commissioning pain management services: what do care pathways for people with long term pain and...
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Commissioning pain Commissioning pain management services: management services: what do care pathways what do care pathways
for people with long term for people with long term pain and clinicians need?pain and clinicians need?
Dr Frances Cole Clinical Lead, NHS Kirklees
GP + Pain Rehabilitation Specialist, Bradford Teaching Hospitals
June [email protected]
Undertake daily activities Not feel bodily painJoin in social activities Feel peaceful and happyDo physical tasks Feel full of life
WHO 1984, Ware 1993
Undertake daily activities Not feel bodily painJoin in social activities Feel peaceful and happyDo physical tasks Feel full of life
WHO 1984, Ware 1993
Health is a resource for living so we are able to:
Self coverage Health services programmes not flexible to meet needs
Self coverage Health services programmes not flexible to meet needs
Housing structure / location unsuitable adaptations need to reduce disability
Housing structure / location unsuitable adaptations need to reduce disability
Difficult to use public transportUnable to drive due to drugs
Difficult to use public transportUnable to drive due to drugs
Multidimensional impact of chronic pain on health
Multidimensional impact of chronic pain on health
Long term low income +/- benefit issues
Long term low income +/- benefit issues
Perceived lack of control over their pain and their life
Less contact with family, friends, social networks, specific support
Less contact with family, friends, social networks, specific support
Health needs change due to changing illness, disability. Pain relief mixed, variable
Health needs change due to changing illness, disability. Pain relief mixed, variable
Carers needs; little appropriate support Carers needs; little
appropriate support
Reduce goals, planning, pacing of daily life activities,
Fitness activity levels reduced
Reduce goals, planning, pacing of daily life activities,
Fitness activity levels reduced
Loss of work (paid/unpaid) Loss of work
(paid/unpaid)
Poor sleep patterns;
DepressionFear, Anger,
Shame, Fatigue
Poor understanding of pain condition/s and self manage confidentlyDyslexia, literacy, language
Poor understanding of pain condition/s and self manage confidentlyDyslexia, literacy, language
Women > Men >65 more than<65
Vitamin D insuff
National policies – UKChief Medical Officer report 2009; Dept of Work &
Pensions 2006 Dept of Health Long Term Health Condition Programme
NICE Guidelines; UK Pain Summit 2011 British Pain Society MoM pathways; Royal College
General Practice
Kirklees Joint Strategic Needs Kirklees Joint Strategic Needs Assessment (JSNA) 2009Assessment (JSNA) 2009
Pain worst impact on health - physical function
20% = no physical activity Affects 1 in 3 people 104,817 adults in Kirklees
89,679 affected = working age. People < 65 years 31% pain in past year People > 65 years 46% pain in past year: women >
men Poor sleep 1 in 3 Depressed 1 in 2 esp. back pain More have heart disease, diabetes, stroke 75% at least overweight Linked to low income £££ Impact on carers – many have chronic pain
www.kirklees.nhs.uk/
What do patients need to manage What do patients need to manage pain?pain?2 Commissioners engaged patients
NHS Kirklees; NHS Bradford + Airedale
Self care: key part of control on their lives + pain; want all GPs to refer all patients > self care services
Better self care information - range of media + sources
Better access to self care resources + servicesConfidence in GP + their skillsSeeing right clinician at right timeContinuity of care: more seamlessConsistency of experience at all steps of pathwayFaster access: assessments + investigationsFaster access: Physiotherapy, Occup.Therapy, Pain
Specialist
What do primary care clinicians What do primary care clinicians need?need?
