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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.
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.
"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.