Integrated Models of Care: Pain Management by 7603kpW

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									      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
         –   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
   Integrative clinical, research, and training program
   Interdisciplinary staff
   “Virtual Clinic”
   Primary Care Clinic integration
   Primary roles of psychologists
    –   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
   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
       PRIME-CBT

 Based  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
   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
   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
   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

								
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