2016 American Academy of Neurology

Transcription

1 2016 American Academy of Neurology

2 PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance Abuse Training (SECSAT). For more information visit: For questions pcss-o@aaap.org 2016 American Academy of Neurology Funding for this initiative was made possible (in part) by Providers Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

3 No conflicts of interest were reported by the presenter or identified by the Program Accreditation Subcommittee. There is no commercial support for this series to disclose. AAN will be providing webinars free of cost, for CME. This material has been reviewed by the lead Clinical Expert on the PCSS-O grant, co-faculty, and AAN staff. Webinars will be available on-demand for participants unable to make the live event American Academy of Neurology

4 Accreditation Statement The American Academy of Neurology Institute is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. AMA Credit Designation Statement The American Academy of Neurology Institute designates this live activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity American Academy of Neurology Slide 4

5 Objectives Understand the principals of primary, secondary and tertiary prevention regarding the care of patients presenting with acute episodes of pain Understand how to layer best practice care delivery from what can effectively be done in the office for more simple pain problems and what can be done using additional community health care resources when pain becomes more complex Describe the importance of preventing the transition from acute to chronic pain and long term disability Describe the importance and key causes of transition from acute to chronic pain Understand the relationship of development of chronic pain to development of long term disability Describe how health care coordination and collaboration can improve outcomes for pain patients 2016 American Academy of Neurology Slide 5

6 PCSS-O Webinar Series: Providing Stepped Care Management for Pain in Your Practice and Community Gary M. Franklin, MD, MPH Research Professor Departments of Environmental Health, Neurology, and Health Services University of Washington Medical Director Washington State Department of Labor and Industries 6

7 The State of US Health, Burden of Diseases, Injuries, and Risk Factors* Years lived with disability 2010 Low back pain Major depressive disorder Other MSK disorders Neck pain Anxiety disorders Diabetes (#8) Alzheimer's (#17) Stroke (#23) 3.18 million YLD 3.05 million YLD 2.6 million YLD 2.13 YLD 1.86 million YLD 1.16 million YLD.83 million YLD.63 million YLD *JAMA 2013; 310:

8 What is stepped care management? Model based on Wagner et al model of chronic care management developed at Group Health Cooperative for diabetes, heart failure, etc. Original goal was to improve chronic disease prevention and management More recently adapted for chronic pain prevention and management Now tightly linked to population-based quality improvement initiatives Also centerpiece of medical home models of care Rothman AA, Wagner EH. Chronic illness management: What is the role of primary care? Ann Int Med 2003; 138:

9 What are key elements of stepped care management? Population based health care Team based support for complex conditions Goal is to keep patient in primary care with sufficient team support Patient-centeredness-key goal is to improve patient self-efficacy with aim to improve health outcomes and reduce avoidable hospital admissions, ED visits Key element is care coordination (e.g., see Crossing the Quality Chasm, Institute of Medicine, 2001) so that care is integrated and patients do not fall through the cracks Clinical information coordination AND clinical care coordination Measurement based-treat to target

10 Collaborative care to prevent and better treat chronic pain-biopsychosocial model of pain Expands role of care coordination to providing clinical assessment and brief interventions-e.g. cognitive behavioral therapy, motivational interviewing Can be partially delivered telephonically so as to reach more rural/isolated patients Behavioral health integration with pain management to address psychosocial barriers to recovery Psychosocial barriers Most important psychosocial barriers to recovery: fear avoidance, catastrophizing, low expectations of recovery

11 Physical inactivity Catastrophizing Pain flare-ups Behavioral Interventions Self-efficacy Distress (stress or depression) Anxiety (fear of movement / re-injury) Perceived injustice Psychosocial Risk / Symptoms Disability conviction Sleep issues Poor treatment adherence Substance issues 11

12 IMPACT Trial 18 clinics in 5 states, 1801 patients RCT published in JAMA, 2003 Collaborative Care achieves the Triple Aim: 1. Better patient and provider satisfaction with care 2. Better clinical outcomes Doubles effectiveness of depression treatment Less physical pain Better functioning Higher quality of life 3. Reduced health care costs 12

