2008 APS SIG: Interdisciplinary Pain Rehabilitation Centers

1. 2008 APS SIG: Interdisciplinary Pain Rehabilitation Centers Mayo Clinic Pain Rehabilitation Center Cynthia Townsend, PhD Barbara Bruce, PhD

2. Mayo PRC Administrative Team Dr. Hooten boarded Internal Medicine, Anesthesiology, Psychiatry became Medical Director in 2005. Dr. Rome will still participate in some PRC activities as Emeritus staff. Dr. Bruce, Jaxon and Connie have each been at Mayo around 20 years. Drs. Bruce and Townsend have specialty training in clinical health psychology. Our charge as the PRC administrative team is to maintain excellence in patient care while also being financially responsible and good stewards of our resources.Dr. Hooten boarded Internal Medicine, Anesthesiology, Psychiatry became Medical Director in 2005. Dr. Rome will still participate in some PRC activities as Emeritus staff. Dr. Bruce, Jaxon and Connie have each been at Mayo around 20 years. Drs. Bruce and Townsend have specialty training in clinical health psychology. Our charge as the PRC administrative team is to maintain excellence in patient care while also being financially responsible and good stewards of our resources.

3. Who Are We? Est. 1974 (Dept. Psychiatry/Psychology) Non-profit, tertiary care academic medical center Outpatient, hospital-based program 3-week (1+15 days) duration (8a – 5p) cognitive behavioral group-based treatment with daily PT and OT Open group (rolling admission) Treatment goals: functional restoration and opioid withdrawal 1 + 15 days = 1 evaluation day to meet with all of the disciplines for baseline assessment and goal setting plus 15 days of treatment. Evaluation day includes baseline evaluations with nurse, PT, OT, pharmacist and biofeedback clinician.1 + 15 days = 1 evaluation day to meet with all of the disciplines for baseline assessment and goal setting plus 15 days of treatment. Evaluation day includes baseline evaluations with nurse, PT, OT, pharmacist and biofeedback clinician.

4. PRC Clinical Programs 3-week adult program Includes 5 hours of family groups per week 3-week Adolescent Program PREP, 2-day abbreviated program Every week (led by CNS and MA) Focus on CBT concepts – no PT/OT Family members also attend ~50% eventually attend 3-week program Often recommended prior to spinal cord stimulator trial Aftercare program 1 day, held twice per month Open admission Focus is on relapse prevention We’ve recently increased the intensity of our family programming to meet clinical needs of patients who need support to maintain rehabilitation progress and for family members to learn how to reinforce functioning. Family members, friend or other significant others are able to attend the weekly programming as much as they are able. We began our adolescent program last year in addition to the full adult program. It is staffed by a pediatric anesthesiologist and assist with pediatric OT, nursing with pediatric psych experience and CNS and psychologist with pediatric experience. We hope to run the program quarterly with 15-20 teens per group. The program includes much more family/parenting programming than the adult program. PREP = Pain Rehabilitation Executive Program developed as a less intensive program to teach cognitive behavioral pain-management to (1) patients who are still functioning and able to work but notice increase in pain-contingent lifestyle, (2) patients who are not functioning well but are skeptical and not ready to commit to full 3-week program, (3) patients being considered for a spinal cord stimulator. PREP – led by CNS and master’s therapist. CNS is able to bill services. Family member or support person also attends to learn concepts to reinforce at home. The Aftercare Program began again a year ago and is held twice per month for former graduates to return as often as needed. More intensive follow-up is arranged or assisted for referral if needed.We’ve recently increased the intensity of our family programming to meet clinical needs of patients who need support to maintain rehabilitation progress and for family members to learn how to reinforce functioning. Family members, friend or other significant others are able to attend the weekly programming as much as they are able. We began our adolescent program last year in addition to the full adult program. It is staffed by a pediatric anesthesiologist and assist with pediatric OT, nursing with pediatric psych experience and CNS and psychologist with pediatric experience. We hope to run the program quarterly with 15-20 teens per group. The program includes much more family/parenting programming than the adult program. PREP = Pain Rehabilitation Executive Program developed as a less intensive program to teach cognitive behavioral pain-management to (1) patients who are still functioning and able to work but notice increase in pain-contingent lifestyle, (2) patients who are not functioning well but are skeptical and not ready to commit to full 3-week program, (3) patients being considered for a spinal cord stimulator. PREP – led by CNS and master’s therapist. CNS is able to bill services. Family member or support person also attends to learn concepts to reinforce at home. The Aftercare Program began again a year ago and is held twice per month for former graduates to return as often as needed. More intensive follow-up is arranged or assisted for referral if needed.

