Pain management after surgery can improve with a coordinated care approach that includes the use of a transitional pain service nurse case manager, according to best practices developed by the George E. Wahlen Department of Veterans Affairs (VA) Medical Center in Salt Lake City.
This model can improve coordination, improve patient satisfaction, and reduce postoperative opioid dependency, says Michael J. Buys, MD, anesthesiologist and section chief for acute pain service at the George E. Wahlen VA. In light of substance use disorders, there is a need for surgery centers to continue to coordinate and manage patients’ care after surgery, Buys says.
“The way it usually happens is patients visit with surgeons in their office, and there’s a discussion of post-op pain, but there is not coordinated care to address increased risk or concern [of opioid use],” he explains. “Surgeons and the anesthesiologist would manage pain at the operative time, then the surgeon writes a prescription for post-op pain.”
Within a few weeks after surgery, the surgeon is no longer involved in the patient’s pain management. If patients need help with their pain, they go to their primary care provider or the ED.
“What happens, and not for an insignificant number of patients, is they continue to receive opioids, and that may persist for years after their surgery,” Buys laments. “We felt there was a need for better pain coordination, and we could do a better job. Maybe we could intervene and stop chronic opioid use, so we developed the transitional pain service in January 2018.”
The transitional pain service includes pain experts, including a nurse practitioner, psychologist, nurse care coordinator, and an anesthesiologist. Based on internal data, the VA found that prior to the program, about 6% of postsurgery patients developed chronic opioid use after orthopedic surgery. After the program, none did, Buys reports.
“For people, who were opioid-naïve ... prior to surgery, we made sure they didn’t develop opioid dependency after surgery,” he says. “Historically, 5% to 13% of opioid-naïve patients, prior to surgery, have their surgery and then get opioids after surgery and never get off of them. Years later, they’re still getting prescriptions for opioids.”
Nearly half of patients who already were chronic opioid users prior to surgery were completely off opioids within 90 days after surgery. Half of these who continued using opioids had reduced their use by an average of 50%, Buys says.
There was anecdotal evidence that patients were pleased with the case management approach. “I’ve run into three veterans who I’ve taken care of. They stopped me in the hall to give me a hug or high five, telling me what a difference it has made to them to feel that someone cares for them,” says Kimberlee Bayless, DNP, FNP-BC, APRN, nurse practitioner in acute pain service and director of transitional pain service at the VA.
Warm handoffs help. “We provide coordinated care of patients to get them where they need to be,” Buys says.
For instance, the patient might need to see a mental health provider or a chronic pain doctor. “We actually go with patients to their primary care provider [PCP] appointments,” Buys says. “We’re there for the first postsurgical visit to help the [PCP] understand what happened, what our goals are, and what our plan is so we’re all on the same page.”
As part of the warm handoff, Bayless will contact the PCP before the appointment and ask if she can join. “One thing that lends itself to our service nicely is that as a VA, we’re a closed network, and veterans see providers all within the VA system,” Bayless explains. “We have a video connect or telehealth, and I connect with the provider through the computer while sitting at my desk.”
It did not take long for PCPs to become big fans of the transitional pain service because they liked that someone provides recommendations for care, Buys says. “They’ve been very receptive,” he adds. “We take the time needed with the patient, and we have a relationship with the primary care physician.”
Care coordination relies on a surgical team approach. The trust and communication between the providers has resulted in surgeons not renewing prescriptions for opioids when the transitional pain service team has explained the goals of tapering patients off opioids, Buys says.
“They reach out to us now,” he says. “If they have a patient who might have surgery and is high risk, they’ll reach out to us ahead of time before they fill a new prescription for opioids.”
The transitional pain service team’s most critical part involves personal interactions. “We have considered ways to do the service via apps and electronically, but I feel it would not be the same,” he says. “The personal contact they have with us, and especially with our nurses, is important.”
Hearing the case manager nurse talk about pain alternatives to opioids and the patient noticing the nurse is listening to his or her concerns is essential. “They trust us because they know the nurses are interested in them and care about their outcomes,” Buys says.
“The No. 1 thing that is a success is a real relationship with surgical teams, nursing staff, primary care providers, and with patients,” Bayless observes. “Each of those relationships is important to provide a successful patient outcome.”
The team works together for a common goal, wanting what is best for patients. “I’ve had days where I had to use my entire day to take care of one veteran because that was what was needed,” Bayless recalls. “If there’s a veteran in crisis, we do whatever it takes to give the veteran what is needed.”
This is why the success rates are high, she adds. “Veterans know that if they have a question about their pain, we’ll answer that question and help them get physical therapy and other care,” Bayless says.
(Editor’s Note: For more information on this topic, please read this article from the August 2019 issue of our sister publication, Hospital Case Management, on the Relias Media website: http://bit.ly/38zEppQ.)