VHA National Pain Management Strategy: VHA National Pain Management Strategy:

Implementation of the stepped care modelImplementation of the stepped care model

Robert D. Kerns, Ph.D.Robert D. Kerns, Ph.D.

National Program Director for Pain ManagementNational Program Director for Pain Management

Veterans Health AdministrationVeterans Health Administration

AndAnd

Professor of Psychiatry, Neurology and PsychologyProfessor of Psychiatry, Neurology and Psychology

Yale UniversityYale University

Veterans Health AdministrationVeterans Health Administration

�� Largest fully integrated healthcare Largest fully integrated healthcare

system in USsystem in US

�� Serves over 5.5 million US military Serves over 5.5 million US military

VeteransVeterans

�� Over 1400 sites of care; 153 Over 1400 sites of care; 153

medical centers, 909 ambulatory medical centers, 909 ambulatory

centers and community based centers and community based

clinics, 135 nursing homes, 47 clinics, 135 nursing homes, 47

residential treatment programs, residential treatment programs,

232 Veteran Centers, 108 232 Veteran Centers, 108

comprehensive homecomprehensive home--based based

programs programs

�� About 90,000 health professionals About 90,000 health professionals

receive training in VHA every yearreceive training in VHA every year

Pain management is a national Pain management is a national

priority for VHApriority for VHA�� As many as 50% of male VA patients in primary As many as 50% of male VA patients in primary

care report chronic pain care report chronic pain (Kerns et al., 2003; Clark, 2002)(Kerns et al., 2003; Clark, 2002)

�� The prevalence may be as high as 75% in The prevalence may be as high as 75% in

female veterans female veterans (Haskell et al., 2006)(Haskell et al., 2006)

�� Pain is among the most frequent presenting Pain is among the most frequent presenting complaints of returning OEF/OIF soldiers; complaints of returning OEF/OIF soldiers; particularly in patients with polytrauma particularly in patients with polytrauma (Clark, 2004; (Clark, 2004;

Gironda et al., 2006)Gironda et al., 2006)

�� Pain is among the most costly disorders treated Pain is among the most costly disorders treated in VHA settings; total estimated costs in VHA settings; total estimated costs attributable to low back pain was $2.2 billion in attributable to low back pain was $2.2 billion in FY99 FY99 (Yu et al., 2003)(Yu et al., 2003)

FrequencyFrequency of of Possible Possible Diagnoses Among Diagnoses Among OEF and OIFOEF and OIF VeteransVeterans

Diagnosis Diagnosis (n = 400,304)(n = 400,304)(Broad ICD(Broad ICD--9 Categories)9 Categories) Frequency * %Frequency * %

Infectious and Parasitic Diseases (001Infectious and Parasitic Diseases (001--139)139) 49,272 12.349,272 12.3Malignant Neoplasms (140Malignant Neoplasms (140--208)208) 3,9883,988 1.01.0Benign Neoplasms (210Benign Neoplasms (210--239)239) 17,274 4.317,274 4.3Diseases of Endocrine/Nutritional/ Metabolic Systems (240Diseases of Endocrine/Nutritional/ Metabolic Systems (240--279) 279) 93,02893,028 23.223.2Diseases of Blood and Blood Forming Organs (280Diseases of Blood and Blood Forming Organs (280--289) 289) 9,6779,677 2.42.4Mental Disorders (290Mental Disorders (290--319) 319) 178,483 44.6178,483 44.6Diseases of Nervous System/ Sense Organs (320Diseases of Nervous System/ Sense Organs (320--389) 389) 146,611 36.6146,611 36.6Diseases of Circulatory System (390Diseases of Circulatory System (390--459) 459) 68,295 17.168,295 17.1Disease of Respiratory System (460Disease of Respiratory System (460--519) 519) 83,771 20.983,771 20.9Disease of Digestive System (520Disease of Digestive System (520--579) 579) 129,656129,656 32.432.4Diseases of Genitourinary System (580Diseases of Genitourinary System (580--629) 629) 44,812 11.244,812 11.2Diseases of Skin (680Diseases of Skin (680--709) 709) 67,384 16.867,384 16.8Diseases of Musculoskeletal System/Connective System (710Diseases of Musculoskeletal System/Connective System (710--739) 739) 197,078 49197,078 49.2.2Symptoms, Signs and Ill Defined Conditions (780Symptoms, Signs and Ill Defined Conditions (780--799)799) 167,959 42.0167,959 42.0Injury/Poisonings (800Injury/Poisonings (800--999)999) 92,023 23.092,023 23.0