5. 3-week Program Census 400+ admissions per year ~9 admissions per week (M-Th) Census goal: 27 patients/day (23 break even) Two simultaneous treatment groups (12-14 per group) 90% of patients complete the program Approximately 30-40 pre-candidacy evaluations/week One full psychologist FTE is dedicated to the candidacy evaluations. A census of 23 patients (on average) was considered to be a financial-clinical expense break even point so we worked backward to determine an ideal census that would be optimal to have a well functioning clinical group that was also financially responsible. One full psychologist FTE is dedicated to the candidacy evaluations. A census of 23 patients (on average) was considered to be a financial-clinical expense break even point so we worked backward to determine an ideal census that would be optimal to have a well functioning clinical group that was also financially responsible.

6. Mayo PRC Team Physician* 0.5 FTE Psychologists* 2.0 FTE Clinical Nurse Specialists (psychiatry)* 3.0 FTE Nurse Manager 0.6 FTE Nurse Care Coordinators (RN, BSN)* 11.0 FTE Masters-trained therapists 2.0 FTE Physical Therapists* 3.0 FTE Occupational Therapists* 2.0 FTE Biofeedback Therapists (OT) 0.75 FTE Pharmacist* 0.4 FTE The disciplines with the asterisks are around the table for patient staffing 4 mornings per week (two times per patient per week) to discuss patients’ progress, concerns and treatment planning. Those in red are billable providers so are able to bill directly for professional fees beyond facility fees. PT/OT are billable but owned by PMR so their revenue does not come back to the program. Our nurses have med surg or psychiatric nursing backgrounds. One Psychology FTE is dedicated to evaluations and the other to the patient treatment groups. CNSs run the treatment groups for the main program, Aftercare program and PREP program.The disciplines with the asterisks are around the table for patient staffing 4 mornings per week (two times per patient per week) to discuss patients’ progress, concerns and treatment planning. Those in red are billable providers so are able to bill directly for professional fees beyond facility fees. PT/OT are billable but owned by PMR so their revenue does not come back to the program. Our nurses have med surg or psychiatric nursing backgrounds. One Psychology FTE is dedicated to evaluations and the other to the patient treatment groups. CNSs run the treatment groups for the main program, Aftercare program and PREP program.

7. Additional Mayo PRC Team Providers Nicotine Dependence Chemical Dependency Counselor Vocational Psychologist Dietician Psychometrists Chaplain Administrative Support Staff Desk assistants, secretary, transcriptionists, data entry Pre-certification Financial Reps (2) These individuals are not part of the core clinical team but are readily available for consultation. The support staff includes desk assistants, secretary, transcriptionists and data entry. We have two pre-certification financial representatives to verify every insurance pre-approval, communicate insurance coverage to patient and notify MD/PhD if appeal process is necessary. The financial representatives are dedicated solely to PRC and know our program well. They know what codes will need to be covered and communicate with insurance rather than patients to decrease patient burden and ensure the correct coverage is being requested. The financial reps also notify the administrative team if they see insurance trends in denials, non-reimbursement, etc. Psychometrists administer an abbreviated cognitive battery to the patients and this testing is interpreted by the psychologist. This is the only service that is billed using a DSM code.These individuals are not part of the core clinical team but are readily available for consultation. The support staff includes desk assistants, secretary, transcriptionists and data entry. We have two pre-certification financial representatives to verify every insurance pre-approval, communicate insurance coverage to patient and notify MD/PhD if appeal process is necessary. The financial representatives are dedicated solely to PRC and know our program well. They know what codes will need to be covered and communicate with insurance rather than patients to decrease patient burden and ensure the correct coverage is being requested. The financial reps also notify the administrative team if they see insurance trends in denials, non-reimbursement, etc. Psychometrists administer an abbreviated cognitive battery to the patients and this testing is interpreted by the psychologist. This is the only service that is billed using a DSM code.

