Chronic Pain as a Chronic Illness Self Management Support Strategies

1
Chronic Pain as a Chronic Illness Self
Management Support Strategies

• David Nowels MD, Marc Grushan MD and
• Samantha Monson, MA
• UCHSC Family Medicine Grand Rounds
• June 3, 2009

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After this session participants will be able to

• Articulate why chronic pain management can be
  aided by following the chronic care model
• List the components of self management support
• Help patients set self management goals with
  greater confidence

3
Chronic Pain is a Chronic CNS Disease

• Long term pain can remodel CNS on both micro-and
  macro-structural levels and modify long-term
  function
• Chronic pain can cause/ augment psychiatric
  disease, just as psychiatric disease can cause/
  augment pain
• We all have differing abilities to cope with
  pain, and thus for some, it becomes a chronic
  illness

4
When Chronic Pain is a Chronic Illness

• Individualized, ongoing treatment and
• re-evaluation
• Aim is to control, not cure
• Psychosocial interplay
• Improvements and relapses
• Frustrations

5
Usual Chronic Illness Care

• Oriented to acute exacerbations
• Focus on physical findings and lab results
• Focus on physicians
• treatment, not patients role
• in management
• Not designed well for the commonalities of
• chronic illness
• The patient wont do
• what I say!

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Chronic Pain Affects All Aspects of a Patients
Life

• Functional Status
• Physical functioning
• Ability to perform activities of daily living
• Work
• Recreation

• Psychological Morbidity
• Depression
• Anxiety, anger
• Sleep disturbances
• Loss of self-esteem

• Social Consequences
• Marital/family relations
• Intimacy/sexual activity
• Social isolation

• Socioeconomic
• Consequences
• Healthcare costs
• Disability
• Lost workdays

Used with the permission of Professional
Postgraduate Services
7
The Chronic Care Model

• Early 1990s MacColl Institute for Healthcare
  Innovation partners with Robert Wood Johnson
  Foundation, Chronic Care Model synthesized,
  refined. Published 1998

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The Chronic Care Model

• Designed to transform health care from a system
  that is essentially reactive - responding mainly
  when a person is sick - to one that is proactive
  and focused on keeping a person as healthy as
  possible
• Designed to maximize the length and quality of
  life for patients with chronic conditions and to
  satisfy patient and caregiver needs, while
  maintaining or decreasing the total cost of care

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The Chronic Care Model
Health System
Community
Resources and Policies
Health Care Organization
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
Used with permission from Wagners Chronic
disease management What will it take to improve
care for chronic illness? Effective Clinical
Practice, 1998 (American College of Physicians)
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A Proven Model of Care

• 1.5-2 times as many patients with major
  depression have been recovered at six months
• Average HbA1c of type II diabetics 1 lower
• Readmission rates of patients hospitalized with
  CHF cut nearly in half
• Inner city kids with moderate to severe asthma
  have 13 fewer days per year with symptoms

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• Early 1990s MacColl Institute for Healthcare
  Innovation partners with Robert Wood Johnson
  Foundation, Chronic Care Model synthesized,
  refined. Published 1998
• 2000 Dissemination
• Breakthrough Series Collaboratives with the
  Bureau of Primary Health Care / IHI
• 2001 The Institute of Medicine issues report,
  Crossing the Quality Chasm A New Health System
  for the 21st Century, chronic care model
  emphasized
• 2002 Future of Family Medicine Project
• 2002 WHO publishes Innovative Care for Chronic
  Conditions Building Blocks for Action

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Health Care Organization

• Senior leaders visibly support improvement in
  chronic pain care
• Organization's business plan includes measurable
  goals for chronic pain

Delivery System Design

• Define roles and delegate tasks amongst team
  members
• Planned visits
• Assure continuity and follow-up

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Decision Support

• Embed evidence-based guidelines into daily
  clinical practice
• Use standardized assessments in evaluating
  chronic pain
• Integrate specialist expertise into the care
  plans
• Inform patients about guidelines pertinent to
  their care

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Clinical Information Systems

• A registry includes clinically useful and timely
  information on all patients
• Registry can identify relevant patient subgroups
  for proactive care

Community Resources and Policies

• Identify effective programs in the community and
  encourage patients to participate
• Understand the expectations of the Board of
  Medical Examiners, DEA

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Self Management Support

• Emphasize the patient's central role and
  responsibility in managing their illness
• Recognize and validate the patients expertise in
  what they can and cannot do
• Assess patient self-management knowledge,
  behaviors, confidence, and barriers
• Collaborative goal setting
• Provide effective behavior change interventions
  and ongoing support
• Support healthy coping

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Chronic Pain Affects All Aspects of a Patients
Life

• Functional Status
• Physical functioning
• Ability to perform activities of daily living
• Work
• Recreation

• Psychological Morbidity
• Depression
• Anxiety, anger
• Sleep disturbances
• Loss of self-esteem

• Social Consequences
• Marital/family relations
• Intimacy/sexual activity
• Social isolation

• Socioeconomic
• Consequences
• Healthcare costs
• Disability
• Lost workdays

Used with the permission of Professional
Postgraduate Services
17
The Chronic Care Model
Health System
Community
Resources and Policies
Health Care Organization
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
Used with permission from Wagners Chronic
disease management What will it take to improve
care for chronic illness? Effective Clinical
Practice, 1998 (American College of Physicians)
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How would I recognize a productive interaction?
Prepared Practice Team
Informed, Activated Patient
Productive Interactions

• Tailoring of clinical management by guidelines
• Collaborative goal-setting and problem-solving
• Shared care plan
• Constant re-assessment
• Active, sustained follow-up

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When Chronic Pain is a Chronic Illness