Change of model + pathway: biospychosocial model for long term pain
More knowledge + skills: <10 hrs training for doctors More time with patient in consultation
Improve medicines management + clinical skills ◦ Pain symptoms, side effects, guidance + decision aid tools◦ Manage emotional distress, cope with setbacks
Referral - minimum data > single entry point in pathway Referral guidance – decision aids; Map of Medicine Stop referring for spinal surgery for pain Know about self care resources; where / how to refer or use
them More awareness - financial costs; primary + (secondary care
clinicians)
Kirklees Council Scrutiny Panel Kirklees Council Scrutiny Panel for Health Inequalitiesfor Health Inequalities
20102010Main recommendations:Consistent pain services - person
centred approaches to pain management
Services closer to homeTraining & professional development
about self management options Reduce referral times – physiotherapyPilot person centred chronic pain
service across Kirklees
Pathway Objectives Pathway Objectives forfor NHS NHS KirkleesKirklees
Improve health & resilience by reducing disability + distress
experience of persistent pain sufferers
by a comprehensive, accessible + quality programme that
Commissions services with sustainable, consistent delivery + measure performance management
Monitors quality of clinical practice + meet standards set in line with local / national guidance
Ensures ongoing professional development
Ensures cost effectiveness + efficiency
Patient Centred OutcomesPatient Centred Outcomes Improve health as a resource for life Improve confidence + sense of control (self efficacy) so….
improve self care with more ways to help themselves Return to or stay in work Reduce pain distress + intensity; total relief not expected Improve mental health & wellbeing; less anxious +
depressedReduce unhealthy behaviours: weight loss, stop smoking,
more physically activeReduce in health care use: GP, specialist referrals
Patient Reported Outcomes Measure Scores
Commissioning services: Commissioning services: so people self care better in Kirkleesso people self care better in Kirklees
• Expert Patients Programmes self management courses or support to develop self-care skills (for conditions e.g. diabetes, mental health, COPD + chronic pain
• Health Trainers / Physical Activity Leisure Scheme - Help to change behaviour (e.g: lose weight, stop smoking, take up activity), 1:1 or group support, Specific for pain: REVIVE
• Self Care Web Portal – Local information in one place. Access to Networks and opportunities to talk to people in same situation i.e. support groups, forum;
• Libraries - bibliotherapy + range of self help books, pain toolkit ,CDs etc
• Gateway to care offers advice, practical support for both patients + carers; network to relevant services
• Better health at work – confidential support and advice for all work related issues
www.kirklees.nhs.uk/self care
Self management resources Self management resources neededneeded
Tier 1
Tier 2
Tier 3
www.npowered.co.uk
www.paintoolkit.org/
www.overcoming.co.uk/
Resources in clinics, libraries etc
Oral + written information =
important as drugs, test, scan or surgery
Information needs change over time
Clinicians need more medicines Clinicians need more medicines management guidancemanagement guidance
Neuropathic Pain algorithmOpioid algorithm
Boost confidence so prescribe safely, effectively + ££Provide range of patient tools: self assess + self manageProvide clinical tools to assess + review Integrate
◦ into GP computer System 1 + PCT website◦ with pain specialist clinicians
www.kirklees.nhs.uk/yourhealth/long-term-pain
Commission pain specialist Commission pain specialist procedures procedures
Agreement on range of treatments provided
Evidence focus + clinician dialogue with public health
Specific contracts; so stop some procedures + agree to limit repeats
Prior commissioning approval for complex treatments e.g. spinal cord stimulators
Outcomes so far – 4 yearsOutcomes so far – 4 yearsTier 3 Pain specialist services: Overspend agreed budget limits – moving to prior approval Map of Medicine changes starting
Tier 2 Pain service 90% less referral to pain specialist 50% less health care use – primary care Patient confidence to self care increased by 50% More GP’s confident to use drugs + support self care Tier 2 specification + tender for 250,000 pop.
Tier 1 Primary care Medicines Management GP survey - use + helpful, costs
flattening + savings GP implement incentive scheme - drugs + self care referral
Self care services Greater use + more proactive care pharmacy schemes, leaflets,
other ways etc
Key messagesKey messagesPeople with pain must be taken seriously!!!!!
