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This lecture was given by Dr Cathy Price, Consultant in Pain Management for the Southampton University Hospitals NHS Trust, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
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Managing Pain Management
Cathy Price
Consultant in Pain Management
Where we are now
Aims:
• Introduce Southampton’s Pain service’s model of care
• Detail on tiered approach
• Impact on secondary care service
• Impact on outcomes
Challenges and Opportunities for Pain management – the frameworks
• Challenges– Not in QOF
• Opportunities– MSF– Care Closer to Home
The Problem
50,000 care population-endless waiting list for specialist medical care
pain cannot be managed
Dodgy thinking had lead to dodgy expectations
What are the PCT’s expectations?
end the scatter gun effect for MSK referrals and doctor shopping
Pain patients are high demand- clog other services
Local access
Patients to increase own responsibility for health
Southampton’s Solution(took 3 months to come up with it, 6
months to implement it)
Solution
• To provide & develop a pain management service encouraging self-management based largely outside hospital
• Empower primary care physicians to provide the majority of care for people with long term pain in a systematic fashion
Mantra:Manage expectations, provide clear pathway in and out of specialist care
The Service Structure (pain is a long term condition)
Kaiser Permanente NW Pain care model 2000
Von Korff- Stepped care BMJ 2002
DH LTC 2003
Intensive
or Case Management
Assisted Care or Care Management
Usual Care with Support
Level 170-80% of a CCM pop
Level 2High risk members
Level 3Highly complex members
Intensive
or Case Management
Assisted Care or Care Management
Usual Care with Support
Level 170-80% of a CCM pop
Level 2High risk members
Level 3Highly complex members
Increasing complexity of biopsychosocial factors
What could we do about Primary Care?
•Educational programme for GP’s- pain, aetiology, psychosocial risk factors•Prescribing guidelines- support of DPC – pharmacy driven•Pharmacy teaching of community pharmacists•Clear pathways of care
•Practices nurses jealously guarded!
Intensive
or Case Management
Assisted Care or Care
Management
Usual Care with Support
Level 170-80% of a CCM
pop
Level 2High risk members
Level 3Highly complex members
Intensive
or Case Management
Assisted Care or Care
Management
Usual Care with Support
Level 170-80% of a CCM
pop
Level 2High risk members
Level 3Highly complex members
Allows 30% of paper triage discharges
Specialist team
What can happen when pain patients exit primary care?
Keeps wait to a minimum as triage generally accurate
Psychosocial Risk Factors
• Screening designed to detect these “Yellow and Orange” flags from the outset (Main)– 7 domains for yellow flags – (Main/Kendrick/Linton 1997)– Orange Flags require psychiatric assessment– More complex patients would require
specialist services– Relatively successful in spinal care, much
less successful in shoulders/knees
Pain Management – community interventions
Complex individual case
management-
Self management programmes- varying levels
of intensity
Usual Care with Support- primary care doctor medicines, explanations of pain within a
biopsychosocial framework, musculoskeletal practitioners, community pharmacists
Level 170-80% of a CCM
pop
Level 2High risk members
Level 3Highly complex members
Short secondary prevention groups
Some individual care
Operational policy for the community screening teams
Expert patient Programme
Interdisciplinary CBT-based pain management Programmes
Council run leisure centre schemes
Link with MIND
Patient support groups
20% OF REFERRALS
What did it take?
• Consultants to move out to do community clinics
• PMP’s to be based in community centres – allowed accessibility of psychologist
• Some secondary care staff volunteered to take part in pilot- allowed development of competencies
• Developed systematic way of identifying risk
What results won hearts and minds?(still need to do it)…..
47% other pathway
34%Complex individual care management
19% pain management programme
Overall Outcomes of Assessment for Level of Need
User Surveys
Triage88% felt the assessment process was about right
75% were satisfied with the outcome of assessment
A small number were unclear as to the next step
Secondary Care:
95% highly satisfied with care in RSH
Pain management programme:
90% patient satisfaction
City PCTAlliance
PCT National
Musculoskeletal pain 89 80 70
Pain Intensity 25 27 23
Pain impact scale 47 47 44
depression score (Beck) 29 25 ?
Duration > 2 years 85 80 80
Case Mix
What’s been the impact on secondary care pain services?
Activity 2002-6 Secondary care
0200400600800
100012001400
2002-3
2003-4
2004-5
2005-6
Decreased medical follow-ups Increased emphasis
on coping and self management skills
Decreased short term solutions
Waiting times:steady at 6 weeks
8% do not opt in from assessment
Budget decreased
Impact on specialist team…tricky patients…wide range of needs
• Needed to redesign team – to provide self management skills training to
patients– Ability to motivate, negotiate– Function as MDT– Range of skills
• Redesign process of care- patients struggle with group programmes
Process to rebuild team
• Mapping patient journey
• Functional skills analysis
• Skills matrix done as team
• Regular business meeting
• Regular team meeting
Opt in from triage
“taster”
Team member
Complete needs assessment
Stuck team meeting
Intervention Discharge
Now…
• Psychologists offer regular supervision- nearly all staff have this
• Core team = medic/physiotherapist/nurse
• Plus:– Strong Mental health support-
psychology/psychiatry – Pharmacist input– Vocational rehabilitation specialists
Activity
• 25% need mental health needs formally assessed
• 25% highly complex (see > 3 team members)
28% doctor only
Nurses 68%
Doctors 70%
Physios 48%Psychologists 6% but consultancy offered
Pharmacist
Challenges
• Interaction between community and secondary care team
• Single vision across multiple organisations• Many staff very part time ? Sufficient to
learn• Clinical governance structures different
with each organisation• Strong community service- secondary care
cases costly – not adequately reimbursed
Summary Pain Management - The
solution…
The Pain FrameworkThe right patient is in the right place at the right time
Complex individual case
management-
Self management programmes
Usual Care with Support- primary care doctor medicines, explanations of pain within a
biopsychosocial framework, musculoskeletal practitioners, community pharmacists
Level 170-80% of a CCM
pop
Level 2High risk members
Level 3Highly complex members
Increasing complexity of biopsychosocial factors
Re-referral rate is 10% at present- needs to be closely monitored
What you can see by working in the community!
SouthamptonSouthampton