Managing Pain Management

Cathy Price

Consultant in Pain Management

Where we are now

Aims:

• Introduce Southampton’s Pain service’s model of care

• Detail on tiered approach

• Impact on secondary care service

• Impact on outcomes

Challenges and Opportunities for Pain management – the frameworks

• Challenges– Not in QOF

• Opportunities– MSF– Care Closer to Home

The Problem

50,000 care population-endless waiting list for specialist medical care

pain cannot be managed

Dodgy thinking had lead to dodgy expectations

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

Southampton’s Solution(took 3 months to come up with it, 6

months to implement it)

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

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

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

Specialist team

What can happen when pain patients exit primary care?

Keeps wait to a minimum as triage generally accurate

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

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

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

What results won hearts and minds?(still need to do it)…..

47% other pathway

34%Complex individual care management

19% pain management programme

Overall Outcomes of Assessment for Level of Need

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

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

What’s been the impact on secondary care pain services?

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

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

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

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

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

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

Summary Pain Management - The

solution…

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

What you can see by working in the community!

SouthamptonSouthampton