Many helpful key drivers – clear frameworks, JSNA, Health Inequalities, Map of Medicine, etc
Quality information about local impact + evidence for action
Person Centred thinking so real outcomes specified
Being in control / resilience crucial i.e. able to Self care
Pathways need to be seamless, integrated with better skilled clinicians delivering consistent messages
Deliver more effectively for less ££££Collaboration between patients, clinicians,
public health + politicians
Reviewing pain services
• Involve services users at each stage of developing chronic pain pathway.
• Patient views – needs based care pathway. • Feedback to service providers and PCT
commissioners – inform care pathway
Engagement of service users
• Recruitment – Public & Patient Involvement (PPI) database, via pain services, Expert Patient Programme (EPP) support groups
• Discussion groups across Kirklees• Sessions facilitated by PPI team and Public Health• Report back to service users for comments
Proposed care pathway
• Overall support for the proposals:• Liked patient centred approach- HNA’s and health
trainer input• Improve access to GP /primary care - referral to
specialist services• Want all GP’s to refer all patients to self care services• Better condition management• Improved emphasis on control via self care
One single
point of access
Self Care
Menu of options•Self management courses•One to one support•On line support•Structured education courses•Support groups•Weight management•Behaviour change•Smoking cessation•Support for carers•Physical activity courses
Patient & Health Care Professional – Shared decision makingand discussion of self care options to support motivation to change and manage social, emotional and physical impact of LTC
Referring patients to self care Referring patients to self care servicesservices
Kirklees approachKirklees approachChronic Pain as a Long Term
Condition (LTC)LTC organisational structureChronic Pain programmeChronic Pain - Health
Improvement Team (HIT)
Joint Strategic Needs Assessment• Affects 1 in 3 people,104,817 adults in Kirklees• Pain - worst impact on health function, esp. physical function, 20%
did no physical activity• People 65 > - 31% experienced pain over past year;• People < 65 - 46% experienced pain esp. women. • Poor sleep 1 in 3 • Depressed 1 in 2• More likely to have heart disease, diabetes, stroke • 75% overweight or obese, • Linked to low income• Impact on carers – many have chronic pain themselves.
What Happened Next
• Pain recognised as a significant issue across Kirklees• Service users involved in developing a new pathway• Pain specific self management services• Review of practice in Primary Care• Medicines management guidelines• Priority for our CCG – tendering for a community based
pain service• Work with secondary care specialists to develop evidence
based policies for key procedures
What will this achieve?
The following patient centred outcomes:– Reduced levels of distress and disability– Improved symptom control, physical functioning
and well-being– Improved confidence to self manage their pain,
medication and their health
TimescalesTimescalesPhase 1(June 09)- experience of
chronic pain, current service provision and needs for future.
Over 70 participants attendedPhase 2 (Sept 09) – presenting draft
care pathway & whether it meets service user needs.
Over 25 participants attended
Phase 1 - key issuesPhase 1 - key issues More immediate action for relevant assessments /
investigations. Improved GP understanding of other support services
e.g. self care programmes Being able to see the right person at the right time Improve waiting times for referral to Physiotherapy,
O.T, pain clinics More continuity of care with each service having an
understanding about other services that can provide help
Similar service provision across PCT area. Better patient information. Self care as an key part of managing pain with regular
access to self care resources and services
Chronic condition management as applied to the Chronic condition management as applied to the NHSNHS
3. 5% case management
2. 15-25% Condition
management
1. 70-80%
self-management
LTC framework
NHS Kirklees LTC Programme Delivery
Group
Kirklees LTC Partnership Board
LTC HITS (Health Improvement Teams)
Cardiology PainStroke NeurologyRespiratory Self CareDiabetes & Renal Dermatology
LTC programme delivery group
WORKSTREAM Workforce
capability and capacity
LTC Project Boards
TelehealthPredictive risk
NHS KirkleesStrategic Development
Commitee
WORKSTREAM Rehabilitation and
self care
WORKSTREAM Information and
performance
WORKSTREAM Personalised care
planning
LTC Programme Dependencies
End of Life Older PeopleIntermediate care Urgent Care Medicines Mental healthManagement Planned careCHIK Programmes
LTC frameworkLTC framework
NHS Kirklees LTC Programme Delivery
Group
Kirklees LTC Partnership Board
LTC HITS (Health Improvement Teams)
Cardiology PainStroke NeurologyRespiratory Self CareDiabetes & Renal Dermatology
LTC programme delivery group
WORKSTREAM Workforce
capability and capacity
LTC Project Boards
TelehealthPredictive risk
NHS KirkleesStrategic Development
Commitee
WORKSTREAM Rehabilitation and
self care
WORKSTREAM Information and
performance
WORKSTREAM Personalised care
planning
LTC Programme Dependencies
End of Life Older PeopleIntermediate care Urgent Care Medicines Mental healthManagement Planned careCHIK Programmes
Reviewing pain servicesReviewing pain servicesInvolve services users at each
stage of developing chronic pain pathway.
