VHA  NATIONAL  PAIN  MANAGEMENT  STRATEGY  Implementa8on  of  a  stepped  care  model  of  

pain  management  

ROBERT  D.  KERNS,  PH.D,  NATIONAL  PROGRAM  DIRECTOR  FOR  PAIN  MANAGEMENT  

February 2012

Learning  Objec8ves  

1.  Tell  an  overview  of  Pain  Management  Task  Force.  

2.  Outline  similari8es  and  differences  with  pain  management  challenges  facing  Department  of  Defense  and  Veterans  Health  Administra8on.  

3.  Iden8fy  best  prac8ces  of  pain  management  alterna8ves  from  the  Pain  Management  Task  Force.  

Disclosure  Statement  

•  Robert  Kerns  has  no  financial  rela8onships  with  proprietary  en88es  that  produce  health  care  goods  and  services.    

•  Kevin  Galloway  has  no  financial  rela8onships  with  proprietary  en88es  that  produce  health  care  goods  and  services.  

Pain  Management  is  a  priority    

•  As  many  as  50%  of  male  VHA  pa8ents  in  primary  care  report  chronic  pain  (Kerns  et  al.,  2003;  Clark,  2002)  

•  The  prevalence  may  be  as  high  as  75%  in  female  Veterans  (Haskell  et  al.,  2006)  

•  Pain  is  among  the  most  costly  disorders  treated  in  VHA  se]ngs;  total  es8mated  cost  a^ributable  to  Veterans  with  low  back  pain  was  $2.2  billion  in  FY99  (Yu  et  al.,  2003)  

•  Number  of  Veterans  with  chronic  low  back  pain  is  growing  steadily  (Sinno^  &  Wagner,  2009)  

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Frequency of Diagnoses1 among Operation Enduring Freedom/Operation Iraqi

Freedom/Operation New Dawn (OEF/OIF/OND) Veterans

Cumulative from 1st Quarter FY 2002 through 1st Quarter FY 2013  

Diagnosis  (Broad  ICD-­‐9  Categories)a   Frequency   Percentb  

Infec8ous  and  Parasi8c  Diseases  (001-­‐139)   144,167     16.0    

Malignant  Neoplasms  (140-­‐209)   13,016     1.4    

Benign  Neoplasms  (210-­‐239)   64,424     7.2    

Diseases  of  Endocrine/Nutri8onal/  Metabolic  Systems  (240-­‐279)   302,719     33.6    

Diseases  of  Blood  and  Blood  Forming  Organs  (280-­‐289)   36,899     4.1    

Mental  Disorders  (290-­‐319)   486,015     54.0    

Diseases  of  Nervous  System/  Sense  Organs  (320-­‐389)   415,543     46.2    

Diseases  of  Circulatory  System  (390-­‐459)   198,140     22.0    

Disease  of  Respiratory  System  (460-­‐519)   241,229     26.8    

Disease  of  Diges8ve  System  (520-­‐579)   326,338     36.3    

Diseases  of  Genitourinary  System    (580-­‐629)   142,687     15.9    

Diseases  of  Skin  (680-­‐709)   199,803     22.2    

Diseases  of  Musculoskeletal  System/ConnecBve  System  (710-­‐739)   519,721     57.8    

Symptoms,  Signs  and  Ill  Defined  Condi8ons  (780-­‐799)   478,267     53.2    

Injury/Poisonings  (800-­‐999)   267,407     29.7    

1Includes  both  provisional  and  confirmed  diagnoses.  aThese  are  cumula8ve  data  since  FY  2002,  with  data  on  hospitaliza8ons  and  outpa8ent  visits  as  of  September  30,  2011;  Veterans  can  have  mul8ple  

 diagnoses  with  each  health  care  encounter.  The  total  may  be  higher  than  899,752  unique  Veterans  because  a  Veteran  can  have  more  than  one    diagnosis  and  each  is  entered  separately  in  this  table.    

bPercentages  reported  are  approximate  due  to  rounding.  

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PTSD N=232 68.2%

2.9% 16.5%

42.1% 6.8%

5.3%

10.3%

12.6% TBI

N=227 66.8%

Chronic Pain N=277 81.5%

Lew et al., (2009). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. Journal of Rehabilitation Research and Development, 46, 697-702.

