Stepped Care Model for Stepped Care Model for Pain ManagementPain Management

Nabiha Gill, MDNabiha Gill, MDStaff Physician PM&RStaff Physician PM&R

Chair, Indianapolis VA Pain CommitteeChair, Indianapolis VA Pain CommitteeChair, VISN 11 Pain CommitteeChair, VISN 11 Pain Committee

Assistant Professor, PM&R, IUPUI, Indianapolis, INAssistant Professor, PM&R, IUPUI, Indianapolis, IN

ObjectivesObjectives

• Progress as facility pain committee

• Progress as VISN pain committee

• Successes

• Struggles

• Next steps

Indianapolis VA Pain Indianapolis VA Pain CommitteeCommittee

Indianapolis VA Pain CommitteeIndianapolis VA Pain Committee

• Updated pain committee member list• Added more pain disciplines rep• E-mail group for communication• More structured• More enthusiasm, motivation, energy among

members• Updated/reviewed committee objectives• Developed “Multidisciplinary Virtual Pain Team

Consultation”

““Multidisciplinary Virtual Pain Team Multidisciplinary Virtual Pain Team Consultation”Consultation”

• Developed “Multidisciplinary Virtual Pain Team Consultation”

• Subgroup of facility pain committee• Primary and secondary (back up) key people

from each discipline• Support from departmental chiefs and EMT• More than 10 disciplines on the team• Regular communication among team members• Pilot program done in primary care

““Multidisciplinary Virtual Pain Team Multidisciplinary Virtual Pain Team Consultation”Consultation”

• Key members from following disciplines;1. Physical Medicine & Rehab Physician2. Pain Psychologist3. Physical therapist4. Rec therapist5. Interventional pain specialist6. Ortho spine surgeon7. Neurosurgery8. Primary care physician9. Pharmacist10. Patient advocate11. Social worker

““Multidisciplinary Virtual Pain Team Multidisciplinary Virtual Pain Team Consultation”Consultation”

• Developed CPRS consult order, virtual/historical visit/note title/note/alerts

• Chart review by all disciplines prior to case discussion

• Primary care provider gets invited to meeting, short case presentation by PCP….then consultation from all disciplines

• Opportunity for provider education about services from different pain disciplines and pain management

• Support for PCP • Case example

Proposed “Stepped care Proposed “Stepped care model for pain management model for pain management

for Indianapolis VA”for Indianapolis VA”

TERTIARY LEVEL

SECONDARY LEVEL

PRIMARY LEVEL

Proposed Stepped care model for Proposed Stepped care model for pain for Indianapolis VA pain for Indianapolis VA

Provider education

Pain Medication Management

Pain Medication Management

Pain Policy

Pain School

Primary Care Clinics/Teams

Bupe Clinic/SATS

Secondary ConsultsInt Pain Clinic

Chronic Pain Rehab Program

Multi-dis pain

Tertiary

Sec

Primary

CBT

CBT

CRIPPCRIPPCComprehensive omprehensive RRehab ehab IIntegrative ntegrative PPain ain PProgramrogram

(Proposed)(Proposed)

CRIPPCRIPP (Comprehensive Rehab (Comprehensive Rehab Integrative Pain Program)Integrative Pain Program)

Chronic Pain Consult

Screening Clinic

Bupe clinic/SATS

Chronic Pain rehab program

PMMP

PMMP

Sec.consults/int/SATS/Biofeedba/PT/accupuncture

CBT

CBT

Pain School

Multi-dis Pain

PCP

Team meetings with OEF clinic, pain clinic, CRIPP staffing, PCP staffing (q6mon)

Tampa VA “Chronic Pain Rehab Tampa VA “Chronic Pain Rehab Program” trainingProgram” training

• Excellent training

VISN 11 Pain committee VISN 11 Pain committee progressprogress

VISN 11 Pain Committee progressVISN 11 Pain Committee progress

• V-Tel

• Communication

• Face to face meeting

• HSB

• Stepped care model/policy/education plans

• VISN Ambulatory care council

VISN Ambulatory care councilVISN Ambulatory care council

• “Too many clinical reminders”• “Not enough support for PCP’s decisions”• “Lack of access to comprehensive pain services”• “Lack of pain care standards and policies”• On-site workshops on chronic pain management for providers• Pain schools• ORC• CBT groups• Multidisciplinary virtual pain team consultations• Aquatic therapy• Interdisciplinary pain rehab programs• Opioid detox programs• CAM

Successes!!!Successes!!!

Struggles!!!Struggles!!!

Next Steps!!Next Steps!!

Questions!!Questions!!