Developing Integrated Care Clinical Pathways: The Example of Chronic Pain

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Developing Integrated Care Clinical Pathways The
Example of Chronic Pain

• Kirk Strosahl Ph.D.
• Central Washington Family Medicine
• mconsultinggrp_at_embarqmail.com
• www.behavioral-health-integration.com

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Clinical Pathway Targets What Are the Priorities
in Your Clinic?

• High prevalence (depression) or high impact
  (chronic pain) conditions
• Variability among providers
• Evidence available for preferred treatment
• Patient preference
• Provider preference
• Resources (opinion leaders, grants)
• Cost savings or practice leveraging

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Five Steps To Developing Population-Based Pathways

• 1. Choose a common condition that is amenable to
  a systems approach to care.
• 2. Identify a method for identifying patients in
  the primary care practice who have the selected
  condition.
• 3. Choose measurable outcomes that reflect best
  evidence-based medical or behavioral health
  practice for that condition.
• 4. Form a high performance team to implement a
  system of care that improves outcomes.
• 5. Measure outcomes regularly and make changes as
  needed to improve outcomes

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Examples of Clinical Pathway Targets

• Depression
• Alcohol-Drug Abuse
• Diabetes
• Chronic Pain Syndrome
• Anxiety
• Smoking
• Obesity

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Qualities of an Integrated Pathway

• Stepped care approach to accommodate varying
  levels of severity and motivation
• Shortened sessions
• Condensed treatment packages
• Multiple delivery formats
• Patient education philosophy
• Designed for use by all PC team members
• Culturally competent

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What Makes Chronic Pain So Difficult For
Physicians?

• There is no cure for it (even successful
  treatment involves residual pain)
• The help seeking, help rejecting stance of CP
  patients (My pain is at a 10, but dont try to
  get me to do those morning stretches) pushes a
  lot of hot buttons
• Negative feedback loop (nothing you are doing is
  helping me) makes it very unrewarding for the
  provider
• Fear of substance abuse, addiction and diversion
  and possible legal sanctions
• Many PCPs use acute care strategies for a problem
  which is a chronic condition (PRN medications for
  pain presentations) and thus develop a revolving
  door

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What Makes Chronic Pain So Difficult For The
Patient?

• Pervasive sense of isolation
• Loss of contact with a normal day
• Perception that others do not believe the pain is
  real
• Perception of being promised one thing (a cure),
  but delivered another (a curse) by the medical
  establishment
• Perception of being viewed as an addict by
  others because of dependency on narcotics
• Criticism from family members and friends for
  variable day to day performance
• Self criticism for not being able to rise above
  the pain
• Common co-morbid states like depression, anxiety
  amplify pain experience

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Which Treatments Are Effective for Chronic Pain
and Which Arent?

• Evidence for long term usefulness of narcotics is
  very limited (particularly end state functioning)
• NSAIDS are more likely to reduce or eliminate
  pain and should be first line treatments
• Cognitive and behavioral interventions have been
  repeatedly shown to be effective at improving
  functional status, less so with pain
• Regimens of exercise aimed at stretching and
  limbering have been repeatedly shown to reduce
  pain and improve functional status

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A Contextual Behavioral Model of Chronic Pain
(McCracken, 2006)

• Pain plus the unwillingness to have pain leads to
  a refusal to accept the reality of pain
• Pain is perceived as the main obstacle to vital
  living thus, the goal is first to eliminate pain
  and then vital living can happen
• Since pain cannot be controlled or eliminated,
  the paradoxical result is an increasing focus on
  pain experience and its elimination
• This leads to an ever widening pattern of
  behavior designed to control pain, at the expense
  of living a vital life

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Components of Contextual Cognitive Behavioral
Treatment

• PacingAdapting daily activity pattern to match
  pain tolerance, so as to optimize up time
• Attention DiversionMental strategies for
  focusing attention away from pain, or
  re-associating pain sensations in a way that
  reduces pain experience
• Cognitive RestructuringStrategies designed to
  defeat pain catastrophizing and pain related
  avoidance
• Acceptance/MindfulnessStrategies that promote
  pain acceptance and the ability to stay detached
  in the presence of pain
• Value Based, Motivation EnhancementStrategies
  designed to clarify and help patient pursue
  valued life directions in spite of pain

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Clinical Philosophies of the Pain and Comfort
Program