8. Who Are Our Patients? Age: 45 (12-85+) Residence: 47% MN + 36% IA, WI + 17% oth Pain Duration: 9 years (50% > 5 yrs) Disability: 84% receiving/applying Workman’s Comp: <10% Opioids: 45% daily, avg oral ME = 99 mg/day Pain Sites: Back (25%) Fibromyalgia (20%) Headache (11%) Generalized (8%) Abdominal (7%) Other (29%) Mayo has a Fibromyalgia Treatment Program [1.5 day program for fibro diagnostic, education and brief self-management training, clinic is in PMR dept]. A large number of patients participating in the come to the 3-week intensive program due to their poor level of functioning. Generalized pain includes CRPS. Other includes face, limb, foot, hand, knee, hips, neck, and non-pain conditions like chronic fatigue and POTS. Patients have been using opioids on average about 2 years prior to admission to PRC. 45% are on daily opioids, 10% prn.Mayo has a Fibromyalgia Treatment Program [1.5 day program for fibro diagnostic, education and brief self-management training, clinic is in PMR dept]. A large number of patients participating in the come to the 3-week intensive program due to their poor level of functioning. Generalized pain includes CRPS. Other includes face, limb, foot, hand, knee, hips, neck, and non-pain conditions like chronic fatigue and POTS. Patients have been using opioids on average about 2 years prior to admission to PRC. 45% are on daily opioids, 10% prn.

9. Patients continued Referred from various disciplines at Mayo Clinic (~40 subspecialty clinics): Psychiatry 14% PMR (Fibro) 13% Neurology 12% General Internal Med. 9% Pain Clinic/Anesthesia 8% Rheumatology 5% Internal marketing/referrals - We’ve sent department-specific letters containing information about treatment outcomes for patients directly referred from each department. We have several “frequent flyer referring providers” in most subspecialty clinics. They know our program well and “tee” patients up for PRC well so patients understand the treatment and expectations. This referral base also ensures our patients have undergone thorough medical evaluation and are ready for rehabilitation when they come to the pre-candidacy evaluation.Internal marketing/referrals - We’ve sent department-specific letters containing information about treatment outcomes for patients directly referred from each department. We have several “frequent flyer referring providers” in most subspecialty clinics. They know our program well and “tee” patients up for PRC well so patients understand the treatment and expectations. This referral base also ensures our patients have undergone thorough medical evaluation and are ready for rehabilitation when they come to the pre-candidacy evaluation.

10. 1. Hospital-based Treatment Program Allowed to charge Facility Fee Avg $1,000/day Patient care, non-billable services Access to all hospital services Treat medically and psychiatrically complex patients JCAHO accreditation The next 6 points identify some aspects of our program which the administrative team has identified as really making a difference in our clinical organization and financial survival. We are a hospital-based treatment program and the program has both a program and facility fee as well as professional fees. Inpatient programs may have higher facility fee. As a hospital program, we have to meet all JCAHO accreditation guidelines.The next 6 points identify some aspects of our program which the administrative team has identified as really making a difference in our clinical organization and financial survival. We are a hospital-based treatment program and the program has both a program and facility fee as well as professional fees. Inpatient programs may have higher facility fee. As a hospital program, we have to meet all JCAHO accreditation guidelines.

