Pain Management Innovations in the Primary Care Medical Home Ilene R. Robeck, MD
Faculty and Disclosures Sondra M. Adkinson, PharmD, DAAPM, CPE – Nothing to Disclose
Jeremiah C. McKelvey, PharmD – Nothing to Disclose
Ilene R. Robeck, MD – Nothing to Disclose
Robert S. Sproul, PharmD – Nothing to Disclose
Learning Objectives Describe the use of the pain school to improve patient education and safety Recognize how primary care-based pain teams improve access to a comprehensive approach to pain in the primary care setting Describe use of electronic consulting for provider to provider consultation and education
E-Consult: INNOVATIONS IN CONSULT MANAGEMENT
Robert S. Sproul, PharmD
VHA Innovations In Clinical Services Support Our Veterans and Their Providers
E-Consult Background Access to specialty care from outlying and rural locations is challenging for Veterans and their primary care providers Non Face-To- Face – E-Consults provide specialty consultation without face-to-face contact by the Veteran with the specialist
Different way of delivering health care – Improve coordination of care for veterans – Increase collaboration between specialist and referring providers
E-Consult Pain Management
PCP
Bridging the Gap OVAMC E-Consult Pain Management One of “Many” Formats
E-Consult PM Primary Care Daily PM Issues, Support
Specialty Care Pain Clinics Management Services
OVAMC E-Consult PM
E-Consult PM Fundamental Goals This service can answer many “seemingly” routine but important questions/issues that often burden our PCPs Many issues do not necessarily need to be shunted to a Specialty Pain Clinic Provides “easy access” for the consulting provider – “Easy Access” equates with “Timely Support?” – Paramount for addressing patient safety issues
Typical concerns addressed by the E-Consult Pain – Opioid related
• Titration, rotation, conversions, tapering • Alternative treatment modalities
– Urine Drug Screen
• Interpretation, policy, provider recourse • Associate opioid tapering and ethical considerations
OVAMC E-Consult PM Limitations – No intent to replace existing Specialty Pain Clinic (SPC) services • SPC which “temporarily managed” until stable and then discharged back to the PCPs
– Conversely, the E-C Pain service does not manage but rather provide a one time evaluation – However, a provider may continue to follow up with additional consults as appropriate – E-consult team representative(s) will document the recommendations in CPRS – However, it is at the discretion of the consulting provider to accept and implement the team’s recommendations
Innovations in Consult (ICM)
Project Coordinator Pain Pharmacist
CPRS Provider E-Consult (Countable/non-Billable Clinic)
E-Consult
CPRS Review/Documented Recommendations
Provider Education Week Teleconference
Pain Pharmacist: Initial Responder Triage Based on Level of Complexity (LOC)
L1 Pharmacotherapy concerns L2 Pharmcotherapy /MH Comorbity Concerns a. Multidisciplianary L3 Complex Comorbitity/High Risk Patients: Teleconferencing a. Interdisciplinary VHAORL E-Consult Pain Management Outlook Provider Non-CPRS Follow up Contact Option
Triage Chart Review
MH Screen
Pain Psychologist +Screen-Comorbitity L2
CPRS Clinical Review Progress Notes
Primary Responder-Pharmacist
Pain Pharmacist 1.0 FTE Pain Psychologist % FTE Pain Physician % FTE
Outcomes Quarterly/Annual Data Pain Psychologist
Recommendations/Documentation What’s In A Name? Intent – Is not to “paint a provider into a corner” – Is to provide guidance for / with options to the provider Wording – How a recommendation is “worded” is crucial • Stipulates the recourse the Pain Service would take • Offers alternative to the Clinic’s stance (opinion) – Acknowledges provider's discretion
Example – For the following patient safety issues detailed above a.b.c., the Pain Clinic would no longer prescribe opioids for this pt at this time – However, should the provider determine opioids will be continued, then the Pain Clinic would recommend the following • Frequent UDS • No more than a seven day supply, etc
VISN 8 E-Consult PM Provider Education VISN 8 E-Consult
– Chronic Pain Audio Conference
Weekly Case-Base Provider Education (CME) – Moderate to High Risk Patients – Complex patients with Comobitity
Supporting didactics Provides an Interdisciplinary Forum – Explore alternatives – Discuss controversies – Provider recommendations
Hidden Treasures Transcending the Routine E-Response Typical consults –Often directly address important daily issues, such as urine drug screens, opioids, and associated concerns
However, provider support is not limited to "treatment modalities" alone –May directly assist the provider in resolving difficult scenarios • Patient treatment and or ethically related issues • Assist in coordination of care
E-Case Study Ethical Considerations Reason for Consult
– Terminally ill cancer patient – In the ambulatory care setting – Non-End of Life Scenario – On significant amount of opioids – Test positive for cannabis / alcohol
Provider's Comments "I'm concerned that the patient is going to overdose or hurt someone else” “Is a second chance reasonable, or must I discontinue the opioids” “I don’t want to cut the opioids” “I know he’s in a lot of pain” “What should I do”
E-Hidden Treasures PCP Doesn’t Have to Walk the Walk Alone Ultimately it will be the provider's discretion that determines the recourse which will be taken However, the provider can reach out to a "team" for support and or advice – Options with the supporting details – To address a controversial pain / ethical issue
Means to avoid the unilateral decision process – An uncomfortable situation for many providers – Due to perceived scrutiny
• From oneself or from others • Laced in the form of legal, ethical, moral considerations/implications
VHA Pain Management Support of and Care for our Veterans
To All of Our Veterans Who Have Sacrificed
THANK YOU FOR YOUR SERVICE
(Roger-That)