8/28/2017. How to Develop a Multi-Disciplinary Pain Management Team Including Therapy and Pharmacy

Transcription

1 How to Develop a Multi-Disciplinary Pain Management Team Including Therapy and Pharmacy 1

2 Presented by Sharon Litwin RN, BSHS, MHA, HCS D Sheryl Bellinger MA, BSN, RN, CHCA Senior Managing Partner Administrator, Owner 5 Star Consultants, LLC Professional Home Health Care, Inc. Introduction 2

3 An Effective Multi-Disciplinary Pain Management Team Successful Models acknowledge and support the interdependence among team members that fosters an alliance of mutual respect and open communications. Effective, interdisciplinary care does not happen by chance or by individual members simply working harder. It requires the concerted and coordinated activities of multiple people and disciplines. It requires teams that can effectively blend diverse skills and perspectives toward a common aim. An Effective Multi-Disciplinary Pain Management Team A key component of what home health does in caring for patients involves how the multi or interdisciplinary team work together in order to improve pain outcomes for a patient. The full team must start at the admission and share the goals for pain management. In order to then achieve success, the strategies include a thorough pain assessment every visit by every discipline. The Home Health Aide is also be a big component of the pain management model, as they are with the patient for longer and more intimate periods of time, in which they will note pain variance and report to the team in real time. The Pharmacist is also a key, but often forgotten team member in home health. The Multidisciplinary team, and therefore, the patient can benefit greatly by involving the Pharmacist! 6 3

4 An Effective Multi-Disciplinary Pain Management Team The Multi-Disciplinary team, in working to improving the patient s outcome in pain, must: Note what is working and what is not working and brainstorm, then contact the physician. Involve the patient and caregivers so that they understand the patients goals, the barriers to improving pain outcome, and strategies that will be successful in the patients' environment. Communicate with each other frequently Document the in the clinical record. Be each other's eyes and ears and work as a team to improve the patients pain outcomes! Objectives This session will: Define the members of an interdisciplinary pain management team and what their roles are, Analyze best practices in Multi-disciplinary team pain management to include: Skills for plan development, Intervention choices Meeting modalities Lessons from discussions on outcome measures Triggers for therapeutic changes to the plan of care 4

5 CoP Care Planning, Coordination of Services, and Quality of Care (d) Standard: Coordination of Care - The HHA must: (1) Assure communication with all physicians involved in the plan of care. (2) Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. (3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. (4) Coordinate care delivery to meet the patient s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. (5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. Pain The Big Picture! Pain is a major health and economic issue in the United States and the number one cause of adult disability. There are currently more than 100 million Americans suffering from chronic pain Chronic pain affects more people than diabetes, coronary heart disease, stroke, and cancer combined Pain costs an estimated $560 billion to $635 billion annually in lost workdays, medical expenses, and other benefit costs. Unrelieved pain can result in longer hospital stays, increased rates of rehospitalization, increased outpatient visits Unrelieved chronic pain problems often result in an inability for patients to work and maintain health insurance. 5

6 2 Key Points 1. Pain is the 5 TH VITAL SIGN 2. Pain Management is MORE THAN Medication Management Other Important Points Pain is a subjective experience that requires an individualized approach to treatment. Pain is whatever the experiencing person says it is, existing whenever he or she says it exists and at whatever level he or she says. It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. 6

7 Pain Management Team Multi-Disciplinary Pain Management Historically, management of patients reports of pain was addressed by individual health care providers, usually a physician. However, the presence of pain affects all aspects of an individual s functioning, psychosocial and behavioral factors as well as the extent of their underlying physical pathology. Therefore, an interdisciplinary approach that incorporates the knowledge and skills of a number of health care professionals and their teams is essential for successful treatment and patient management that address the many facets of pain. 7

8 Who is on the Multi-disciplinary Pain Management Team? Members of the team should have complementary roles that enhance patient care. Each discipline involved in the interdisciplinary team has a valuable base of knowledge and a set of discrete skills that complement each other. Every single staff member that is taking care of a patient is on the team! Includes RN, LPN, Aide, PT, PTA, SLP, OT, COTA, MSW Includes the PRN staff or those working weekends Include the sub-contractors! So Mrs. Jones may have Nancy Nurse, Susie the weekend nurse, Bob- PT, Sally OT, Tom COTA on her home health team. Who is on the Multi-disciplinary Pain Management Team? The Home Health team is only a portion of the Pain Management Team! Included in order to be successful in increasing patient outcomes are: Physician(s) Pharmacist(s) Patient! Family and / or Caregiver(s) 8