Prevalence  of  Chronic  Pain,  PTSD  and  TBI:  sample  of  340  OEF/OIF  veterans  

VHA  Pain  Management  Direc8ve  (2009-­‐053)  

•  Objec8ves  of  Na8onal  Pain  Management  Strategy  

•  Pain  Management  Infrastructure  –  Roles  and  responsibili8es  

•  Stepped  Pain  Care  Model  

•  Pain  Management  Standards  –  Pain  assessment  and  treatment  

–  Evalua8on  of  outcomes  and  quality  –  Clinician  competence  and  exper8se  

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Na8onal  Pain  Management  Strategy  

Objec8ve  is  to  develop  a  comprehensive,  mul8cultural,  integrated,  system-­‐wide  approach  to  pain  management  that  reduces  pain  and  suffering  for  Veterans  experiencing  acute  and  chronic  pain  associated  with  a  wide  range  of  illnesses,  including  terminal  illness.    

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VHA  Na8onal  Pain  Management  Strategy  Infrastructure  

•  Pain  Management  Program  Office  

–  Specialty  Care  Services;  Pa8ent  Care  Services;  DUSH  for  Policy  and  Services  

•  Na8onal  Pain  Management  Strategy  Coordina8ng  Commi^ee    

–  Coordina8ng  Commi^ee  Working  Groups  •  VISN  Pain  Points  of  Contact  •  Facility  Pain  Points  of  Contact  •  Primary  Care  Pain  Champions  

•  Pain  Resource  Nurses  •  VISN  and  Facility  Pain  Management  Commi^ees  

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VHA  Stepped  Care  Model  for  Pain  Management  

•  Single  standard  of  pain  care  for  VHA  –  Popula8on  based  approach  –  Timely  access  to  pain  assessment  –  State  of  the  art  treatment  and  follow-­‐up  –  Reliable  communica8on  and  care  management  –  Pa8ent  and  family  par8cipa8on    

•  Empirically  supported  model  –  Von  Korff  et  al.  (2001).  Stepped  care  for  back  pain:  Ac8va8ng  approaches  

for  primary  care.    Annals  of  Internal  Medicine,  134,  911-­‐917.  –  Dobscha  et  al.  (2009).  Collabora8ve  care  for  chronic  pain  in  primary  care.    

Journal  of  the  American  Medical  Associa9on,  301,  1242-­‐1252.  –  Kroenke  et  al.  (2009).  Op8mized  an8depressant  therapy  and  pain  self-­‐

management  in  primary  care  pa8ents  with  depression  and  musculoskeletal  pain:  A  randomized  controlled  trial.    Journal  of  the  American  Medical  Associa9on,  301,  2099-­‐2110.  

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Veteran-­‐Centered  Pain  Management  

•  Informed  by  chronic  illness  model  

•  Empowering  Veterans  through  reassurance,  encouragement  and  educa8on    

•  Conserva8ve  use  of  analgesics  and  adjuvant  medica8ons  

•  Promo8on  of  regular  exercise  and  healthy  and  ac8ve  lifestyle  

•  Development  of  adap8ve  strategies  for  managing  pain  

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Pa8ent  Educa8on  Ini8a8ves  

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•   Veterans  Health  Library  •   “Taking  Opioids  Responsibly”  •   Krames  resources    •   Pa8ent/Family  Pain  Management  

 Educa8on  Toolkit  •   MyHealtheVet  

• Pa8ent  Educa8on  Management    System  (PEMS)  • VISN  20  Chronic  Pain  

 Educa8on  for  Veterans  • Veterans  Pain  Management  

 Resource  Program  •   Pain  Coach  (Mobile  Pain  App)  

 Stepped  Care  Model  for  Pain  Management  

STEP  1  

STEP  2  

STEP  3  

Ter8ary  Interdisciplinary  Pain  Centers  Advanced  diagnos8cs  &  interven8ons  

Commission  on  Accredita8on  of  Rehabilita8on  Facili8es  accredited  pain  rehabilita8on  

Integrated  chronic  pain  and  Substance  Use  Disorder  treatment  

Primary  Care/Pa8ent  Aligned  Care  Teams  (PACTs)  Rou8ne  screening  for  presence  &  intensity  of  pain  

Comprehensive  pain  assessment  Management  of  common  acute  and  chronic  pain  condi8ons  Primary  Care-­‐Mental  Health  Integra8on,  Health  Behavior  Coordinators,  OEF/OIF/OND  &  Post-­‐Deployment  Teams  

Expanded  nurse  care  management    Clinical  Pharmacy  Pain  Medica8on  Management  

Opioid  Pain  Care  and  Renewal  Clinics

Complexity  

Treatment  Refractory  

ComorbidiBes  

RISK  

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Implementa8on  ini8a8ves  

•  OEF/OIF  Pain  Care  Enhancement  Ini8a8ve  •  Communica8on/educa8on  infrastructure  

–  VA  Pain  List  Serve,    –  Na8onal  Pain  Management  Website  (www.va.gov/painmanagement)  –  Monthly  Pain  Management  Leadership  Teleconference  –  Monthly  “Spotlight  on  Pain  Management”  webinar  (collabora8on  with  