*These are cumulative data since FY 2002, with data on h*These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of September 30, ospitalizations and outpatient visits as of September 30, 2008; v2008; veterans can have multiple diagnoses with each healthcare encounteterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any er. A veteran is counted only once in any single diagnostic category but can be counted in multiple categosingle diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than ries, so the above numbers add up to greater than 400,304.400,304.

Cumulative thru 4th Quarter FY2008Cumulative thru 4th Quarter FY2008

Concomitants of persistent painConcomitants of persistent pain

�� Pain is associated with:Pain is associated with:

�� poorer selfpoorer self--rating of health status,rating of health status,

�� greater use of healthcare resources,greater use of healthcare resources,

�� more tobacco use, alcohol use, diet/weight more tobacco use, alcohol use, diet/weight

concerns,concerns,

�� decreased social and physical activities,decreased social and physical activities,

�� lower social support,lower social support,

�� higher levels of emotional distress, andhigher levels of emotional distress, and

�� among women, high rates of military sexual among women, high rates of military sexual

trauma. trauma. (Haskell et al, 2008; Kerns et al., 2003; Mantyselka et al., 200(Haskell et al, 2008; Kerns et al., 2003; Mantyselka et al., 2003)3)

PTSD N=23268.2%2.9%

16.5%

42.1%

6.8%

5.3%

10.3%

12.6%

TBIN=22766.8%

Chronic Pain

N=27781.5%

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

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)

VHA National Pain Management VHA National Pain Management

StrategyStrategy

Objective is to develop a Objective is to develop a

comprehensive, comprehensive,

multicultural, integrated, multicultural, integrated,

systemsystem--wide approach to wide approach to

pain management that pain management that

reduces pain and reduces pain and

suffering for veterans suffering for veterans

experiencing acute and experiencing acute and

chronic pain associated chronic pain associated

with a wide range of with a wide range of

illnesses, including illnesses, including

terminal illness. terminal illness.

Goals of the VHA National Pain Goals of the VHA National Pain

Management StrategyManagement Strategy

•• Provide a systemProvide a system--wide VHA standard of care for wide VHA standard of care for pain management that will reduce suffering from pain management that will reduce suffering from preventable painpreventable pain

•• Ensure that pain assessment is performed in a Ensure that pain assessment is performed in a consistent manner.consistent manner.

•• Ensure that pain treatment is prompt and Ensure that pain treatment is prompt and appropriate.appropriate.

•• Include patients and families as active Include patients and families as active participants in pain management.participants in pain management.

Goals of the VHA National Pain Goals of the VHA National Pain

Management StrategyManagement Strategy

•• Provide for continual monitoring and Provide for continual monitoring and

improvement in outcomes of pain treatment.improvement in outcomes of pain treatment.

•• Provide for an interdisciplinary, multiProvide for an interdisciplinary, multi--modal modal

approach to pain management.approach to pain management.

•• Ensure that clinicians are competent through Ensure that clinicians are competent through

education and trainingeducation and training

•• Encourage development of clinical support Encourage development of clinical support

systemssystems

Stepped pain care modelStepped pain care model�� Single standard of pain care for VHASingle standard of pain care for VHA

�� Population based approachPopulation based approach

�� Timely access to pain assessmentTimely access to pain assessment

�� State of the art treatment and followState of the art treatment and follow--upup

�� Reliable communication and case managementReliable communication and case management

�� Patient and family participation Patient and family participation

�� Empirically supported modelEmpirically supported model�� Von Korff et al. Stepped care for back pain: Activating Von Korff et al. Stepped care for back pain: Activating approaches for primary care. Ann Int Med 2001;134:911approaches for primary care. Ann Int Med 2001;134:911--917.917.

�� Dobscha et al. Collaborative care for chronic pain in primary Dobscha et al. Collaborative care for chronic pain in primary care. JAMA 2009;301:1242care. JAMA 2009;301:1242--1252.1252.

