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Pain program includes cognitive, physical therapy
Multidisciplinary approach includes classroom
A multidisciplinary pain management program with a strong case management focus helps members of Kaiser Permanente with moderate to severe levels of pain receive effective care and avoid using treatments that don't work.
"The goal of the program is to help our members to live as full and productive a life as they can in spite of their chronic pain condition. We want to make sure they don't end up using just one technique, such as medication, but use a variety of strategies to manage their pain," says Andrew Bertagnolli, PhD, care management consultant with Kaiser Permanente's Care Management Institute in Oakland, CA.
The program includes an intensive 10-week program of cognitive behavioral therapy and physical therapy followed by individual contacts by care case managers who work with members for about a year, acting as health coaches and helping members follow care plans.
"We treat chronic pain as a chronic condition, like diabetes or congestive heart failure, and work with the member to develop strategies that can help them learn to self-manage their pain," Bertagnolli says.
The program is a win-win situation for Kaiser Permanente and its members, Bertagnolli points out.
"The literature shows that members with chronic unmanaged pain are high utilizers of health care services. These people's lives are topsy-turvy because of the pain. That often drives them to come in to the medical centers for service. By learning to manage their pain effectively, members feel better, improve their functional status, and cut down on their use of the health care system," he says.
Kaiser developed the program in 2000 in response to employers who expressed concern about increases in absenteeism due to chronic pain and the health plan's goal of ensuring that members with chronic pain receive treatment based on scientific evidence.
A work group of physicians, physical therapists, psychologists, pharmacists, nurses, and osteopaths with expertise in chronic pain developed clinical practice guidelines that emphasize a multidisciplinary approach to treatment.
The program was distributed to medical directors in all Kaiser regions. The regions have tailored the program to meet the needs of their members.
"The program is being used in many of the Kaiser regions but not uniformly. The program is being used most frequently in Northern California, Southern California, the Northwest region, and the Mid-Atlantic states region," Bertagnolli says.
The majority of members eligible for the program are identified through referrals from their primary care physicians. In addition, when claims data identify members who are heavy users of health care services that may indicate chronic pain, they contact the member's physician to determine if the member could benefit from the chronic pain program. The majority of the members in the program have back pain diagnoses. Other conditions include fibromyalgia, nerve disorders such as diabetic neuropathy, chronic headaches, neck pain, shoulder pain, and other painful bone and muscle conditions, he says.
"In addition to chronic pain, these members are also experiencing moderate to severe levels of impacted functional status. Not only do they have severe pain but their lives are a wreck. They're not working, they have problems with activities of daily living, and their social lives are in chaos," Bertagnolli says.
When members are identified for the program, they are contacted by a nurse case manager who tells them about the program and lets them know that their physician believes the program would benefit them.
Evaluating program participants
Program participants are evaluated by the chronic pain team that includes a physician, a psychologist, and a physical therapist, all trained in chronic pain management. The team develops an individual care plan for reducing pain, which is shared with the member's primary care physician. During the initial evaluation, members are assigned to either the moderate or the high intensive program, based on their pain and dysfunction.
The more complicated, dysfunctional patients are in the more intensive program and may be managed by a psychologist following the 10-week classroom session. Those at lower risk may have mild mood symptoms or problems with relationships and are managed by a care case manager.
The team may suggest strategies that include physical therapy, diet, medications, walking and stretching, stress management techniques, and psychotherapy for depression and anxiety, depending on the needs of the individual member.
The intensive treatment phase of the program is a group intervention led by a psychologist and a physical therapist at Kaiser medical centers throughout the regions.
The program includes cognitive behavior therapy led by the psychologist and sessions with physical therapists who help the members learn exercises and body mechanics that can help alleviate their pain.
The team works with members to help them accept their pain as a chronic condition.
"Most people who experience chronic pain believe that it is an acute pain problem that will go away with the right medication and right treatment. There is no magic bullet for chronic pain. It's a condition you manage not only by medication, but a variety of strategies," he says.
During the 10-week program, the case managers help participants overcome barriers to attending the sessions, such as child care or lack of transportation, and may help them adjust their pain medication using protocols under the direction of the chronic pain physician.
"During the intensive phase of the program, the case manager's role is lessened, unless that patient is being titrated on medication," he says.
An individualized program may include psychology, physical therapy, medication, and complementary medicine techniques such as acupuncture and acupressure.
"Chronic pain is not an easy problem to solve because it affects so many aspects of life, including recreation, occupations, and relationships. When people have severe chronic pain, they become depressed and need help in managing their moods as well as their pain," he says.
When the intensive phase ends, the team meets again and develops a follow-up plan for each member. The plan includes the strategies the member should follow and the estimated frequency of the case management contacts.
After the program, the case managers contact the members regularly by phone to help them learn how to self-manage their pain.
"Research shows that the primary treatment for chronic pain is learning to self-manage the condition and to use the health care system in a consultative role. This program helps empower the members to do just that," Bertagnolli says.
The frequency with which the care case manager calls the member depends on the individual's needs. It may be as frequently as every two weeks or as little as every two months.
"If the member is having a problem, the case managers can identify it earlier, rather than later, and ensure that the member gets the care he needs," Bertagnolli says.
The case managers help the members stick with their treatment plan, which may involve stress management, diet and exercise, and taking medications as directed, and assist members in finding support groups in the community.
"The case managers encourage them to use stress management and mood management techniques as well as other behavioral strategies. If the patient seems to be slipping, the case manager can refer him or her to the psychologist or the physical therapist for reinforcement," he says.
One of the areas the case managers concentrate on is diet, Bertagnolli says.
"Many of the members are overweight and the evidence shows that if they lose weight, their lower back, hip, or knee pain gets better. Participants who have migraine headaches need to learn to identify what foods can trigger a headache," he says.
Case managers follow the members for up to a year, suggesting pain management techniques and providing referrals for acupuncture, psychiatric care, and other services.
If a member in the program pops up on the list of high utilizers of health care services, the case manager is alerted and calls the member to find out what's going on.
"Sometimes it may be a problem with the primary care physician. We want to hear about it as soon as possible so the physician on the chronic team can work with the primary care physician to modify the treatment plan," he says.