9 The Multi-Disciplinary Pain Management Team Works towards the same goal of increasing the patient s outcome in pain This may be the most critical component to be successful! Coordinate in order to: Effectively implement interventions, Educate the patient and caregiver(s) Evaluate the modalities effect on pain, Ensure that patient is compliant Observe if any adverse reactions Obtain new modalities if ineffective Goals of Pain Management Team Although there are common goals for the entire team, each discipline may target specific issues to the specific disciplines. Example: Therapy - upper body strength, flexibility, & endurance- goal to improve physical function and establishment of a self-management program (e.g, daily exercises). Nursing addresses components of a healthy life style, compliance with meds The physician optimizes med benefits (analgesia, improved mood, & restorative sleep) The pharmacist -focus on safety, limiting adverse events, and monitoring for adverse events and misuse. A unified message should be provided to patients so that the team members reinforce the methods being used across disciplines. 9

10 The Multi-disciplinary Pain Management Team Uses a holistic approach in caring for the patient, never directed toward an isolated body part or symptom, and which include physical, emotional, social and psychological aspects. Is patient-centered, also being very cognizant of the family and/or caregiver(s). Efforts are made to achieve empowerment of the patient and his or her caregivers or significant others. This approach leads to increased success with pain management! Communicates (Reports) to each other whenever status of the plan needs to be revised as patient s pain and/or effects of medications have changed. The Multi-disciplinary Pain Management Team Each team member must be familiar with the overall treatment plan, the methods and modalities being used, and the goals of each discipline working with the patient that contribute to the overall goals (i.e., reduction of pain, improved pain tolerance, and improvements in physical and emotional functioning, patient satisfaction). All goals should be clear, focused, realistic, and measurable. Evaluation of treatment effectiveness must be based on a prespecified method of assessment; Example: How will the team, person with pain, or significant others know whether these goals have been or are being met? Monitors progress toward goal achievement 10

11 Pain Assessment Initial Assessment of Pain A thorough as possible history of pain experiences should be done Ask patient and/or family, caregiver(s) to describe past and current experiences with pain including: Effectiveness of the methods used to manage the pain, both pharmacologic and non- pharmacologic Experiences with side effects, interactions Typical coping responses while having pain and what is effective What, if any, are the patient s concerns that may affect their willingness to report pain and use analgesics Then work with the patient to see how to overcome these issues 11

12 Pain assessments on Every Visit: Pain assessment must be done at each home visit by each member of the team and in detail. Assessment addresses: Pain characteristics onset, duration, location, quality, intensity Specific pain location(s) Associated symptoms Factors that help to alleviate or exacerbate pain. Functional abilities with and without pain Pain Assessments on Every Visit Be sure to address PRN pain medications Examples: The patient s pain is an 8, but the patient did not want to take the pain meds because they make him too tired? Or is the pain a 0 today do not just document denies pain. Is it because the patient has taken his prn pain meds as ordered throughout the day? Aides will not do a pain assessment, however will note anything the patient tells them about the pain and report the information to the appropriate clinicians in the team. 12

13 Improving Frequency of Pain Interfering with Patient s Activity or Movement Key Goal of the Multi-Disciplinary Pain Management team is to improve the OASIS M item Outcome NOT ONLY THE OASIS CLINICIANS! When full team focuses on improving on improving this outcome, the patient typically can improve at a higher level due to the coordinated approach by the plan 25 M1242 -Frequency of Pain interfering with Patient s Activity or Movement OASIS Guidelines and Intent Indicates that interference in activities does not just include ADL s, e.g. sleeping, watching TV, recreational activities Look at the frequency with which pain interferes with patient s activities, with treatments, etc. Pain interferes with activity when pain results in: Activity being performed less often than otherwise desired, Required the patient to have additional assistance in performing the activity, or Causes the activity to take longer to complete. 13

14 Improving Frequency of Pain Interfering with Patient s Activity or Movement Be careful not to overlook decrease in ADL s due to pain (ex: the patient says she sits in the chair all day and puts off going to the bathroom, because it hurts so much to get up from the chair or to walk). Evaluating the patient s ability to perform ADL s and IADL s can provide additional information about pain. WATCH THE PATIENT to identify functional ability and pain The patient s treatment for pain (whether pharmacologic or nonpharmacologic) must be considered when evaluating whether pain interferes with activity or movement. Pain that is well controlled with treatment may not interfere with activity or movement at all. Geriatric Pain 14

15 Geriatric Pain Older people who live in the community experience pain to a lesser degree than those in long term care (80%), but it is still a significant number, reported to be as high as 50%. Generally, people who have pain seek effective pain medication. However, 1 in 5 older people reported taking pain medication only occasionally during a 1-week period of time. Important to assess the reason for this: Undertreatment by prescribers; Financial difficulties (i.e., affording the cost of medications); or Reluctance of older patients to take pain medications due to side effects? The Consequences of Geriatric Pain Can Be Depression and/or Anxiety, Decreased socialization Sleep disturbances, Impaired ambulation, and Increased healthcare utilization and costs. The Team caring for older patients can help advocate for better pain relief when they encounter patients who are not receiving appropriate treatment for pain. Find out WHY the patient is leery of taking pain medications then work with the team for resolution! 15