• Pain must be assessed and treated within a
  biopsychosocial framework
• The goal of treatment is not the elimination of
  pain, but the restoration of functioning
• Any treatment that is not improving functional
  status will not be continued
• Long term narcotics treatment always comes with
  strings attached
• Evidence based care is the strongest platform
  from which to engage the patient
• All chronic pain patients started as acute pain
  patients and thus there must be a place for
  prevention

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Pain Comfort Program Goals

• Promote functional improvement
• Increase pain acceptance engagement in life
• Decrease reliance on long term narcotics use
• Identify and manage patients at risk for
  substance abuse or addictive behaviors
• Prevent the onset of chronic pain by working
  aggressively with acute pain patients
• Seamlessly integrate behavioral and medical
  interventions within a single care plan

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Primary Care Behavioral Health Model The
Platform For An Integrated Pain Pathway

• Behavioral Health Consultation
• BHC works within medical exam room area as a core
  team member
• Schedule is open and designed for fast, easy
  access at the time of medical visits (Lucy is in)
• Visits are short (15-25 minutes) and
  consultatively oriented
• The MD remains in charge of the patients
  healthcare plan
• Intervention model is a temporary co-management
  approach
• Most patient encounters are warm handoffs from a
  immediately preceding medical visit

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Components Of The CWFM Pain Comfort Program

• Standardized format for initial MD assessment
• Establish the diagnosis (acute vs. chronic pain)
• Assess level of pain related disability
• Establish the treatment plan (includes medication
  and behavioral management)
• Assess potential for opiod abuse and make a
  decision about medication (Opioid Risk Tool)
• Establish pain contract and set functional goals
• Refer to BHC in every case for evaluation of
  psychosocial factors and preparation for class

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Components of the CWFM Pain and Comfort Program

• Treatment Phase
• Generally, long acting narcotics are substituted
  for short acting narcotics as the base pain
  treatment
• Monthly Pain and Comfort Class is center piece of
  the treatment and is required for continuation of
  narcotics
• Class uses CCBT model of pain treatment with
  different modules offered repeatedly over time
• Pain disability assessments are taken on every
  patient at every class meeting
• Scores entered into EMR note, along with
  narrative comments about patient progress

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Components of the CWFM Pain and Comfort Program

• Progress Monitoring
• Outcomes are measured monthly in terms of pain
  disability index and pain acceptance scale
• PADT (Pain Assessment Documentation Template)
  used by MDs at every pain management visit
• Failure to improve in functional status over time
  triggers a review of the entire treatment plan
• MD and BHC consult to identify barriers to
  improvement and develop new interventions
• MD may choose to taper off narcotics because of
  lack of functional improvement

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Components of the CWFM Pain and Comfort Program

• Risk Monitoring
• Three Strikes Program establishes three levels
  of aberrant drug use behavior
• Misuse/abuse/addiction
• Misuse ? re-educate patient
• Abuse ? Caution
• Express concern and set limits
• Consider tapering/stopping addictive medicines
• Consider specialty consultation or referral to
  BHC for 11 evaluation
• Addiction/Diversion ? STOP

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Components of the CWFM Pain and Comfort Program

• Prevention
• Chronic pain syndrome is an iatrogenic phenomenon
• By changing the initial message to acute pain
  patients, MDs and the BHC can avoid the control
  and eliminate pain trap
• Protocol
• When an acute pain patient requests the first
  refill of a prescribed narcotic, an automatic
  referral to the BHC is generated
• A chronic pain risk assessment is performed
• A high risk patient is managed differently than a
  low risk patient

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Components of the CWFM Pain and Comfort Program

• High Risk Patient Prevention Protocol
• A definite, short range date is set for the
  termination of narcotic medicine
• Patient is told that some pain complaints turn
  out to be chronic and the goal is to learn to
  live a vital life even if the pain persists
• BHC is involved with patient to teach pain
  management skills, to identify the patients
  values and to address any reversible risk factors
  (i.e., patient hates job or is seeking workman's
  compensation for an injury)

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Summary

• Chronic pain syndrome is a complicated
  biopsychosocial disorder that nevertheless is
  very manageable using an integrated primary care
  team model
• The new contextual behavioral treatments are
  extremely potent and are easily adapted to a
  classroom format
• Physicians readily respond to a structured,
  evidence based approach that is easily learned
  and easy to apply
• Clinic wide, the program is actually popular with
  patients and has improved MD self perceived
  efficacy in working with chronic pain patients
• A fully integrated biopsychosocial program for
  chronic can be implemented in a relatively short
  period of time