©2016 American Academy of Neurology

©2016 American Academy of Neurology

PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine

(AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance Abuse Training

(SECSAT).

For more information visit: www.pcss-o.orgFor questions email: pcss-o@aaap.org

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services;

nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

©2016 American Academy of Neurology

No conflicts of interest were reported by the presenter or identified by the Program Accreditation Subcommittee.

There is no commercial support for this series to disclose. AAN will be providing webinars free of cost, for CME.

This material has been reviewed by the lead Clinical Expert on the PCSS-O grant, co-faculty, and AAN staff. Webinars will be available on-demand for participants unable to make the live event.

©2016 American Academy of Neurology

Accreditation StatementThe American Academy of Neurology Institute is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA Credit Designation StatementThe American Academy of Neurology Institute designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Slide 4

©2016 American Academy of Neurology

ObjectivesUnderstand the principals of primary, secondary and tertiary prevention regarding the care of

patients presenting with acute episodes of painUnderstand how to layer best practice care delivery from what can effectively be done in the office

for more simple pain problems and what can be done using additional community health care resources when pain becomes more complex Describe the importance of preventing the transition from acute to chronic pain and long term

disability Describe the importance and key causes of transition from acute to chronic painUnderstand the relationship of development of chronic pain to development of long term disability Describe how health care coordination and collaboration can improve outcomes for pain patients

Slide 5

PCSS-O Webinar Series: Providing Stepped Care Management for Pain in Your Practice and Community

Gary M. Franklin, MD, MPHResearch Professor

Departments of Environmental Health, Neurology, and Health Services

University of Washington

Medical DirectorWashington State Department of

Labor and Industries

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• Years lived with disability 2010• Low back pain 3.18 million YLD• Major depressive disorder 3.05 million YLD• Other MSK disorders 2.6 million YLD• Neck pain 2.13 YLD• Anxiety disorders 1.86 million YLD• Diabetes (#8) 1.16 million YLD• Alzheimer's (#17) .83 million YLD• Stroke (#23) .63 million YLD

The State of US Health, 1990-2010Burden of Diseases, Injuries, and Risk Factors*

*JAMA 2013; 310: 591-608

What is stepped care management?• Model based on Wagner et al model of chronic care management

developed at Group Health Cooperative for diabetes, heart failure, etc.

• Original goal was to improve chronic disease prevention and management

• More recently adapted for chronic pain prevention and management• Now tightly linked to population-based quality improvement

initiatives• Also centerpiece of medical home models of care

Rothman AA, Wagner EH. Chronic illness management: What is the role of primary care? Ann Int Med 2003; 138: 256-61.

What are key elements of stepped care management?• Population based health care• Team based support for complex conditions• Goal is to keep patient in primary care with sufficient team support• Patient-centeredness-key goal is to improve patient self-efficacy with

aim to improve health outcomes and reduce avoidable hospital admissions, ED visits

• Key element is care coordination (e.g., see Crossing the Quality Chasm, Institute of Medicine, 2001) so that care is integrated and patients do not fall through the cracks

• Clinical information coordination AND clinical care coordination• Measurement based-treat to target

Collaborative care to prevent and better treat chronic pain-biopsychosocial model of pain • Expands role of care coordination to providing clinical assessment and brief

interventions-e.g. cognitive behavioral therapy, motivational interviewing• Can be partially delivered telephonically so as to reach more rural/isolated

patients• Behavioral health integration with pain management to address psychosocial

barriers to recovery• Psychosocial barriers • Most important psychosocial barriers to recovery: fear avoidance,

catastrophizing, low expectations of recovery

Psychosocial Risk / Symptoms

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Behavioral Interventions

Physical inactivity

Catastrophizing

Pain flare-ups

Self-efficacy

Distress (stress or depression)

Anxiety (fear of movement / re-injury)

Perceived injustice

Disability conviction

Sleep issues

Poor treatment adherence

Substance issues

IMPACT Trial 18 clinics in 5 states, 1801 patientsRCT published in JAMA, 2003

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Collaborative Care achieves the Triple Aim:1. Better patient and provider satisfaction with care

2. Better clinical outcomes• Doubles effectiveness of depression treatment • Less physical pain• Better functioning• Higher quality of life

3. Reduced health care costs

Collaborative Care: Defined

• A type of integrated healthcare developed to treat common behavioral health conditions

• Originally mental health conditions• Used now for pain & other conditions

• Team-based system of care• Based on 5 core principles

https://aims.uw.edu/collaborative-care• Cochrane Review 2012: 79 trials and 24,308 patients

