Development and Implementation of an Interdisciplinary Group Medical Visit for Chronic Pain in a Rural Health Clinic

Transcription

1 Session # H5b Development and Implementation of an Interdisciplinary Group Medical Visit for Chronic Pain in a Rural Health Clinic Maxwell Moholy, PhD, Behavioral Health Consultant, Cascade Medical Center David Bauman, PhD, Behavioral Health Education Director, Central Washington Family Medicine CFHA 20 th Annual Conference October 18-20, 2018 Rochester, New York

2 Faculty Disclosure The presenters of this session currently have or have had the following relevant financial relationships (in any amount) during the past 12 months. David Bauman is a consultant for Beachy Bauman Consulting

3 Conference Resources Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at Slides and handouts are also available on the mobile app.

4 Learning Objectives At the conclusion of this session, we hope that will be able to: Discuss the need for an interdisciplinary approach to pain management in a rural primary care setting. Describe the process, including successes and ongoing challenges, of developing and implementing an interdisciplinary chronic pain group medical visit in a rural primary care clinic. Evaluate the feasibility and effectiveness of a chronic pain group medical visit for improving patient care and provider satisfaction.

5 About us Maxwell Moholy, PhD Behavioral Health Consultant for Cascade Medical Center Roles include: PCBH Clinical, QI committee David Bauman, PsyD Behavioral Health Education Director for Central Washington Family Medicine Roles include: PCBH clinical, core faculty for FM residency, RTD of PCBH psychology internship

6 Outline Background Chronic Pain Group Medical Visits Implementation at Cascade Medical Center Discussion

7 Who s here? Physicians? Nurses? Behavioral Health Clinicians? Administrators? Other?

8 Who s here? Who has helped run a group medical visit? What challenges/barriers have people faced in trying developing/implementing a group visit? What successes have people seen?

9 What is Chronic Pain? 1 Acute vs Chronic Pain Pain lasting longer than 3 6 months Chronic pain Usually no clear etiology Musculoskeletal disorders Muscles, ligaments/tendons, bones and nerves Localized or generalized Low back pain Most common disability Lumbar degenerative disc disease 30% of people (30-50 y/o) May or may not cause discomfort W/o structural abnormality, can still have pain

10 What is Chronic Pain? Chronic Pain Joint disease Arthritis Rheumatoid arthritis immune system attacks own cells Other forms of chronic pain Chronic fatigue syndrome Endometriosis Fibromyalgia Lupus Inflammatory bowl disease Interstitial cystitis Temporomandibular joint dysfunction Headaches Migraines

11 What is Chronic Pain? 1,2 Influence of CP on the PC system: CP is the most common reason for seeking medical attention Estimated 20-50% of patients seen in PC Think about that 20-50% Current treatments: only about 30% reduction in pain levels3 However, partial reduction in pain can significantly improve patient s QOL Demand for opioid intervention Lacking of long-term benefit and sx/qol improvement; increase in serious risk of harm5,6 Recommended CP tx by multidisciplinary team Medications should NOT be sole focus of treatment We will come back to this

12 Lifestyle factors associated w/ Chronic Pain 1-3 Tobacco use Higher levels of smoking = higher level of pain & less physical involvement9 Depression (similar pathways emotion & pain) 4x s higher rate of having disabling pain Greater pain intensity Overweight or Obese What came first?

13 Behavioral interventions for chronic pain 1-7 Research on behavioral techniques Eh could be better CBT recommended for general chronic pain and chronic low back pain In addition to CBT, relaxation techniques, exercise, self-care, education have been shown to be somewhat effective Self-care Pacing, returning to functioning, helpful in pain reduction and functionality Exercise therapy helpful in pain reduction and functioning Mind body interventions (mediation and mindfulness) budding research but not clear regarding effectiveness Education budding research, not conclusive, focus on neurophysiology education vs biomechanical may be more beneficial In addition to the above, we like to promote the NEEDS approach N Nutrition; E Enjoyable activities; E Exercise; D Don t smoke or drink; S Sleep