13 Collaborative Care: Defined A type of integrated healthcare developed to treat common behavioral health conditions Originally mental health conditions Used now for pain & other conditions Team-based system of care Based on 5 core principles Cochrane Review 2012: 79 trials and 24,308 patients 13

14 Principles of Effective Collaborative Care Accountable Reaching treatment targets Patient-Centered Team Care / Collaborative Team focused on patient s goals Evidence-Based Care Psychosocial and pharmacological treatments Measurement- Based Treatment to Target Outcomes measured + stepped up care Population-Based Care No patients falling through the cracks Specialists support care 14

15 Traditional vs collaborative behavioral health care Traditional (treatment as usual) Single behavioral health expert Psych assessment Typically address a very targeted problem Costly training Rigid protocols Limited population generalizability Time consuming treatments - Typically delivered face-to-face Point of care treatment, no outreach Limited population reach Collaborative Care Care manager (specialist consultants) Systematic screening Brief evidence based treatments Interdisciplinary team care Medication management and consultation Utilizes telehealth to reach patients Flexible Focus on patient engagement Increased intensity in treatment as needed Lower cost than traditional treatments Broad population reach 15

16 Collaborative Care Model Providers Give patient a choice of treatments Consultants: Psychologist Psychiatrist Pain expert Feedback Decision support Care coordination Patient Care Manager Motivate adherence & treatment response Provide brief treatments Facilitate community support Weekly case supervision Treatment adjustment Manage treat-to-target

17 Roles for Collaborative Care Team Members during Episode of Care Injured Worker Complete screenings Shared decision making and track outcomes Communicate concerns Report updates and complete L&I requirements Attending provider Refer to collaborative care Share information across team Follow up on specialist recommendations Facilitate return to work Care manager Assessment / plan Monitor and coordinate care Consultation with specialists Link team and data Engagement in care Patient and team education Step up care and refer as needed Brief evidence-based psychosocial tx s Relapse prevention plan Consultants Weekly consultations on new and nonimproving cases Facilitate stepping up care as needed Training sessions to team Psychologist Brief behavioral tx s Behavioral plans for difficult clinical situations Support burn out Psychiatrist Psychotropic medication tx s Support burn out Pain Expert Multidisciplinary biopsychosocial intervention Health Services Coordinator Link team Facilitate L&I and clinical team coordination of care Facilitate return to work 17

18 Core Behavioral Interventions Education (including sleep hygiene education) Self-monitoring: identifying progress & strengths Goalsetting/values Behavioral activation (including activity coaching) Cognitive restructuring Mindfulness meditation Relaxation training Problem solving Building helpful social support & engagement Nurturing positive emotions Motivational Interviewing 18

19 Episode of Chronic Pain & Behavioral Health Care 2-6 months Session /Activity Content Care Manager & Injured Worker Session 1 Sessions 2 to # Session frequency will range from 1/week to 1/month & typically decreases over time Patient-centered assessment & care planning: Assessment Self-management & care Set recovery expectations Develop initial treatment plan Ongoing sessions: Monitor outcomes & response Monitor adherence, self-management, & work status Coordinate medical management Provide brief behavioral interventions Provide support for pain self-management & maintenance of gains Intensify/step up treatment Final Session Relapse prevention plan Provide resources to maintain gain Specialist weekly consultation Discuss new patients Discuss non-responding patients Review progress, barriers, plan Monitor outcomes Recommend treatment adjustments Other Activities Inform L&I staff as needed Facilitate referrals (i.e., PGAP, voc services) 19

20 Emerging examples of stepped care management/collaborative care for pain VA Health System Stepped Care Model of Pain Management Dorflinger et al. A Partnered Approach to Opioid Management, Guideline Concordant Care and the Stepped Care Model of Pain Management. J Gen Int Med 2014; Suppl 4, 29: S Vermont Spoke and Hub regional support for medication assisted treatment for opioid use disorder/severe dependence WA state Centers of Occupational Health and Education/Healthy Worker 2020

