Need a painless way to boost revenue?

Experts offer tips on pain management services

As the demand for chronic pain management expands, a growing number of same-day surgery managers are discovering that the service fits well with their programs and offers a significant new revenue source; however, pain management experts advise managers to consider patient selection, nurse training, outcomes measurement, and other issues involved with pain management.

Reimbursement through managed care and Medicare is favorable, particularly since pain management can sometimes help patients avoid back surgery, says Carolyn Lekien, RN, manager of Bethesda North Ambulatory Surgery Center in Cincinnati, OH.

"Everyone is looking for options you can try short of doing surgery," says Lekien, whose center sees about 1,000 pain patients a year, with a facility fee of $320. "This is one of them."

Yet payers will also want to see outcomes measurements that demonstrate long-term improvement among pain management patients, cautions Karen Wielde, RN, CCM, director of the Rehabilitation, Evaluation, and Comprehensive Treatment Center at Promina Windy Hill Hospital in Marietta, GA.

Same-day surgery managers and pain management experts say you should consider the following issues when offering these services:

* Scope of service.

Patients seeking pain management may range from those with back pain from newly herniated disks to those with complex regional pain syndrome, a misfiring of the autonomous nervous system that is difficult to treat. Referrals may come from orthopedists, podiatrists, neurosurgeons, family practitioners, and anesthesiologists who bring the patients to the facility. (For more information on pain management, see Same-Day Surgery, November 1992, p. 161.)

The needs of your target market may influence how you set up a clinic and what type of patient you accept, Wielde says. A few nerve blocks may be enough for the gardener who strained muscles. Yet an initial patient assessment may determine that a patient who has suffered from chronic pain for years needs the services of a more comprehensive rehabilitation center, she says.

Some need referrals for additional services

A pain management program should at least be prepared to offer referrals for patients to psychologists or psychiatrists, physical therapists, and other specialists, Wielde says.

Workers' compensation is a major source of referrals for pain management. Several states require workers' compensation patients to receive pain management from a clinic accredited by Tucson, AZ-based Commission on Accreditation of Rehabilitation Facilities (CARF).

For Lekien, an example of a typical patient is a young woman who hurt her back while trying to lift a television. "She could hardly move, she was in so much pain," says Lekien. After three epidural treatments, the woman's pain resolved, and she didn't need to return.

"We did not realize the kind of major population out there who needs this service," Lekien says.

In fact, Lekien herself recently received a trigger point injection of a local anesthetic and a steroid after hurting her neck. "I'm a total believer in it," she says.

When anesthesiologists perform procedures on older patients or those who have had multiple back surgeries, they may require the use of a C-arm or fluoroscopy unit, which can cost from $100,000 to $160,000, Wielde says. Otherwise the equipment needs of pain management are similar to those available in a recovery room, such as pulse oximetry and other monitoring equipment.

* Physician involvement.

Anesthesiologists can receive certification in pain management from the Skokie, IL-based American Academy of Pain Management or the Raleigh, NC-based American Board of Anesthesiology. In addition to asking about the clinical qualifications of physicians, same-day surgery managers should ask about their philosophy of pain management, Wielde advises.

"Does he understand the psychological dimension of chronic pain? A lot of them don't recognize that," she says. "Is he interested in offering some additional limited services?"

For example, an anesthesiologist may regularly work with a psychologist or physical therapist, she says. Some anesthesiologists may simply try to do as many procedures as possible without considering other needs of the patient, but Wielde considers this a short-sighted attitude.

"[Eventually] what they find is their patients aren't getting better and they aren't getting [further] referrals, particularly from workers' compensation, because there isn't an end of treatment," she says.

* RN training.

Chronic pain patients often have had multiple surgeries, have taken various pain medications, and have personal problems related to their condition, says Lynn Maltby, RN, CAPA, coordinator of the outpatient surgery center and pain management at Florida Hospital in Altamonte Springs. As a result, nurses should have special personal skills as well as clinical ability, Maltby says.

"The nurses have had to be reoriented to the [special] needs of their patients," she says. "They spend a lot of time with these patients talking with them, assessing them when they come in, and working with their families."

Because this field of nursing is new, specific training materials are difficult to find, Maltby says. She has targeted nurses with good communication skills. Anesthesiologists conduct inservice training on issues of pain management.

Post-anesthesia care unit (PACU) nurses are often used in pain management because of their experience monitoring patients. Lekien assigns a PACU nurse to assess and monitor pain patients.

* Case management.

Managers should assign one nurse the responsibility of assessing pain management patients and documenting, coordinating, and evaluating each patient's pain management plan, advises Wielde. In other words, if the patient is also seeing a physical therapist and psychologist, the case manager would note the appointments and treatment in the patient's file, Wielde says.

Documentation of care is particularly important because these patients may be involved in litigation, she says. "Be thorough and complete," Wielde advises. "You're going to be dealing with attorneys if you're dealing with workers' compensation or automobile accident patients."

* Outcomes monitoring.

Payers and patients want to know when they can expect to feel better. "[Centers] should have some type of protocol that they could show a patient or payer," says Wielde. "If you come to me with a herniated disk, this is the treatment you're going to have: how many blocks, the type of block, the cost, the outcome expected."

Obtain a baseline of pain (based on a 1-10 scale) and functioning from patients when they first arrive for treatment, Wielde suggests. Measure those factors at intervals that will vary depending on their condition and pain management plan, she suggests. The SF-12, created by The Health Institute at the New England Medical Center Hospital in Boston, is one such tool for measuring functional health of patients, such as ability to perform daily activities. (For more information on the SF-12, see SDS, December 1995, p. 137.)

"[Pain management] can be a big money maker," says Wielde. "But long-term success depends on more than that. They will have to do outcomes measurement to remain viable." *

For more information on outcomes measurement, standards, and accreditation for chronic pain management, contact:

* The Commission on Accreditation of Rehabilitation Facilities, 4891 E. Grant Road, Tucson, AZ 85712. Telephone: (520) 325-1044. Fax: (520) 318-1129.

To order Program Evaluation in Chronic Pain Management Programs, an outcomes assessment tool (No. 5140.4, $16 plus $3.50 for shipping and handling), write CARF at the above address or fax (520) 318-1129.

For more information on starting a pain management service, contact:

* Karen Wielde, Director, Rehabilitation, Evaluation, and Comprehensive Treatment Center, Promina Windy Hill Hospital, 2540 Windy Hill Road, Marietta, GA 30067. Telephone: (770) 644-1597.