14 Population based efforts 1-8 Limitations of one on one visits Need to have population based approaches to get the message/interventions out to the masses Say hello to chronic pain groups Most of the affirmation behavioral interventions have been adapted and applied in group formats Similar results to individual Encouraged to include multidisciplinary team members, which could include medical providers, behavioral health providers, nutritionists, physical therapists, etc. (emphasizes the team approach) Research: Not well defined but showing evidence of improvement in both pain reduction and functioning

15 Last few thoughts Anecdotally from our experience at CWFM Include a BHC, resident and PA patients per group (two monthly groups) Best part of the group? Love isn t everything, it s the only thing Chronic pain pathways Great ideas! Hell is paved with good intentions. - Samuel Johnson Often, difficult to implement Need: Provider support Administration support Support staff support Etc., etc., We are going to give an overview of an initiative and be REAL about it

16 Implementation efforts at a clinic in Leavenworth, WA

17 The Setting

18 The Setting Other 46.00% Medicare 40.00% Medicaid, 14.00%

19 Patients with chronic pain 515 patients on long-term opioid therapy 140 patients with a long-term opioid therapy treatment agreement 83 patients with concurrent opioids + benzos

20 Long-term opioid therapy treatment agreements 84-day refill appointments Annual urine drug screens + provider discretion Prescription monitoring program How to involve BHC?

21 Early Development of Group Realistic expectations/goals for the group Group Medical Visit vs. Traditional Behavioral Health Group How to conduct the medical part of the visit

22 The Group Who Provider, BHC, two support staff Guest speakers: Dietician, PT, Clinical Pharmacist, others? When Monthly 2-hour schedule block, 90-minutes for the group

23 Recruitment Letter + follow-up phone calls Identifying patient s at refill visits Patient buy-in? Counts as an office visit for pain med refills Become more proactive in management of your pain

24 Group Agenda Check-in / Vitals / Complete Pain Tracker Brief individual visit with provider minute presentation/discussion Pathophysiology of pain Mindfulness Exercise/Pacing Sleep Nutrition

25 Measurements University of Washington Pain Tracker PEG Sleep PHQ-4 Satisfaction w/ Tx

26 PEG

27 Participants 26 patients across 5 groups to date Our target? 8-12 Patient feedback 8 patients have been to 2+ groups

28 Pain Tracker Data PEG Sleep PHQ-4 Satisfaction

29 Comments from our provider Recruitment efforts Clinic initiative Nuts and bolts

30 Discussion/Questions

31 Final Thoughts Different way of engaging patients and providers Shifting perspective clinic-wide Ongoing evaluation and improvement

32 Handouts/Tools available for you Sample group visit planning checklist Sample group visit flyer Sample group visit recruitment letter UW Pain Tracker (

33 References 1. Rosenquist, E. W. (2018). Overview of the treatment of chronic non-cancer pain. In UpToDate. Retrieved September 30, 2018, from 2. Chou, R. (2018). Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment. In UpToDate. Retrieved September 30, 2018, from avioral%20therapy&topicref= Janke, EA, Collins, A, Kozak, AT. Overview of the relationship between pain and obesity: What do we know? Where do we go next? Journal of Rehabilitation Research and Development 2007; 44(2): Geneen, L. J., Moore, R., Clarke, C., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane database of systematic reviews. doi: / cd pub3 5. Robinson, P., Bauman, D., & Beachy, B. (2016). Promoting healthy lifestyle behaviors in patients with persistent pain. In J. Mechanick, & R. F. Kushner (Eds), Lifestyle medicine: Manual for clinical practice. New York, NY: Springer Science, Business Media, LLC. 6. Monticone, M., Cedraschi, C., Ambrosini, E., Rocca, B., Fiorentini, R., Restelli, M. Moja, L.(2015). Cognitive-behavioural treatment for neck pain. Cochrane database of systematic reviews. doi: / cd pub2 7. Williams, A. C., Eccleston, C., & Morley, S. (2012). Psychological therapy for adults with longstanding distressing pain and disability. Cochrane database of systematic reviews. doi: / cd pub3 8. Gaynor, C. H., Vincent, C., & Safranek, S. (2007). Group medical visits for the management of chronic pain. American Family Physician, 1(76),

34 Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

35 Session Evaluation Use the CFHA mobile app to complete the evaluation for this session. Thank you!