• Individualized, ongoing treatment and
• re-evaluation
• Aim is to control, not cure
• Psychosocial interplay (patient and provider)
• Improvements and relapses
• Frustrations

20
When Chronic Pain is a Chronic Illness

• Individualized, ongoing treatment and
• re-evaluation
• Aim is to control, not cure
• Psychosocial interplay (patient and provider)
• Improvements and relapses
• Goal setting, with focus on function and quality
  of life

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Self Management - components

• Engaging in activities that promote physical and
  psychological health
• Interacting with healthcare providers and
  adhering to treatment recommendations
• Monitoring health status and making associated
  care decisions
• Managing the impact of illness on physical,
  psychological, and social functioning

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Self Management tailoring to meet individual
needs

• Factors to target in a tailored, personalized,
  intervention
• Education
• Skill development
• Medical/social support
• Environmental modifications
• Relationships with healthcare providers
• Medication effects management
• Lifestyle changes

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Self Management tailoring to meet individual
needs

• Patients often have several self-management needs
  making prioritization and goal setting critical
• Selecting wrong or too many targets lowered
  adherence
• Long-term benefits may require ongoing
  collaborative relationship/process
• Bayliss, et al. Chronic Illness. 2007

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Re-frame
Self-Management Strategies

• Re-frame treatment as geared toward quality of
  life
• happy pain free
• happy sitting through kids baseball game

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Self-Management Strategies

• Identify how pain interferes with valued action
• legs hurt with standing cannot cook
• back aches with sitting cannot sit through
  kids baseball game
• hands hurt with typing cannot work

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Self-Management Strategies

• Prioritize valued action
• working
• sitting through kids baseball game
• cooking

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Self-Management Strategies

• Installation of hope in gradual improvement

make dinner M,W,F
active spouse/ partner
take pill at same time daily
make b-fast T,R

walk to mailbox M,W,F
learn how to set alarm
order groceries online
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Goal Setting improves performance in 90 of
studies

• Goals affect performance by
• Directing attention
• Mobilizing effort
• Increasing persistence
• Motivating strategy development
• Goal setting improve performance when
• Goals are specific and challenging
• Goals are attainable
• Feedback and Rewards are provided
• Manager is supportive
• Goals are accepted by individual
• Locke et al. Psych Bull. 1981

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Goal Setting in Chronic Pain Management

• As part of collaborative multidisciplinary
  interventions, development of individualized
  functional goals has been associated with
  improved outcomes in at least 3 studies in
  patients with chronic pain
• Improvements have been modest
• National pain organizations and National
  Federation of State Medical Boards recommend
  development of individualized functional goals in
  the management plan of patients with chronic
  pain.

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Goal-Setting Strategies

• Specific
• Measurable
• Aligned with values
• Realistic
• Target date for completion
• Scale importance likelihood
• Problem-solve around barriers follow-up

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Goal-Setting Strategies

• Specific
• Measurable
• Aligned with values
• Realistic
• Target date for completion
• Scale importance likelihood
• Problem-solve around barriers follow-up

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Goal-Setting Strategies

• Specific
• Measurable
• Aligned with values
• Realistic
• Target date for completion
• Scale importance likelihood
• Problem-solve around barriers follow-up

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Goal-Setting Strategies

• Specific
• Measurable
• Aligned with values
• Realistic
• Target date for completion
• Scale importance likelihood
• Problem-solve around barriers follow-up

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Goal-Setting Strategies

• Specific
• Measurable
• Aligned with values
• Realistic
• Target date for completion
• Scale importance likelihood
• Problem-solve around barriers follow-up

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Goal-Setting Strategies

• Specific
• Measurable
• Aligned with values
• Realistic
• Target date for completion
• Scale importance likelihood
• Problem-solve around barriers follow-up

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Goal-Setting Strategies

• Specific
• Measurable
• Aligned with values
• Realistic
• Target date for completion
• Scale importance likelihood
• Problem-solve around barriers follow-up

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References

• Affleck, G., Tennen, H., Urrows, S., Higgins, P.,
  Abeles, M., Hall, C., Karoley, P., Newton, C.
  (1998). Fibromyalgia and womens pursuit of
  personal goals a daily process analysis. Health
  Psychology, 17, 40-47.
• Bayliss EA, Bosworth PH, Noel JL, et al.
  Supporting self-management for patients with
  complex medical needs recommendations of a
  working group. 2007.Chronic Illness 3 167-175.
• Dobscha, S.K., Corson, K., Perrin, N.A., Hanson,
  G.C., Leibowitz, R.Q., Doak, M.N., Dickinson,
  K.C., Sullivan, M.D., Gerrity, M.S. (2009).
  Collaborative care for chronic pain in primary
  care. JAMA, 301, 1242-1252.

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References

• Filoramo, M.A. (2007). Improving goal setting and
  goal attainment in patients with chronic
  noncancer pain. Pain Management Nursing, 8,
  96-101.
• Hurn J, Kneebone I, Cropley M. Goal setting as an
  outcome measure a systematic review. 2006.
  Clinical Rehabilitation. 20 756-772.
• Locke EA, Shaw KN, Saari LM, and Latham GP. Goal
  setting and task performance1969-1980. 1981.
  Psych Bull. 90(1) 125-152.

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References

• Platt, F.W., Gordon, G.H. (2004). Field guide
  to the difficult patient interview (2nd ed.).
  Philadelphia Lippincott, Williams, Wilkins.
• Rollnick, S., Miller, M.R., Butler, C.C.
  (2008). Motivational interviewing in health care
  Helping patients change behavior. New York The
  Guilford Press.
• Von Korff M, Balderson BHK, Saunders K, et al. A
  trial of an activating intervention for chronic
  back pain in primary care and physical therapy
  settings. 2005. Pain. 113323-330.