16 The Team and Geriatric Patient s Pain Management The team, including the physician and the pharmacist, can effectively treat pain in older patients by careful prescribing, frequent reevaluation, and combining treatments to achieve better pain control. Older individuals may be reluctant to report pain for several reasons: Many older people think that pain is a normal part of aging; They do not want to be a nuisance; and They fear the consequences of acknowledging pain, such as expensive and uncomfortable testing or hospitalization or being placed in a Nursing Home The Team must be aware of the potential for underreporting pain and make every effort to pursue an evaluation of pain in this population. The Team and Geriatric Patient s Pain Management Individual self-reporting remains the most reliable indicator of pain, even for patients with mild cognitive impairment. For all older adults, the language used for assessment may need to be modified to include pain descriptors used by the patient, such as a pinching or squeezing type of pain or what the term "discomfort" means to the patient. Pain is often thought of as being "high" on a continuum of discomfort, and a patient may respond that he or she does not have "pain" when questioned. However, patients may respond to words, such as achy, sore, or discomfort. Once a term to describe an individual's pain has been identified, it is recommended that this term be used throughout the assessment and reassessment of that individual's pain. ALL team members must be consistent! 16

17 Nonpharmacologic Techniques A Key Component of Effective Pain Management Some simple comfort measures can help reduce pain. Listening to music, watching television, and storytelling are all distraction techniques that allow patients to reduce their focus on pain. Massage, soft touch, and warm applications are relaxation techniques that are beneficial for patients. Sensory stimulation in the form of pet therapy or folding warm clothes as well as cognitive therapies that include reading or reminiscing have all been used to reduce pain. Participation in regular physical activity not only reduces pain, but enhances functional capacity and mood. Therefore, a physical activity program should be considered for all patients. The program should be individualized to meet the needs and preferences of the patient. This is especially important for older adults. Pain Management Intervention 17

18 Nonpharmacologic Techniques A Key Component of Effective Pain Management Music therapy Evidence based studies have shown the positive responses to this nonpharmacologic modality. One study examined the effectiveness of using music as an intervention for relieving pain caused by osteoarthritis in elderly people living in the community. The results indicate that those who had listened to music had significantly reduced pain. Results show that the experimental group experienced a decrease, both in the perception as well as in the intensity of pain, throughout the whole period of the study, while the control group maintained relatively the same level of pain. The study found that listening to music is an effective intervention for the reduction of chronic pain perceived in populations with osteoarthritis that are older than 65 years and living in the community Therefore, the team should be aware that there is good evidence to suggest that music is an effective intervention in patients with chronic pain, helping to reduce pain, depression and disability, and increasing capacity (empowerment). Interventions for Pain Management Thinking Outside of the Box Duke University s Pain Management in Homecare: Along with medications, the home health team also offers the patient education to manage the pain at every visit and ways to manage pain without drugs called a Getaway in a Bag The bag includes opportunities for relaxation, aroma and guided imagery therapies, meditation cd, as well as a squeeze ball and cuddly item for general comfort. They have shown increases in outcomes and patient satisfaction with this program that stresses the importance of Non Pharmacologic interventions as part of the Home Health Plan of Care. 18

19 Pharmacologic Pain Management Techniques Pharmacologic management is the most common treatment for pain control in older adults. There are a variety of pharmacologic agents to treat pain in the elderly, and no 2 patients will respond in the same way. It is important that nurses, pharmacists and the other clinicians on the team be aware of specific properties of drugs that are prescribed and common age-related changes that can influence how drugs are metabolized and absorbed. This is necessary so that as signs and symptoms are seen in the patient by the team members, it can immediately be reported to the Nurse and Physician in order to catch it early! Reassessing the effect of the drug as dosages are changed due to ineffective drug therapy are important components of effective analgesic management. Early Physician Notification if often key to preventing an emergent care visit, rehospitalization and/or poor patient outcomes due to pain medications! The Role of the Pharmacist To exclude a Pharmacist from the Home Health Multi-Disciplinary Pain Management team is a mistake, as they have a vital role in ensuring safe and effective pain management. They are often the first point of contact for patients seeking nonprescription analgesics and advice regarding prescription analgesics. When pharmacists provide education to their patients with pain, they experience a decrease in the incidence of adverse events and improvements in their satisfaction with care. They can help patients understand the appropriate use of the medication and periodically assess them to ensure that pain management goals are being adequately met. 19