�� Kroenke et al., Optimized antidepressant therapy and pain selfKroenke et al., Optimized antidepressant therapy and pain self--management in primary care patients with depression and management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial. JAMA musculoskeletal pain: A randomized controlled trial. JAMA 2009;301:20992009;301:2099--2110.2110.

STEP

1

STEP

2

STEP

3

VA Stepped Pain VA Stepped Pain

CareCare RISKRISK

Provider educationProvider education

�� Existing resourcesExisting resources

�� www.va.gov/pain_managementwww.va.gov/pain_management

�� VA Pain List ServeVA Pain List Serve

�� Pharmacy Benefits Management resourcesPharmacy Benefits Management resources

�� Learning Management System (on line) Learning Management System (on line)

training (management of complex chronic training (management of complex chronic

pain patient, opioid therapy, pain and pain patient, opioid therapy, pain and

polytrauma)polytrauma)

�� Monthly educational teleconferences Monthly educational teleconferences

�� Cyberseminars (Live Meetings)Cyberseminars (Live Meetings)

Pain and Primary Care ToolkitPain and Primary Care Toolkit

LinksLinks

�� VHA Pain website VHA Pain website

(www.va.gov/pain_management)(www.va.gov/pain_management)

�� Pain.eduPain.edu

�� LMS trainingLMS training

�� VAVA--DoD Clinical Practice GuidelinesDoD Clinical Practice Guidelines

Local ResourcesLocal Resources

�� Contacts for specialty careContacts for specialty care

�� Contacts for alternative care (e.g., Contacts for alternative care (e.g.,

acupuncture)acupuncture)

�� Contacts for aberrancy (e.g., Contacts for aberrancy (e.g.,

Mental Health, Substance Use Mental Health, Substance Use

Disorders)Disorders)

�� Patient Education resourcesPatient Education resources

DocumentsDocuments

�� Pain management Pain management

competenciescompetencies

�� How to develop a pain How to develop a pain

service agreementservice agreement

�� Sample pain service Sample pain service

agreementsagreements

�� How to set up an Opioid How to set up an Opioid

Renewal ClinicRenewal Clinic

�� Urine drug screening Urine drug screening

guidelinesguidelines

�� National Opioid Pain Care National Opioid Pain Care

AgreementAgreement

�� Back pain guidelinesBack pain guidelines

Primary Care CompetencyEducational

Strategy

Measurement of

achievementStrategies for sustainability

Conduct of comprehensive pain assessment

>Web-based training>In-person training sessions>Manuals from Pain.Edu

>Completion of training>Chart review

>Panel size adjustments and increased visit time for pain patients>Performance measures/monitors

History including assessment of psychiatric/behavioral comorbidities, addiction,and aberrant behavior (diversion)

Conduct of routine focused physical/neurological examinations

Judicious use of diagnostic tests/procedures

Optimal patient communication

>Web-based training>In-person training sessions>Manuals from Pain.Edu>Motivational interview training

>Completion of training>Patient feedback>Patient satisfaction surveys, but must account for skew due to disgruntled patients, secondary gain, >Ongoing reassessment of treatment plan>Appropriately soliciting patient questions and concerns

>Availability of wellness programs,>Behavioral management/pain psychology>Patient support groups>Templates for functional evaluation and re-evaluation

How to encourage realistic evidence-based expectations

How to provide reassurance and discourage negative behavior

How to foster pain self-management

Negotiating behaviorally specific and feasible goals

Pain Management >Web-based training>In-person training sessions>Manuals from Pain.Edu>List of available services>Service agreeements>Web-based info on local arrangements>Links to practice guidelines

>Completion of training>Medication utilization monitoring (long acting vs short acting opioids, non-opioid therapy)>Utilization of adjuvant therapy, other interventions>Chart review

>Separate problem patients from regular PC pain population>Identify and review outliers>Availability of wellness programs,>Behavioral management/pain psychology>Performance measures/monitors

Knowledge of accepted clinical practice guidelines

Rational, algorithmic based polypharmacy

Opioid management

Knowledge/use of common metrics for measuring function

Determining the need for secondary consultation

Promoting safe and effective Promoting safe and effective

use of opioidsuse of opioids�� Opioid Opioid –– High Alert Medication High Alert Medication

