Moving from Acute to Chronic Treatment

Transcription

1 Moving from Acute to Chronic Treatment and Getting Back to Reality (While Avoiding Disaster Cases) Steven D. Feinberg, MD, MS, MPH Feinberg Medical Group Functional Restoration Programs Constantine Gean, MD, MS, MBA, FACOEM Liberty Mutual and Helmsman Insurance Groups

2 What is a Disaster Case?

3 Who Are the Players? Specialis t Lawyer Chiro

4 What goes wrong early on in a claim? Urgent Care Clinic / Specialist's Office

5 Good Employee(EE) Employer(ER) Interactions are Essential (Positive interactions are the key to controlling psychosocial risk factors and preventing disaster cases) Employer Interactions positive Employee Post injury GOOD Good EE:ER Communication Good Relations Concern for IW No/minimal Psychosocial issues Good Performance Accepted Claim UR Approvals Excellent care Early RTW all trying DISASTER Employer Interactions negative Employee Post injury ER Pressures EE (recordables) ER Unhappy Psychosocial issues Bad Performance Denied Claim UR Denials Perceived Bias No RTW occurs

6 Our Patient for Today Mother of two Delivery Truck Driver S/p Rotator Cuff Repair

7 Dr. Bad History: "How bad is your pain? " Fired Abuse Percocet Separated No money Losing house Reinjury fear Boss was rude Blues fixed by Percocet Uncle never wkd again

8 Dr. Bad s response Shoulder MRI Shoulder Injection (maybe repeat surgery?) Opioid, Soma and Compound Cream

9 Why is this a Disaster Case?

10 Recognition of Psychosocial Risk Factors (to prevent delayed recovery) Pain Behavior Suffering Pain Perception Acute Injury Pain

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13 Vs. Biomedical Model

14 OUR PATIENT AGAIN Mother of two Delivery Truck Driver S/p Rotator Cuff Repair

15 Dr. GOOD History: How are you getting along? Same Psychosocial Risk Factors Fired Abuse Percocet Separated No money Losing house Reinjury fear Boss was rude Blues /Percocet Uncle story THIS TIME Handled Much Better You had a difficult childhood & things are not going well recently. But until this injury, things were going well for you. We can work together to get you feeling better and perhaps RTW. More tests, injections or surgery probably won't help. Clearly the medications aren't working. Your employer likes you and wants you back to work.

16 Sounds great! So how EXACTLY do we get this to happen?

17 Functional Restoration Approach What is it? Functional restoration is an approach (not a specific and expensive chronic pain program) Multidisciplinary and coordinated team effort Education IW active not passive Focus on function Locus of control shifts to individual Physical Restorative Therapies Education and Psychosocial Focus Cognitive Behavioral Therapy MED Dose/day Medication/opioid Optimization

18 The Opioid and Psychotropic Drug Dilemma

19 Dr. GOOD: Recommendations for Mary s case Let s work together to reduce you reliance on pills. We are going to start with carefully and slowly reducing the Percocet and Soma over the next 6 weeks while slowly adding OTC acetaminophen. For the short term, I am also adding a low dose antidepressant, trazodone to help with sleep and depression. Our therapy team can give you practical ways to help you cope with your pain and depression. You will see our psychologist for CBT 6 sessions to help you with pain coping skills. With your goal of getting back to work, our physical therapist will design a back to work conditioning rehabilitation program for you. So Mary, I am convinced you can feel better, become more functional and meet your goals including returning to work - do you want to give it a try?

20 Back to reality Take Home Points Disaster cases have several identifiable causes. Psychosocial issues = delayed recovery. You can prevent these if you (1) Detect problems & (2) Intervene A team effort is needed for success. Including all the payers The Functional Restoration approach can prevent these disaster cases. Treatment: Medical care carefully tailored to the patient s level of severity. More effective done early rather than late.