20 The Role of the Pharmacist To effectively partner with patients to assist in pain management, a pharmacist must have an understanding of the Epidemiology of pain, Pain mechanisms, Frequently encountered pain conditions, Variables which influence the patients perception of and response to pain, Valid and reliable methods of clinical pain assessment, and both pharmacological and non-pharmacological methods for pain relief. Much of this knowledge can be imparted by the pain management team as they share information. The Role of the Pharmacist Discussion points that may be important to patients Reinforce that it is important to use one pharmacy for all medications. This simple step can help avoid harmful drug interactions and ensure that the pharmacist can consult with the patient and family about the medication regimen. Pharmacists should ask patients to inform them about all the medications that they may be taking, including OTC s, dietary and herbal supplements. The team can set up a communication method that ensures the Pharmacist delivers this information, when new or revised, to the Team. Pharmacists can help patients understand how each medication is to be taken, including how often and when to take the medication, whether or not to take it with food, what to avoid while taking the medications, and any potential drug interventions. Again, this can be shared & coordinated with the team. 20

21 Documentation Frequent communication among team members has to occur for the pain management model to be successful. The team can identify problems in an area that may be addressed by another discipline. So, issues have to be communicated to the team members. Example: Mrs. Jones tells the MSW that she is too fatigued over the past week, so she doesn t do the Home Exercise Program the therapist gave her. The MSW documents this in her visit note. However, This may be due to the medication regimen, possible CHF symptoms, or fear of falling. If the MSW simply documents that the patient stated she is fatigued, none of the other teams members will know, so that they can assess the patient, and report to the physician as necessary. This is a very common problem in the home health industry and can effect the patient s outcomes! 21

22 Communication between Team is Key! It is critically important for the team to communicate regularly Direct phone call, Voic , Texting (if HIPAA compliant), Through the EMR, In person The more urgent the issue, the more responsive the communication method needs to be: Example: If signs of impending CHF are indicated, a direct phone call to team member and possibly to supervisor and physician is necessary. Communication Must be frequent with the Physician, the Patient and Caregiver(s) as well for the pain management team to be effective! Documentation When multiple disciplines and treatment strategies are involved, documentation becomes critical as a means of establishing progress toward the shared short term and long-term goals. It is essential that necessary documentation such as follow up assessments, should be shared, but additionally all important and relevant information in visit notes, orders and reports should be made available to all team members. Therefore, it is necessary to identify in the EMR or in a paper clinical record a location in the clinical record for all Team coordination to be entered. Policies subsequently stating the frequency with which team members must view the communication section must be implemented. 22

23 QAPI QAPI and the Pain Management Team QAPI is a responsibility of all team members! All team members should have input into the QAPI plan and Quality indicators. Team members must be provided with updates on progress and problems identified so that they can be part of the solution. Whenever possible, detailed QI plans should be in place and indicators that demonstrate each of these elements should be clearly specified. From QAPI and patient outcome results, the Multi-Disciplinary Pain Management teams can assist in developing practice standards and pain policies which are developed from the programs challenges and successes! 23

24 QAPI Indicator - Pain Review 20% (or higher if your outcome in pain is lower than national) clinical records quarterly to ascertain if pain improved, stayed the same or declined. For all the patients that stayed the same and/or declined, perform a detailed audit to be able to drill down to the issues. Goal is to identify if your agency could have done more to improve the patients pain. For those patients that stayed the same, may have a streamlined audit. Review visit notes to identify if all clinicians are completing a thorough pain assessment every visit Review to identify if there is a communication section where the pain management team is coordinating care on a regular basis. 24

25 QAPI Indicator - Pain Share results with all team members- overall and for their specific patients Choose a Pain task force of various disciplines in order to enhance the Multi-disciplinary Pain Management Team Model Brainstorm to think outside the box generally and patient specific Identify if: Therapy is not sufficiently utilized Team is not reporting signs/symptoms of pain and/or ineffectiveness of pain meds Early intervention is utilized by team Physician is contacted when pain is not improving Sufficient education is performed Conclusion Often a Multi-Disciplinary team approach, including the patient, family members, nurses, therapists, and aides, pharmacists and physicians is needed to reach optimal pain relief and improve patient outcomes. Evidence is mounting in support of the central role of teamwork in delivering better health care and improving outcomes both in primary care and in pain management. THINK NEW COPS, Star Ratings, Impact Act and Value Based Purchasing! Have a much higher Quality of Care by enhancing your patient s outcomes AND be a Viable Agency long into the future! 25

26 Sharon M. Litwin, RN, BSHS, MHA, HCS-D Senior Managing Partner 5 Star Consultants, LLC slitwin@5starconsultants.net Sheryl Bellinger, MA, BSN, RN, CHCA Owner Professional Home Health Care, Inc. 26