InitiativeInitiative

�� Opioid Renewal ClinicOpioid Renewal Clinic

�� Collaborative Addiction and Collaborative Addiction and

Pain (CAP) ProgramPain (CAP) Program

�� Opioid Decision Support Opioid Decision Support

SystemSystem

�� Chronic Opioid Therapy Chronic Opioid Therapy ––

Clinical Practice GuidelineClinical Practice Guideline

�� Opioid Therapy Web CourseOpioid Therapy Web Course

�� Medical Marijuana DirectiveMedical Marijuana Directive

Primary Care Rural Health InitiativePrimary Care Rural Health Initiative

The The specified objectivesspecified objectives of this program are to:of this program are to:

�� Develop uniform expectations/competencies for primary Develop uniform expectations/competencies for primary

care providerscare providers

�� Develop education program and materials to address Develop education program and materials to address

these expectations and competenciesthese expectations and competencies

�� Provider interface between specialty and primary care Provider interface between specialty and primary care

through the development of primary care through the development of primary care ““specialistsspecialists””

�� Provide seamless integration between specialty and Provide seamless integration between specialty and

primary care as primary care providers are better able to primary care as primary care providers are better able to

provide focused specialty care to veterans within primary provide focused specialty care to veterans within primary

care with more limited need for referrals. care with more limited need for referrals.

�� Comprehensive Pain AssessmentComprehensive Pain Assessment�� Characterization of pain condition, including contributors and Characterization of pain condition, including contributors and impactimpact

�� Identification of behavioral and psychiatric comorbiditiesIdentification of behavioral and psychiatric comorbidities

�� Assessment of risk for opioid misuse, addiction, and diversionAssessment of risk for opioid misuse, addiction, and diversion

�� Identification of functional goalsIdentification of functional goals

�� CommunicationCommunication�� ReassuranceReassurance

�� Establish realistic expectationsEstablish realistic expectations

�� Encourage pain selfEncourage pain self--managementmanagement

�� TreatmentTreatment�� Algorithmic (psycho)pharmacological managementAlgorithmic (psycho)pharmacological management

�� EvidenceEvidence--based psychotherapybased psychotherapy

�� Ongoing reassessment of responsivity to interventionsOngoing reassessment of responsivity to interventions

Expansion of Integrative Expansion of Integrative

Primary Care ProgramsPrimary Care Programs

Dobscha et al. Collaborative care for chronic pain in primary caDobscha et al. Collaborative care for chronic pain in primary care. re.

JAMA 2009;301:1242JAMA 2009;301:1242--1252.1252.

�� Assistance with Pain Treatment Assistance with Pain Treatment

(APT) vs Treatment as Usual (APT) vs Treatment as Usual

(TAU)(TAU)

�� 42 primary care clinicians/401 42 primary care clinicians/401

patientspatients

�� Measures:Measures:�� Roland Morris Disability Questionnaire Roland Morris Disability Questionnaire

�� Chronic Pain Grade Chronic Pain Grade –– Pain IntensityPain Intensity

�� Patient Health Questionnaire Patient Health Questionnaire -- 99

�� APT:APT:

�� Clinician educationClinician education

�� Pt assessment, education & Pt assessment, education &

activationactivation

�� Symptom monitoringSymptom monitoring

�� Feedback and Feedback and

recommendationsrecommendations

�� Facilitation of specialty careFacilitation of specialty care

Kroenke et al., Optimized antidepressant therapy and pain Kroenke et al., Optimized antidepressant therapy and pain

selfself--management in primary care patients with depression management in primary care patients with depression

and musculoskeletal pain: A randomized controlled trial. and musculoskeletal pain: A randomized controlled trial.

JAMA 2009;301:2099JAMA 2009;301:2099--2110.2110.

