.1002/14651858.CD007407.pub3
8. Gaynor, C. H., Vincent, C., & Safranek, S. (2007). Group medical visits for the management of chronic pain. American Family Physician, 1(76), 1704-1705.
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted
at the end of this presentation.
Session Evaluation
Use the CFHA mobile app to complete the
evaluation for this session.
Thank you!
top related