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

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A question and answer period will be conducted

at the end of this presentation.

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