�� Stepped Care for Affective Stepped Care for Affective

Disorders and Musculoskeletal Disorders and Musculoskeletal

Pain (SCAMP) vs. Usual care (UC)Pain (SCAMP) vs. Usual care (UC)

�� SCAMPSCAMP�� 12 wks optimized antidepressant 12 wks optimized antidepressant

therapytherapy

�� 6 sessions of pain self6 sessions of pain self--managementmanagement

�� 6 mos continuation6 mos continuation

�� 250 patients250 patients

�� MeasuresMeasures�� Hopkins Symptom ChecklistHopkins Symptom Checklist

�� Brief Pain InventoryBrief Pain Inventory

�� Global Improvement in PainGlobal Improvement in Pain

Veteran IdentificationScreens/ Direct referral

BHL Initial Assessment

Referral to MHC or pain

clinic

Provider Recommendations

No treatment &

Refusal of care

Pain Educationprovided

Care Management (&/or pain school)

Pain, Depression, Anxiety, Alcohol misuseReferral

Management

Behavioral Health Lab: Clinical ProcessBehavioral Health Lab: Clinical Process

Pain Management: Exploring Primary Care Providers Pain Management: Exploring Primary Care Providers

Attitudes, Knowledge, and Practices Attitudes, Knowledge, and Practices

�� Research questions: Research questions: �� 1) What are primary care providers1) What are primary care providers’’ attitudes, beliefs, and knowledge about pain attitudes, beliefs, and knowledge about pain

management? management?

�� 2) Is there a relationship between provider characteristics, kno2) Is there a relationship between provider characteristics, knowledge and beliefs regarding wledge and beliefs regarding

pain management and their patterns of opioid use and adherence tpain management and their patterns of opioid use and adherence to practice guidelineso practice guidelines

�� Methods: mixed methods using survey tools and administrative datMethods: mixed methods using survey tools and administrative data setsa sets

�� Evaluation Evaluation

Cohort of pts with chronic pain

Knowledge

Provider demographics

Beliefs/attitudes

Frequency of opioid use

Adherence to practice standards

Pain scores

PatientPatient--Centered Medical Home: Centered Medical Home:

Innovations P4 ProjectInnovations P4 Project�� Objective: Develop and implement an intervention to Objective: Develop and implement an intervention to

improve chronic pain management in primary care improve chronic pain management in primary care

through the use of enhanced PCMH team communication through the use of enhanced PCMH team communication

and increased use of collaborative, multimodal treatment and increased use of collaborative, multimodal treatment

for Veteransfor Veterans

�� Aims:Aims:

�� Improve provider communication skillsImprove provider communication skills

�� Increase use of integrative behavioral and Increase use of integrative behavioral and

Complementary and Alternative Medicine (CAM) Complementary and Alternative Medicine (CAM)

interventionsinterventions

�� Interdisciplinary team buildingInterdisciplinary team building

Donaghue/MaydayDonaghue/Mayday

Program for Research LeadershipProgram for Research Leadership

Study Tasks Year 1 Year 2 Year 3 Year 4

Intervention Development

Retrospective Baseline Assessment

Phase 1 SCM step 1: Primary Care

Phase 1 Evaluation/DisseminationPhase 2 SCM steps 2 & 3: secondary and tertiary consultation and referral services

Phase 2 Evaluation/DisseminationPhase 3:Model integration and sustainability

Phase 3: Evaluation/Dissemination

Data Analysis

Knowledge Uptake Processes

Implementing a VA SCM-PM

� Study Goal: To study the adoption and implementation of SCM-PM at VACHS and disseminate findings nationally

� Study Aim 1: To evaluate the implementation of the SCM-PM at VACHS using qualitative and quantitative methods (process).

� Aim 1a: To evaluate implementation of SCM-PM through documentation of changes in pain management policies and procedures.

� Aim 1b: To evaluate the experience of organizational change and acceptability of the new model to VACHS pain management providers through qualitative interviews and organizational assessments.

� Study Aim 2: To test the effectiveness of the SCM-PM at VACHS

Future innovations in the delivery of Future innovations in the delivery of

pain selfpain self--management interventionsmanagement interventions

�� CSP#581 (not funded): Integrative CSP#581 (not funded): Integrative

behavioral intervention delivered on the behavioral intervention delivered on the

Internet with distance Internet with distance ““coachingcoaching””

�� HSR&D: Interactive Voice Response HSR&D: Interactive Voice Response ––

CBTCBT

�� HSR&D Pilot: (pending): CBT delivered by HSR&D Pilot: (pending): CBT delivered by

videoconferencingvideoconferencing

Thanks!Thanks!

robert.kerns@va.govrobert.kerns@va.gov