Managing Pain Management
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Transcript of Managing Pain Management
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Managing Pain Management
Cathy Price
Consultant in Pain Management
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Where we are now
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Aims:
• Introduce Southampton’s Pain service’s model of care
• Detail on tiered approach
• Impact on secondary care service
• Impact on outcomes
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Challenges and Opportunities for Pain management – the frameworks
• Challenges– Not in QOF
• Opportunities– MSF– Care Closer to Home
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The Problem
50,000 care population-endless waiting list for specialist medical care
pain cannot be managed
Dodgy thinking had lead to dodgy expectations
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What are the PCT’s expectations?
end the scatter gun effect for MSK referrals and doctor shopping
Pain patients are high demand- clog other services
Local access
Patients to increase own responsibility for health
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Southampton’s Solution(took 3 months to come up with it, 6
months to implement it)
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Solution
• To provide & develop a pain management service encouraging self-management based largely outside hospital
• Empower primary care physicians to provide the majority of care for people with long term pain in a systematic fashion
Mantra:Manage expectations, provide clear pathway in and out of specialist care
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The Service Structure (pain is a long term condition)
Kaiser Permanente NW Pain care model 2000
Von Korff- Stepped care BMJ 2002
DH LTC 2003
Intensive
or Case Management
Assisted Care or Care Management
Usual Care with Support
Level 170-80% of a CCM pop
Level 2High risk members
Level 3Highly complex members
Intensive
or Case Management
Assisted Care or Care Management
Usual Care with Support
Level 170-80% of a CCM pop
Level 2High risk members
Level 3Highly complex members
Increasing complexity of biopsychosocial factors
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What could we do about Primary Care?
•Educational programme for GP’s- pain, aetiology, psychosocial risk factors•Prescribing guidelines- support of DPC – pharmacy driven•Pharmacy teaching of community pharmacists•Clear pathways of care
•Practices nurses jealously guarded!
Intensive
or Case Management
Assisted Care or Care
Management
Usual Care with Support
Level 170-80% of a CCM
pop
Level 2High risk members
Level 3Highly complex members
Intensive
or Case Management
Assisted Care or Care
Management
Usual Care with Support
Level 170-80% of a CCM
pop
Level 2High risk members
Level 3Highly complex members
Allows 30% of paper triage discharges
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Specialist team
What can happen when pain patients exit primary care?
Keeps wait to a minimum as triage generally accurate
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Psychosocial Risk Factors
• Screening designed to detect these “Yellow and Orange” flags from the outset (Main)– 7 domains for yellow flags – (Main/Kendrick/Linton 1997)– Orange Flags require psychiatric assessment– More complex patients would require
specialist services– Relatively successful in spinal care, much
less successful in shoulders/knees
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Pain Management – community interventions
Complex individual case
management-
Self management programmes- varying levels
of intensity
Usual Care with Support- primary care doctor medicines, explanations of pain within a
biopsychosocial framework, musculoskeletal practitioners, community pharmacists
Level 170-80% of a CCM
pop
Level 2High risk members
Level 3Highly complex members
Short secondary prevention groups
Some individual care
Operational policy for the community screening teams
Expert patient Programme
Interdisciplinary CBT-based pain management Programmes
Council run leisure centre schemes
Link with MIND
Patient support groups
20% OF REFERRALS
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What did it take?
• Consultants to move out to do community clinics
• PMP’s to be based in community centres – allowed accessibility of psychologist
• Some secondary care staff volunteered to take part in pilot- allowed development of competencies
• Developed systematic way of identifying risk
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What results won hearts and minds?(still need to do it)…..
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47% other pathway
34%Complex individual care management
19% pain management programme
Overall Outcomes of Assessment for Level of Need
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User Surveys
Triage88% felt the assessment process was about right
75% were satisfied with the outcome of assessment
A small number were unclear as to the next step
Secondary Care:
95% highly satisfied with care in RSH
Pain management programme:
90% patient satisfaction
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City PCTAlliance
PCT National
Musculoskeletal pain 89 80 70
Pain Intensity 25 27 23
Pain impact scale 47 47 44
depression score (Beck) 29 25 ?
Duration > 2 years 85 80 80
Case Mix
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What’s been the impact on secondary care pain services?
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Activity 2002-6 Secondary care
0200400600800
100012001400
2002-3
2003-4
2004-5
2005-6
Decreased medical follow-ups Increased emphasis
on coping and self management skills
Decreased short term solutions
Waiting times:steady at 6 weeks
8% do not opt in from assessment
Budget decreased
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Impact on specialist team…tricky patients…wide range of needs
• Needed to redesign team – to provide self management skills training to
patients– Ability to motivate, negotiate– Function as MDT– Range of skills
• Redesign process of care- patients struggle with group programmes
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Process to rebuild team
• Mapping patient journey
• Functional skills analysis
• Skills matrix done as team
• Regular business meeting
• Regular team meeting
Opt in from triage
“taster”
Team member
Complete needs assessment
Stuck team meeting
Intervention Discharge
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Now…
• Psychologists offer regular supervision- nearly all staff have this
• Core team = medic/physiotherapist/nurse
• Plus:– Strong Mental health support-
psychology/psychiatry – Pharmacist input– Vocational rehabilitation specialists
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Activity
• 25% need mental health needs formally assessed
• 25% highly complex (see > 3 team members)
28% doctor only
Nurses 68%
Doctors 70%
Physios 48%Psychologists 6% but consultancy offered
Pharmacist
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Challenges
• Interaction between community and secondary care team
• Single vision across multiple organisations• Many staff very part time ? Sufficient to
learn• Clinical governance structures different
with each organisation• Strong community service- secondary care
cases costly – not adequately reimbursed
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Summary Pain Management - The
solution…
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The Pain FrameworkThe right patient is in the right place at the right time
Complex individual case
management-
Self management programmes
Usual Care with Support- primary care doctor medicines, explanations of pain within a
biopsychosocial framework, musculoskeletal practitioners, community pharmacists
Level 170-80% of a CCM
pop
Level 2High risk members
Level 3Highly complex members
Increasing complexity of biopsychosocial factors
Re-referral rate is 10% at present- needs to be closely monitored
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What you can see by working in the community!
SouthamptonSouthampton