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Principles of Effective Collaborative Care

Patient-Centered Team Care / Collaborative • Team focused on

patient’s goals

Population-Based Care• No patients “falling

through the cracks” • Specialists support

care

Measurement-Based Treatment to Target• Outcomes

measured + stepped up care

Evidence-Based Care• Psychosocial and

pharmacological treatments

Accountable• Reaching treatment

targets

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Traditional vs collaborative behavioral health care

Traditional (treatment as usual)

• Single behavioral health expert• Psych assessment • Typically address a very targeted problem• Costly training• Rigid protocols• Limited population generalizability• Time consuming treatments - Typically

delivered face-to-face• Point of care treatment, no outreach • Limited population reach

Collaborative Care

• Care manager (specialist consultants)• Systematic screening• Brief evidence based treatments• Interdisciplinary team care• Medication management and consultation • Utilizes telehealth to reach patients • Flexible• Focus on patient engagement• Increased intensity in treatment as needed • Lower cost than traditional treatments• Broad population reach

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Collaborative Care Model

Patient

Providers

Consultants:PsychologistPsychiatristPain expert

Care Manager

Feedback Decision supportCare coordination Weekly case supervision

Treatment adjustmentManage treat-to-target

Motivate adherence & treatment responseProvide brief treatmentsFacilitate community support

Give patient a choice of treatments

Roles for Collaborative Care Team Members during Episode of Care

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Injured Worker•Complete screenings•Shared decision making and track outcomes

•Communicate concerns•Report updates and complete L&I requirements

Care manager •Assessment / plan•Monitor and coordinate care•Consultation with specialists•Link team and data•Engagement in care•Patient and team education•Step up care and refer as needed•Brief evidence-based psychosocial tx’s•Relapse prevention plan

Attending provider•Refer to collaborative care•Share information across team•Follow up on specialist recommendations

•Facilitate return to work

Consultants•Weekly consultations on new and non-improving cases

•Facilitate stepping up care as needed•Training sessions to team•Psychologist•Brief behavioral tx’s•Behavioral plans for difficult clinical situations

•Support burn out•Psychiatrist•Psychotropic medication tx’s•Support burn out

•Pain Expert•Multidisciplinary biopsychosocial intervention

Health Services Coordinator•Link team•Facilitate L&I and clinical team coordination of care

•Facilitate return to work

Core Behavioral Interventions

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Education (including sleep

hygiene education)

Self-monitoring: identifying progress & strengths

Goal-setting/values

Behavioral activation

(including activity coaching)

Cognitive restructuring

Mindfulness meditation Relaxation training Problem solving

Building helpful social support &

engagement

Nurturing positive emotions

Motivational Interviewing

Episode of Chronic Pain & Behavioral Health Care

2-6 months

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Session /Activity ContentCare Manager & Injured WorkerSession 1 Patient-centered assessment & care planning:

• Assessment• Self-management & care• Set recovery expectations• Develop initial treatment plan

Sessions 2 to #

Session frequency will range from 1/week to 1/month & typically decreases over time

Ongoing sessions:• Monitor outcomes & response • Monitor adherence, self-management, & work status • Coordinate medical management• Provide brief behavioral interventions • Provide support for pain self-management &

maintenance of gains• Intensify/step up treatment

Final Session • Relapse prevention plan• Provide resources to maintain gain

Specialist weekly consultation

• Discuss new patients• Discuss non-responding patients• Review progress, barriers, plan• Monitor outcomes• Recommend treatment adjustments

Other Activities • Inform L&I staff as needed• Facilitate referrals (i.e., PGAP, voc services)

Emerging examples of stepped care management/collaborative care for pain

• VA Health System Stepped Care Model of Pain Management• Dorflinger et al. A Partnered Approach to Opioid Management, Guideline

Concordant Care and the Stepped Care Model of Pain Management. J Gen Int Med 2014; Suppl 4, 29: S870-6.