HSR&D  Center  for  Informa8on  Dissemina8on  and  Educa8onal  Resources  [CIDER]  

–  Na8onal  Pain  Management  Leadership  Conferences  –  VA  Pharmacy  Pain  Management  Mentors    (VAPPMM)  Outlook  

exchange    •  Clinical  Prac8ce  Guidelines  

–  Opioid  Therapy  for  Management  of  Chronic  Pain  –  Peri-­‐opera8ve  pain  management  –  Dissemina8on  of  American  Pain  Society/American  Academy  of  Pain  

Management  guidelines  

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Implementa8on  Ini8a8ves  

•  Web-­‐based  educa8on  –  General,  opioid  therapy  for  acute  and  chronic  pain,  polytrauma  –  Primary  Care  Rural  Health  Ini8a8ve  pain  management  courses  

•  Post-­‐Deployment  and  Integrated  Care  Ini8a8ves  –  Pos^rauma8c  Stress  Disorder-­‐Trauma8c  Brain  Injury-­‐Pain  Prac8ce  

Recommenda8ons  Consensus  Conference  –  PC-­‐MHI/HBC  ini8a8ves  

•  Nursing  –  Veteran  Affairs  Nursing  Outcome  Database  Nursing  Assessment  and  

Reassessment  Ini8a8ve  (ini8al  focus  on  management  of  acute  pain  in  inpa8ent  se]ngs)  

–  Pain  Resource  Nursing  (PRN)  Ini8a8ve  •  Pharmacy  

–  Na8onal  Clinical  Pharmacy  Pain  Management  Training  –  Opioid  Pain  Care  Clinics  Central  Repository  

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Implementa8on  Ini8a8ves  

•  Telehealth  –  Telebehavioral  Pain  Management  –  Mobile  Pain  App  

•  Pain  Medicine    –  Capacity  for  specialty  pain  medicine  diagnos8cs  and  interven8ons  

•  Mental  Health    –  Evidence-­‐Based  Psychotherapy  –  Capacity  for  pain  management  in  Substance  Use  Disorders  programs  –  Capacity  for  pain  management  in  PTSD  treatment  se]ngs  

•   Externship  training  at  James  Haley  Veterans  Hospital  –  Interdisciplinary  pain  management    –  CARF  accredited  pain  rehabilita8on  

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Promo8ng  safe  and  effec8ve  use  of  opioids  

•  Opioid  –  High  Alert  Medica8on  Ini8a8ve    

•  CPG  on  Management  of  Opioid  Therapy  for  Chronic  Pain  

•  TMS:  Opioid  Therapy  for  Acute  and  Chronic  Pain      

•  Pharmacy  Benefits  Management  Ini8a8ves  and  Clinical  Guidances  

•  Direc8ve  and  Clinical  Considera8ons  regarding  state-­‐authorized  use  of  marijuana  

•  Implementa8on  of  Na8onal  Prescrip8on  Drug  Control  Policy  

•  Opioid  Safety  Ini8a8ve  

•  Par8cipa8on  in  State  Prescrip8on  Drug  Monitoring  Programs  

•  Signature  Informed  Consent  

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VA  Specialty  Care  Access  Network  –  Extension  of  Community  Healthcare  Outcomes  (VA  SCAN-­‐

ECHO)    The  mission  of  VA  SCAN-­‐ECHO  is  to:  

• Meet  the  needs  of  primary  care  providers  and  PACT  teams  for  access  to  specialist  consulta8on  services  and    support  

•  Provide  case-­‐based  learning  modules  to  improve  core  competencies  and  provider  sa8sfac8on  

•  Facilitate  referrals  to  ter8ary  care  centers  when  indicated  

•  Ul8mately  to  improve  veteran  access  to  specialty  care  and  treatment  outcomes  

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HEC  PMWG:  Objec8ves/Ini8a8ves  

•  Stepped Care Model •  Interdisciplinary PC / PACT

Pain Champions & Teams •  Pain Medicine Specialty

support for Primary Care(PCMH)

•  Pain Rehabilitation

•  Opioid Risk Strategy •  COT – CPG •  Opioid Risk Tools •  Urine Drug Screening / Reporting