Patient views – needs based care pathway.
Feedback to service providers and PCT commissioners – inform care pathway
Engagement of service usersEngagement of service users
Recruitment – Public & Patient Involvement (PPI) database, via pain services, Expert Patient Programme (EPP) support groups
Discussion groups across KirkleesSessions facilitated by PPI team and
Public HealthReport back to service users for
comments
Proposed care pathwayProposed care pathwayOverall support for the proposals:Liked patient centred approach- HNA’s
and health trainer inputImprove access to GP /primary care -
referral to specialist servicesWant all GP’s to refer all patients to
self care servicesBetter condition managementImproved emphasis on control via self
care
And information + resources…..And information + resources…..what patients need to copewhat patients need to cope
More tailored information What is wrong and prognosis How to make most of consultations, assessment Understand roles in self care + sources of help Learn how to prevent further problems
Information needs change over time Ensure patient can ask for more help again, again
Pathway: Oral + written inform =
important as drugs, test, scan or surgery
Source: Patient-focused intervention A review of the evidence Angela Coulter, Jo Ellins Picker Institute 2006
Key drivers nowKey drivers nowNational policy – UK
◦CMO report 2009 ◦Pain Summit 2011 www.painsummit.org.uk ◦British Pain Society, RCGP
Local policy – Kirklees - Bradford◦ Joint Strategic Needs Assessment –
population needs led approach www.kirkless.nhs.uk
◦Scrutiny Panel for Health Inequalities agenda◦Long Term Conditions + Self Care
frameworksPatient + Public Involvement
◦ Shaping services commissioned
Impact of painCondition Order of impact on health
Pain Worst Impact
Heart Disease
Backache
Depression
Stroke
High Blood Pressure
Diabetes
Asthma Least Impact
Coping: the efforts to deal with stressful situations that tax or
exceeds one’s individual resources Lazman R Folkman S 1984.
Pain coping efforts: strategies to cope with or deal with, minimise
pain & pain related distress + disability Keefe F J Pain 1983
Resilience - the ability to adapt in the face of adversity and continue
to function ‘normally’.
The sense of control people feel they have over their lives, their
sense of purpose, confidence and self esteem.
Living with pain… and Living with pain… and LTHC’sLTHC’s
Health needs assessment toolHealth needs assessment tool patients guide us…. patients guide us…..their agenda.their agenda
1000 + Patients using a specific HNA tool in 1000 + Patients using a specific HNA tool in clinical settingsclinical settings
Lack of fitness and energy
Walking or moving about, balance or falls
Pain relief or side effects or problems with current medication
Understanding why my pain condition has occurred
Unhelpful pattern of pacing activities
Disturbed sleep
Eating the right types of food
Managing mood changes
Relationship difficulties; with partner, family, work etc
Sex life
Remaining or returning to work and/or training
Financial difficulties, housing or accommodation problems
Concerns about carer/partner, their health or other problems
Other difficulties important to change e.g. hobbies, leisure, social events etc…
Circle 3 priorities for you now