Pain management fast becoming home care’s next major focus

Nurses can help patients by using alternative methods

Just for a moment, put aside all worries about outcomes, cost-cutting, and managed care. Think instead about an aspect of disease that affects most patients but isn’t talked about much: pain. And picture what your staff does to help patients manage it effectively.

Pain management may not have been a big priority in home health care in the past, but experts say it will be a huge focus in the future. Soon home care agencies across the country will start programs that involve pain treatment and may include education about alternative methods of pain management, they predict.

Three forces are pushing this anticipated trend:

• First, the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is working with the University of Wisconsin Medical School in Madison on a $1.6 million grant-funded project studying pain management in home health care. The project could lead to the Joint Commission adopting new standards within the next three years for the assessment and treatment of pain.

• The managed care changes that have caused the home care industry to grow rapidly in recent years are also sending far sicker people home from hospitals, and this means home care nurses will see increasing numbers of patients in pain. Whether their pain is chronic from a terminal illness or a result of orthopedic surgery, it’s an issue nurses will need to address.

• Finally, states are starting to hold hearings on pain management and what can be done legislatively to promote it. This trend was prompted by recently passed bans on assisted suicide in various states. The conventional wisdom is that if the medical profession is outlawed from helping very ill people die, then it should at least be allowed to do everything it can to help them live comfortably.

Wisconsin project leads pain education

"There has been a real groundswell of interest in pain management, and now there is activity on pain management in all 50 states," says Karen Stevenson, RN, MS, project director for Institutionalizing Effective Pain Management Practices in Home Health, which is the project that involves the Joint Commission. The project is funded by a grant from the Robert Wood Johnson Foundation in Princeton, NJ. Stevenson also is involved with the Wisconsin Cancer Pain Initiative of Madison.

The Wisconsin project, which involves home care agencies in south-central and northwestern Wisconsin, is a 12-month effort to teach home care agencies how to improve pain management. The agencies involved in the project will plan, write, and implement new policies and procedures, educational programs, and quality assurance projects on pain treatment.

Stevenson says the project’s findings and programs could be made available to home care agencies across the country once the pilot program is completed.

"People are beginning to realize how much uncontrolled pain really costs, not only financially, but also emotionally," says Patricia Berry, PhD, RN, CRNH, CS, project coordinator for the pain management project.

"People who have uncontrolled postoperative pain recover from surgery slower than patients whose pain is controlled," Berry adds.

Combine this with the fact that nurses and other health care professionals receive very little training in pain management, and there is a major problem, experts say.

"Basically, my perception is that nurses in general are not as aware of pain as they need to be," says Pamela Bennett, RN, BSN, managing director of the St. Elizabeth Medical Center Pain Management Center in Boston and president-elect of the American Society of Pain Management Nurses of Pensacola, FL.

Hospice has handled pain treatment fairly well, but home health agencies, which increasingly are seeing more end-of-life patients, have not been as geared to pain management, Bennett says. "I think that’s going to be a driving force for home care nurses to become more knowledgeable about pain."

Bennett gave testimony recently before the Massachusetts legislature about end-of-life care and pain management. "We were able to talk about advances in health care and reimbursement issues, and what role nursing plays," she explains.

JCAHO may write new pain standards

Berry is working with the Joint Commission on the possible revision of standards to emphasize pain management. Although it’s still too early in the process for Berry to say what type of revisions could result from the project, she does offer this possibility: "I think we will be looking for the organization to look at pain and create its own plan for improvement, deciding on assessment strategies and so on."

The next key step is for the Joint Commission board to give its blessing to the project when the board meets in April, Berry says. Then, Berry and others will draft proposals for new standards on pain management. These will be reviewed by an expert panel and field-tested. If all goes well, the new standards could be implemented in the year 2000 or shortly thereafter, she says.

"We have been delighted with how receptive the home care field is and how [home care managers] generally are really excited about pain being a part of standards and the accreditation process," Berry says.

In recent years, home care agencies have had so many new skills and tasks to teach nurses that training in pain management has had to take a back seat to education about wound care, documentation, and IV therapy, for example.

But, as one Wisconsin education manager has discovered, nurses often are eager to learn more about how to help patients control their pain.

Hillside Home Care Hospice of Beaver Dam, WI, held a week-long pain management fair that had 15 stations covering alternative methods of relieving pain, says Pat Trapp, RN, staff educator of the hospital-based full-service home care and hospice agency that serves south central Wisconsin.

The stations covered a variety of topics, including acupressure, relaxation techniques, fluidotherapy, paraffin baths, and aromatherapy. (See story on pain management fair, p. 38.)

"It was interdisciplinary, and we invited everybody, including the maintenance workers," Trapp says, adding that the fair attracted a large attendance.

Others are following suit

Other home care agencies are teaming up with hospice organizations to provide staff education about palliative care or to provide hospice nurses with basic orientation on home care. These agencies have recognized that end-of-life patients may seek help from either type of provider.

The VNA of Middlesex-East in Stoneham, MA, and its hospice recently formed a partnership in which the hospice teaches home care nurses about pain management. Also, the home care nurses may call a hospice nurse for consultation in cases where patients have problems with pain, says Linda Miller, RN, hospice coordinator for the VNA of Middlesex-East Hospice, which serves an area north of Boston. (See story in the April 1998 issue of Homecare Education Management on how hospice and home care agencies are forming partnerships for palliative care.)

Just how much nurses can do to provide pain management depends on state regulations and the agency’s philosophy toward treatment, as well as the individual nurse’s interests, the experts say.

For example, some nurses may be comfortable massaging a patient’s hand but would balk at providing back massages or specialized forms of healing treatment called therapeutic touch or healing touch. Others might find these techniques to be exactly what are needed in some situations, but their agencies may be against alternative measures except for those treatments prescribed by a physician. (See story on alternative treatments, below.)

In some situations, the state may prohibit unlicensed practitioners from treating patients by using a particular form of alternative treatment, such as massage.

"Nurses have to be aware of the standards of practice in each state they practice in," says Maggie McKivergin, RN, MS, HNC, executive director of the American Holistic Nurses Association of Flagstaff, AZ.

"More and more people are going to be taken care of at home," McKivergin notes. "So the home care nurse needs to have a broad spectrum of options available to her."

(Editor’s note: For more information about pain management and traditional pain treatments, or for some sample pain assessment forms and one agency’s policy for pain management, see Homecare Education Management, August 1997, pp. 117-122.)