•  Integration of non-medication modalities

•  Patient Safety Videos •  Joint Suicide Prevention Initiative

•  PASTOR/PROMIS •  DVPRS •  CREATE

•  DoD/VHA Core Pain Curriculum / Training

•  Collaboration with NiH CoEPES •  ECHO / SCAN-ECHO •  Phone Apps for patient & for

provider •  Tiered acupuncture training and treatment

Standardize Education and

Training

Deliver Measurement

Based Care

Establish Consistent

Model of Care

Ensure Patient Safety

Function Readiness

VHA  Pain  Management  (PACT)  Strategic  Oversight  

CommiTee  

VHA/DOD  HEC  

DOD  Pain  Management  

JIF  Joint  VA/DOD  Pain  EducaBon  

Pain  EducaBon  Advisory  Team  

Community  of  PracBce  

CoordinaBng  Workgroup  

Facility  Pain  Champions  CoordinaBng  Workgroup  

Pain  Management  EducaBon  and  

Training    Workgroup  

Community  of  PracBce  

Monthly  Calls  

Training  Program  

Facility  Pain  Champions  

i.e.  PCP/RNCM  Team,  facility  SME  

Facility/VISN  Pain  Team  

PACT  

Joint  Educa8on/Training  Program  (JPEP)  VA/DoD  HEC  Pain  Management  Working  Group  

Healthcare  Analysis  Informa8on  Group  2010  VHA  Pain  Management  Survey  Results  

•  100%  of  facili8es  have  pain  management  policies  

•  100%  of  Veterans  Integrated  Service  Network  (VISN)  and  95%  of  facili8es  have  iden8fied  Pain  Points  of  Contacts  (POCs)  

•  54%  of  facili8es  iden8fied  a  primary  care  pain  champion  

•  96%  of  facili8es  have  mul8disciplinary  pain  commi^ees  

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Healthcare  Analysis  Informa8on  Group  2010  VHA  Pain  Management  Survey  Results  

0%  

20%  

40%  

60%  

80%  

100%  

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Specialty  Pain  Care  Capacity  

•  100  %  of  VISNs  have  specialty  pain  clinics  •  91%  of  facili8es  have  dedicated  pain  clinics  

FY  2010   FY  2011   FY  2011  (thru  2nd  

quarter)  

FY  2012  (thru  2nd  

quarter)  

%  Change  FY11  Q2    

–  FY12  Q2  

%  Change  FY  2010                -­‐  FY  2011  

Encounters      333,447   374,880   179,352   199,485   11.2%   12.4%  

Unique  Pa8ents   100,833   108,874   71,575   78,209   9.3%   8.0%  

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Building  Capacity  for  Ter8ary,  Interdisciplinary  Pain  

Centers  

•  VHA  Pain  Direc8ve  requires  every  VISN  to  have  a  ter8ary  interdisciplinary  pain  center  by  September  2014  

•  VISN  Directors  survey  in  December  2011  –  19  VISNS  report  mee8ng  standard  for  advanced  pain  medicine  

diagnos8cs  and  interven8ons;  2  have  yet  to  iden8fy  site  

•  Most  recent  data  on  Commission  for  Accredita8on  of  Rehabilita8on  Facili8es  (CARF)  –  7  VISNs  report  having  CARF-­‐accredited  pain  rehabilita8on  programs;  10  have  applica8ons  pending  

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Pain  Research  –  FY  2012  

•  61  pain-­‐related  Office  of  Research  and  Development  funded  research  projects  

•  $11.9  million  for  pain-­‐relevant  research  

•  Pain  Research  Working  Group  

•  Health  Services  Research  and  Development  Pain  Research  Center  funded  (PRIME  Center)  

•  Partnerships  with  Na8onal  Ins8tute  of  Health/Department  of  Defense  

•  Basic  mechanisms  underlying  pain  

•  Pain  diagnosis    

•  Preclinical  studies    •  Pain  management  (medica8ons;  

psychosocial  interven8ons)    

•  Co-­‐morbidi8es    

•  Quality  of  Life  (QOL),  compara8ve  effec8veness;  bioinforma8cs;  dispari8es    

•  Training  (career  development)  

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FY  2013  Priori8es  

•  Opioid  Safety  Ini8a8ve,  and  other  opioid  therapy  ini8a8ves  

•  Pain  and  Primary  Care  ini8a8ves;  Joint  Incen8ve  Fund  Ini8a8ve  

•  Specialty  Care  Services  Transforma8on  Ini8a8ves,  especially  SCAN-­‐ECHO  

•  Guidance  for  Ter8ary,  Interdisciplinary  Pain  Centers  •  Publica8on  of  acute,  peri-­‐opera8ve  pain  management  guideline    

•  Capacity  for  behavioral  services  in  PACT  

•  Pa8ent  Educa8on  Ini8a8ves  

•  Provider  Educa8on  Ini8a8ves  

•  Nursing  ini8a8ves  •  Health  Execu8ve  Council  Pain  Management  and  VA-­‐DoD  

 ini8a8ves  

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