21 Stepped Care Model for Pain Management Comorbidities RISK Tertiary Interdisciplinary Pain Centers Advanced diagnostics & interventions Commission on Accreditation of Rehabilitation Facilities accredited pain rehabilitation Integrated chronic pain and Substance Use Disorder treatment STEP 3 Treatment Refractory Complexity Secondary Consultation Pain Medicine Rehabilitation Medicine Behavioral Pain Management Interdisciplinary Pain Clinics Substance Use Disorders Programs Mental Health Programs Primary Care/Patient Aligned Care Teams (PACTs) Routine screening for presence & intensity of pain Comprehensive pain assessment Management of common acute and chronic pain conditions Primary Care-Mental Health Integration, Health Behavior Coordinators, OEF/OIF/OND & Post-Deployment Teams Expanded nurse care management Clinical Pharmacy Pain Medication Management Opioid Pain Care and Renewal Clinics STEP 2 STEP 1 21

22 Timing of stepped care management to prevent transition to chronic pain Screening for collaborative care 22

23 Where to focus to achieve disability prevention MORE MODIFIABLE LESS MODIFIABLE Clinical Work Administrative Psychological Legal Demographic

24 Screen Assess Intervene FRQ

25 Characteristics associated with disability Perceived Injustice Turner, Franklin, Wickizer, Fulton-Kehoe et al. ISSLS Prize Winner: Early Predictors of Chronic Work Disability: A Prospective, Population-Based Study of Workers With Back Injuries. Spine 2008; 33: Catastrophic Thinking Chou R, Shekelle P. Will this patient develop persistent disabling low back pain. JAMA. 2010;303(13): Low Recovery Expectations Activity Avoidance Osman, A., et al., The Pain Catastrophizing Scale: further psychometric evaluation with adult samples. Journal of behavioral medicine, (4): p Sullivan, M.J., et al., The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. Journal of occupational rehabilitation, (3): p Fulton-Kehoe, D., et al., Development of a brief questionnaire to predict long-term disability. Journal of Occupational and Environmental Medicine, (9): p

26 Positive FRQ = High Disability Risk aka Workers Comp Heart Attack More Attending Provider Attention Required Business As Usual: Not Good Enough It Needs To Be Taken Seriously More Time Should Be Spent With Them Assure These Workers DO NOT Fall Through The Cracks

27 Systematic review of chronic disabling back pain risk factors and risk prediction instruments 20 prospective studies of patients with <8 wks back pain from which likelihood ratios could be calculated Chou and Shekelle: Will this patient develop persistent disabling low back pain? (JAMA 2010; 303: )

28 UW Research Team Department of Labor & Industries External Advisory Committee (ACHIEV) Health Care Community Healthy Worker 2020 Programs COHE Business and Labor Advisory Boards Community Health Care Providers

29 Key Results from COHE Pilots Wickizer et al, Medical Care; 2011: 49: One year follow up 20% reduction in likelihood of one year disability, 30% reduction for back injuries Among COHE participating doctors, high adopters of best practices had 57% fewer disability days than low adopters Eight year follow-up-in preparation 26% reduction in permanent disability (SSDI offset, TPD, 5 yrs TL) among back sprains and other sprains

30 Emerging Best Practices: Current Pilots Functional Recovery Functional Recovery Questionnaire (FRQ) Early identification of potentially at risk workers Functional Recovery Interventions (FRI) Providers incorporate interventions to enhance recovery in addition to 4 the COHE Best Practices 30

31 Emerging Best Practices: Current Pilots Activity Coaching A provider in E. Washington said: This patient had 22 red flags when I referred him to PGAP. At the next visit he was a completely different person. Workers have said: It gives you a reason to get out of bed and how to be in control of your life again. It teaches you how to relearn to manage your pain and life. 31

32 Emerging Best Practices: Upcoming Pilot Emerging Surgical Best Practices Four best practices selected from the literature by a focus group of attending providers & surgeons related to: Transition of Care Return to Work Creation of a Surgical Health Services Coordinator to: Coordinate care and transitions Help providers with complicated cases 32

33 Healthy Worker 2020 Innovation in Collaborative, Accountable Care An Occupational Health Home for the Prevention and Adequate Treatment of Chronic Pain Primary Occupational Health Best Practices Active Physical Med PGAP HSCs OHMS Surgery Prosthetics Burns Specialty Best Practices SIMP Catastrophic Chronic Pain & Behavioral Health Best Practices

34 THANK YOU! For electronic copies of this presentation, please Laura Black For questions or feedback, please Gary Franklin or