New Pain Relief Model Serves Rural Areas
Program’s impact reaches far
Executive Summary
Chronic pain is a $650 billion a year industry that leads to loss of productivity and 18,000 deaths per year from prescription opioid use. A group of healthcare professionals in Washington created TelePain to address the need for better pain management options for people in areas where pain specialists are not available.
• The model provides patients and providers with expanded options for treatment.
• An interdisciplinary panel of experts listens to individual cases and offers advice.
• Case managers, physicians, and other healthcare professionals can virtually attend the weekly meetings, which include an educational segment and a case study segment.
A new study shows success with a case management-style model in treating chronic pain. The program incorporates collaboration, assessment, care coordination, and advocacy for services for people suffering from disabling pain that interferes with their function and quality of life.
“Chronic pain can lead to despair, hopelessness, and loss of productivity, and it is unbelievably expensive — a $650 billion a year industry,” says David Tauben, MD, chief of the division of pain medicine at the University of Washington in Seattle.
“Pain care can include drugs, devices, surgeons, and hospital admissions,” Tauben says. “It’s complex and requires specialized knowledge skills and access to resources that usually are not available.”
This TelePain program gives patients and their providers options far beyond what traditionally would be available, suggesting broader possibilities of case management of chronic pain in other areas.1
The program reaches medically underserved and rural communities through a case management-style community of practice. It incorporates interdisciplinary care plans for complex pain patients, using case study discussions and evidence-based pain management strategies. It connects providers with experts via computer teleconferences.1
“This is a mission-driven program,” Tauben notes. “We give away the services because it’s the right thing to do.”
Since March, 2011, the TelePain program has had more than 500 healthcare providers participating with an average of 30-50 people attending each session, says Ardith Z. Doorenbos, PhD, RN, FAAN, professor in the department of anesthesiology and pain medicine in the School of Medicine and School of Nursing at the University of Washington in Seattle.
“We reach more than 100 different clinics and hospital systems, and some of these have an onsite case manager,” Doorenbos says. “We also have advanced practice nurses who do case management on our side.”
The program was launched after several problems converged: “In primary care, one of the challenges that primary care providers face involves patients with pain,” Doorenbos says.
“Pain patients rank highest in dissatisfaction with healthcare services, and they are very, very challenging patients,” she adds.
Generally, primary care doctors, nurses, pharmacists, and nurse practitioners receive almost no education on how to treat chronic pain, Tauben says.
“In the context of total educational programs, it’s seven to eight hours total in four years of medical school,” Tauben adds. “There’s a similar paucity of training and sense of competency at graduation.”
Published surveys of primary care providers, asking about how competent they feel in treating pain, typically find that providers acknowledge having too little knowledge in this area, he says.
“Two percent of pain is treated by pain specialists, and 98% is treated by folks with no training in it,” Tauben says. “Thirty percent of clinical interactions of primary care providers are the management of chronic pain; it’s one of the most common problems.”
So what happens is that providers who have little to no education in chronic pain and who have little experience treating it with non-pharmaceutical strategies rely on opioid management, which has not been shown in studies to work in the long term, Tauben says.
“Around 18,000 people die from prescription opioids each year, and others are switching over to heroin,” he says. “It’s a structural mess due to geographic, political, educational, and other problems, including the lack of access to proper specialists.”
The need for a case management outreach approach to dealing with the problem was apparent, and Washington was an ideal place to launch the TelePain model, Doorenbos notes.
“We became known as one of the states in the country with more deaths related to opioids than to car accidents,” she explains. “For that reason, the state of Washington passed a law so that anyone who was prescribing over 120mg of opioids needed to consult with a pain specialist.”
The problem was that there are far too few pain specialists in the state, and most of them are located in Seattle, she says.
“Patients out in the country had to travel a long distance, and wait times at clinics were three to six months,” Doorenbos adds. “For those reasons, we started to think about what was a good way we could provide case management for chronic pain in primary care clinics.”
Even urban areas have long wait times for chronic pain treatment, which exacerbates the chronic nature of the problem because outcomes are far better when the pain is treated effectively early on, Tauben says.
“An urban area could benefit from this program, as well,” Tauben adds
They began with an educational series, didactic presentations with pain topics for clinical providers, and then they started case consultations, Doorenbos says.
“It morphed into 1.5 hours of a TelePain session, held twice a week on Wednesdays and Thursdays, from noon to 1:30 p.m.” she says. “They don’t have to be there for the entire session, and they receive continuing education credits as a benefit.”
Direct outcomes of the program include greater satisfaction among primary care providers involved with TelePain, Doorenbos says.
“We can’t directly attribute a decrease in opioid deaths only to our program, but in counties where TelePain has been more active, there has been a greater decrease in opioid deaths than in counties where it’s not active,” she adds. “It’s really, really exciting.”
Community providers who are in areas underserved by pain management services can fill out a referral form with survey questions when they have patients with troubling chronic pain.
“This survey helps us organize our care and prioritize patients,” Doorenbos says. “Then the community provider presents the case, and we have 30 to 50 community providers dialing into the session.”
Besides having on hand a provider certified in pain medicine, the program’s community of practice includes a panel of experts in anesthesiology, rehab, addiction medicine, psychology, pharmacy, and nursing, she adds.
“It’s great to get so many specialties and experiences in the room at the same time,” says Alexa Meins, PhD(c), research assistant, biobehavioral nursing and health systems at the University of Washington.
“This can create comprehensive pain management strategies all in one setting instead of trying to coordinate care from different providers,” she adds.
When TelePain experts make recommendations, these are evidence-based pain management strategies, Meins notes.
The program addresses case referrals from Washington and additional states, including Wyoming, Alabama, Montana, Oregon, and Idaho.
REFERENCE
- Meins AR, Doorenbos AZ, Eaton L, et al. TelePain: A community of practice for pain management. J Pain Relief. 2015;4(2):1-4.
A group of healthcare professionals in Washington created TelePain to address pain management options for people with fewer options.
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