Transcript Integrated Models of Care: Pain Management

Integrated Models of Care:
Pain Management
Robert D. Kerns, PhD
National Program Director for Pain Management, VACO
Chief, Psychology Service, VA Connecticut
Professor of Psychiatry, Neurology and Psychology, Yale
University
Integrative care
Psychology, psychologists, and pain
management
 Primary models of pain perception emphasize the central
role of psychological factors
 Role of psychological factors in the development and
perpetuation of persistent pain is universally accepted
 Psychological interventions for pain management are
accepted as efficacious and cost-effective
 Approximately 20% of members of IASP and APS are
psychologists
 Current president of APS is Dennis Turk, a psychologist
 Goal of VHA National Pain Management Strategy is to
incorporate an interdisciplinary, multimodal approach to
pain management
Efficacy of psychological
interventions for chronic pain
 Meta-analysis of RCTs of psychological treatments for clbp
 Effect sizes were calculated from 22 RCTs
 Positive effects of psychological interventions, relative to
numerous control conditions, were noted for pain intensity,
interference, quality of life, and depression
 Cognitive-behavioral and self-regulatory treatments were
found to be efficacious
 Multidisciplinary treatments that included psychological
interventions had positive long-term effects on return to
work
Integrative model of pain care
 Stepped care approach to pain management
– Level one: Primary responsibility rests with primary care
providers
– Level two: “Living with Pain Class”
 Patient education and rehabilitation model
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Review of common pain conditions
Personal review of medications
Discussion of self-management model
Personalized exercise plan
Practice of self-regulatory pain strategies, e.g., breathing, relaxation,
activity pacing
– Level three: Comprehensive Pain Management Center
Comprehensive Pain Management
Center at VA Connecticut
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Integrative clinical, research, and training program
Interdisciplinary staff
“Virtual Clinic”
Primary Care Clinic integration
Primary roles of psychologists
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Conduct comprehensive pain assessments
Development and enactment of integrative treatment plan
Care coordination
Primary clinician in delivery of psychological treatment
Assessment of outcomes
Education and training
Research
Targets for improvement
 Improved
access
 Successful engagement
 Reduced drop-out
 Enhanced adherence to treatment
recommendations
 Maintenance of treatment gains
 Relapse prevention
Ongoing research
 Targeting these areas for improvement
– Refine CBT to promote engagement, adherence, and
outcomes
– Refine CBT for special populations
 Elderly
 Women with vulvodynia
 Painful diabetic neuropathy
 MS-related pain
– Investigate treatment process variables
 Readiness for self-management of pain
Refining processes of referral
and engagement
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Education/Training of primary care providers
 Knowledge and attitudes about self-management
treatments
 Patient-centered counseling/Use of motivational
interviewing techniques
 Respond to patient concerns and beliefs that are
incongruent with adoption of a self-management
approach
 Endorse self-management treatment and goals
 Assure follow-up and continued coordination of
care
Training primary care providers
Brief educational session
 Relevance of self-management and
rehabilitation approaches
 Overview of multidisciplinary pain center
 Review of pathway for referral
 Group training followed by individual
consultation
 Use of modeling (video) VIDEO_TS.IFO
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PRIME-CBT
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in a primary care setting
 Collaboration with primary care
practitioner (PCP)
 Explication of referral process
 PCP education and training
 Modifications to CBT
Refining self-management treatment
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Collaborative sessions involving primary care provider
Explicit attention to readiness to adopt a self-management
approach
Use of stage-matched tasks and processes of change (e.g.,
consciousness raising with “precontemplators”, increasing
support for “strivers”)
Use of motivational interviewing strategies (expressing
empathy, developing discrepancy, rolling with resistance,
and supporting self-efficacy)
Results of PRIME CBT study
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Both CBT (n=33) and PRIME CBT (n=33), relative to TAU
(n=23), demonstrated significantly greater improvements on
measures of pain, disability, and emotional distress
PRIME CBT, relative to CBT, resulted in:
 significantly increased adherence to weekly homework
and goals
 significantly greater goal accomplishment
 significantly greater patient satisfaction
Mean percent intersession adherence for PRIME CBT was
approximately 70%
Tailored CBT
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CBT as inherently flexible approach that accommodates
to “prescriptive treatment planning”
Assess patient preferences for learning specific pain
coping skills
“Tailor” CBT on the basis of patient preferences
Employ motivational interviewing techniques to
encourage “forward stage movement” or enhanced
readiness to adopt specific pain coping skills