• Vermont Spoke and Hub regional support for medication assisted treatment for opioid use disorder/severe dependence

• WA state Centers of Occupational Health and Education/Healthy Worker 2020

Stepped Care Model for Pain Management

STEP1

STEP2

STEP3

Tertiary Interdisciplinary Pain CentersAdvanced diagnostics & interventions

Commission on Accreditation of Rehabilitation Facilities accredited pain rehabilitation

Integrated chronic pain and Substance Use Disorder treatment

Primary Care/Patient Aligned Care Teams (PACTs)Routine screening for presence & intensity of pain

Comprehensive pain assessmentManagement of common acute and chronic pain conditions

Primary Care-Mental Health Integration, Health Behavior Coordinators, OEF/OIF/OND & Post-Deployment Teams

Expanded nurse care management Clinical Pharmacy Pain Medication Management

Opioid Pain Care and Renewal Clinics

Complexity

Treatment Refractory

Comorbidities

RISK

Secondary Consultation Pain Medicine

Rehabilitation MedicineBehavioral Pain Management Interdisciplinary Pain Clinics

Substance Use Disorders Programs Mental Health Programs

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Timing of stepped care management to prevent transition to chronic pain

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Screening for collaborative care

Where to focus to achieve disability prevention

MORE MODIFIABLE

LESS MODIFIABLE

• Clinical• Work• Administrative• Psychological• Legal• Demographic

Screen Assess Intervene FRQ

Perceived Injustice

Catastrophic Thinking

Low Recovery Expectations

Activity Avoidance

Characteristics associated with disability

Sullivan, M.J., et al., The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. Journal of occupational rehabilitation, 2008. 18(3): p. 249-261

Turner, Franklin, Wickizer, Fulton-Kehoe et al. ISSLS Prize Winner: Early Predictors of Chronic Work Disability: A Prospective, Population-Based Study of Workers With Back Injuries. Spine 2008; 33: 2809-2818

Chou R, Shekelle P. Will this patient develop persistent disabling low back pain. JAMA. 2010;303(13):1295-1302.

Fulton-Kehoe, D., et al., Development of a brief questionnaire to predict long-term disability. Journal of Occupational and Environmental Medicine, 2008. 50(9): p. 1042-1052.

Osman, A., et al., The Pain Catastrophizing Scale: further psychometric evaluation with adult samples. Journal of behavioral medicine, 2000. 23(4): p. 351-365

Positive FRQ = High Disability Riskaka Workers Comp Heart Attack

• More Attending Provider Attention Required• Business As Usual: Not Good Enough• It Needs To Be Taken Seriously• More Time Should Be Spent With Them• Assure These Workers DO NOT Fall Through The

Cracks

Systematic review of chronic disabling back pain risk factors and risk

prediction instruments

20 prospective studies of patients with <8 wks back pain from which likelihood ratios could be calculated

• Chou and Shekelle: Will this patient develop persistent disabling low back pain? (JAMA 2010; 303:1295-1302)

Health CareCommunity

Healthy Worker 2020 Programs

COHE Business and Labor

Advisory Boards

Community Health Care Providers

Department of Labor& Industries

UW ResearchTeam

External Advisory Committee (ACHIEV)

• Wickizer et al, Medical Care; 2011: 49: 1105-11• One year follow up 20% reduction in likelihood of one year disability, 30% reduction for

back injuries Among COHE participating doctors, high adopters of best practices

had 57% fewer disability days than low adopters

• Eight year follow-up-in preparation• 26% reduction in permanent disability (SSDI offset, TPD, 5 yrs TL)

among back sprains and other sprains

Key Results from COHE Pilots

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Emerging Best Practices: Current Pilots

Functional Recovery

Functional Recovery Questionnaire (FRQ) Early identification of potentially “at risk” workers

Functional Recovery Interventions (FRI) Providers incorporate interventions to enhance

recovery in addition to 4 the COHE Best Practices

http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#3

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Emerging Best Practices: Current Pilots

Activity Coaching

A provider in E. Washington said: “This patient had 22 ‘red flags’ when I referred him to PGAP. At the next visit he

was a completely different person.”

Workers have said: “It gives you a reason to get out of bed and how to be in control of your life again.” “It teaches you how to relearn to manage your pain and life.”

http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#2

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Emerging Best Practices: Upcoming Pilot

Emerging Surgical Best Practices

Four best practices selected from the literature by a focus group of attending providers & surgeons related to: Transition of Care Return to Work

Creation of a Surgical Health Services Coordinator to: Coordinate care and transitions Help providers with complicated cases

http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#4

Healthy Worker 2020Innovation in Collaborative, Accountable Care

PrimaryOccupational Health Best

Practices SpecialtyBest Practices

Chronic Pain & Behavioral Health

Best Practices

Prosthetics

HSCsOHMS

Burns

SIMP

CatastrophicActive Physical

Med

PGAP

Surgery

An Occupational Health Home for the Prevention and Adequate Treatment of Chronic Pain

For electronic copies of this presentation, please e-mail Laura

Blackljl2@uw.edu

For questions or feedback, please e-mail Gary Franklin

meddir@u.washington.edu orhplanalp@aan.com

THANK YOU!