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UNCLASSIFIED Stepped Care Model for Pain Implementation “Medically Ready Force…Ready Medical Force”
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Stepped Care Model for Pain Implementation
“Medically Ready Force…Ready Medical Force”
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Disclaimer
The views expressed are those of the author and do not reflect the official policy of the Department of Defense (DoD), the U.S. Public Health Service, or the U.S. Government.
Dr. Jennifer Bell and Psychological Health Center of Excellence (PHCoE) staff have no financial interest to disclose. Commercial support was not received for this activity.
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Objectives
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At the end of this presentation, participants will:
1. Be aware of the Defense Health Agency-Procedural Instruction (DHA-PI) 6025.04 and its purpose.
2. Understand how upcoming Stepped Care Model for Pain implementation pathway intends to operationalize the DHA-PI 6025.04.
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Task: Implementation of DHA-PI 6025.04
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Stepped Care Model for Pain pathway to implement DHA-PI 6025.04 Pain Management and Opioid Safety in the Military Health System (MHS) dated June 8, 2018 aims to:
Enable Clinical Communities to provide evidence-based pain management guided by clinical practice guidelines.
Effectively treat acute and chronic pain.
Promote non-pharmacologic treatment of pain.
Prevent acute pain from becoming chronic.
Minimize use of opioids with appropriate prescribing and risk mitigation.
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Providing Evidence-Based Management Guided by Guidelines1
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Clinical guidelines can help improve providers’ professional practice and quality of care, and may empower patients to make more informed choices.
Presence of guidelines does not necessarily mean recommendations are followed. In a Dutch observational study, for example, GPs followed guidelines in 61% of relevant decisions.
Complexity matters. Guidelines have a greater chance of being used when easy to understand, can easily be tried out, do not require specific resources...
Uh oh!
1. Francke, A. L., Smit, M. C., de Veer, A. J., & Mistiaen, P. (2008). Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC medical informatics and decision making, 8(1), 38.
2. Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H: Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ. 1998, 317: 858-861.
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SCM for Pain Implementation Work Group Members
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Defense Health Agency and Tri-Service clinical subject matter experts
‒ Primary care managers
‒ Pain specialists
‒ Health psychologists
‒ Nurses
‒ Pharmacists
Analytics subject matter experts
Enabling groups:
‒ Defense and Veterans Center for Integrative Pain Management (DVCIPM)
‒ Psychological Health Center of Excellence (PHCoE)
‒ Uniformed Services University and external academia
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SCM for Pain Clinical Pathway
Clinical pathway:
“a documented sequence of clinical interventions, placed in an appropriate timeframe, written and agreed to by a multidisciplinary team. They help a patient with a specific condition or diagnosis move progressively through a clinical experience to a desired outcome.”1
Hunter, B. & Sergott, S. (2008). Re-mapping client journeys and professional identities: A review of the literature on clinical pathways. International Journal of Nursing Studies (45), p. 608-625.
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Screening personnel confirms reason for appointment when patient presents at PCC appointment
Is patient s life, limb, or vision
threatened?
Determine acuity level and transition patient to appropriate level of care
Complete required screening measures including DVPRS. Administer pain intensity item for current pain and pain over the past week by stating (specific language being discussed):
"Look carefully at the pain scale. How would you rate your pain right now?"
Then, Now how would you rate your average pain in the past week?
Is patient s reason for appointment
related to pain or opioids?
Designated PCMH team member(s) pull CarePoint opioid registry data for upcoming appointments
When opioid registry information obtained, team member enters information into TSWF form (will specify location) and alerts IBHC to potential patient
IBHC reviews patient EHR and discusses with PCC
NO
YES
YESEnsure CarePoint opioid registry information is entered in patient s TSWF form. If not, pull and enter data
NO
During PCC Appointment
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Operationalizing the
DHA-PI 6025.04
Pathway will enable patient-centered medical home staff to:
1. Understand the patient variables that perpetuate pain.
2. Screen patients for pain using the Defense and Veterans Pain Rating Scale.
3. Complete a biopsychosocial assessment.
4. Provide pain education and collaboratively set treatment goals.
5. Create an evidence-based, comprehensive treatment plan to effectively treat acute and chronic pain; promote non-pharmacologic treatment; and prevent acute pain from becoming chronic.
6. Support patient’s self-management and behavior changes.
7. Minimize use of opioids; assess and minimize risk when used.
8. Determine level of the Stepped Care Model; connect with team members.
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Pathway Implementation Components
Algorithm/work flow
Initial trainings
o Champion training
o PCMH training
o IBHC training
o Screener breakout training
o Care coordinator breakout
Follow-up support
o Champion mentorship
o Academic advising
o Weekly training tid-bits
Strategic messaging
Job aids/tools for clinic staff
o Tri-folds
o Exit planning sheet
o Talking points for providers
o AHLTA TSWF updates
Tools for champion
o Mapping tool
o Champion reporting tool
o Implementation checklist
o Data pulls
o Feedback forms
o Smart book
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Learning ObjectivesJob Aids and Tools
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Exit Tool to Support Collaborating with Patient on a Treatment Plan
Figure courtesy of Dr. Diane Flynn
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Select Implementation Strategies Incorporated into Pathway
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Use of multifaceted implementation interventions are more likely to be effective that single interventions.1
Stepped Care Model for Pain implementation incorporates a number of implementation strategies, including:
• Mapping of current clinic practices to desired practices.
• Use of local champions.
• Provider/team education.
• Audit and feedback.
• Assessment of/intervention for local barriers.
• Reminders (electronic health record, job aids and tools).
1. Grimshaw, J. M., Shirran, L., Thomas, R., Mowatt, G., Fraser, C., Bero, L., ... & O'Brien, M. A. (2001). Changing provider behavior: an overview of systematic reviews of interventions. Medical care, II2-II45.
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Questions?
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Connect with PHCoE
Email: [email protected]
Web: http://pdhealth.mil
Facebook: www.facebook.com/PHCoE
inTransition: www.pdhealth.mil/resource-center/intransition
Real Warriors Campaign: www.realwarriors.net
Point of ContactJennifer Bell
Branch Chief, Primary Care Behavioral [email protected]