11. 2. Health and Behavior Codes (96150-96155) Focus is on the biopsychosocial factors important to physical health problems and treatments Medical diagnosis (not DSM-IV except psychological testing) No limit on treatment group size or provider-patient ratio (although clinically have optimal/ suboptimal size) Use of psych diagnosis codes may reimburse higher for some treatments however, they have group size limitations -[maximum 8 patients with one provider in room; maximum 12 patients with 2 providers in the room]. We found that switching to HB codes that actually more accurately reflects our patient clinical population allowed us to increase to larger clinical groups without two providers being in the room if not necessary. We’ve preferred our groups to be 8-13 patients as more is difficult to manage clinically and less sometimes led to undue influence from patients with strong personalities. There is a nice blend of new and veteran patients with this size in a rolling admission format. For family programs, you can use 96154 which is HB intervention with family and patient and is reimbursed at a higher rate. You can bill for family members only but we found this does not usually get reimbursed.Use of psych diagnosis codes may reimburse higher for some treatments however, they have group size limitations -[maximum 8 patients with one provider in room; maximum 12 patients with 2 providers in the room]. We found that switching to HB codes that actually more accurately reflects our patient clinical population allowed us to increase to larger clinical groups without two providers being in the room if not necessary. We’ve preferred our groups to be 8-13 patients as more is difficult to manage clinically and less sometimes led to undue influence from patients with strong personalities. There is a nice blend of new and veteran patients with this size in a rolling admission format. For family programs, you can use 96154 which is HB intervention with family and patient and is reimbursed at a higher rate. You can bill for family members only but we found this does not usually get reimbursed.

12. 2. Health and Behavior Codes Cont. PhD, MD and CNS able to run and bill treatment groups or individual sessions Required Documentation: Total time spent face-to-face Medical diagnosis (pain site) Intervention/education Patient’s willingness to change Progress/lack of progress

13. 3. Strong Reliance on Allied Health CNSs and Master’s therapists lead CBT groups Nurse Care Coordinator (NCC): every patient assigned to a NCC vitals/DAS/medication reconciliation, patient staffing, documentation, contact primary care provider and family members PhDs: supervise care/progress/treatment plan/aftercare plan, interpret testing, supervise candidacy evaluations, conduct spinal cord psych evals diagnose/treat co-morbid psych conditions, administrative duties, appeals Research and teaching, referral presentations

14. 4. Diverse Programming Continuum of care (PREP, Family Groups, Aftercare, and Adolescent program) Greatly improves clinical care Also provides increased revenue without necessarily increased cost/FTE supports non-billable or “non-owned” but services vital for rehabilitation (e.g., nursing, PT, OT, vocation, sleep actigraphy)

15. 5. Designated Evaluation/Admission Team Large number of available eval slots to minimize wait-list for non-local patients 30-40 pre-candidacy evaluations per week RN/MA reviews history and program goals and structure; supervised by PhD Pre-certification financial representatives designated for PRC Daily review of census changes to make target census of 27 Outside referrals reviewed by MD RN calls patients a couple weeks before admission to address questions/concerns (significantly decreased no-shows) 30 to 40 pre-candidacy evaluations per week (one hour each – 45 min with allied health and 15 min with PhD who has already reviewed record and met with allied health. For efficiency, two simultaneous evals are scheduled and PhD supervises both). We’re not trying to conduct a full psychiatric evaluation but instead develop a treatment plan to address pain and depression, assess suicidality and get them into rehabilitation or other treatment. Most of the patients that are sent in our direction are medically and psychiatrically complex and need the intensive rehabilitation treatment. High volume of evals per week and availability to see “checkers” allows us to meet referring providers needs and see patients when they are “teed” up to sign up for the program and to offer hope after completion of diagnostic appointments without the “cure”. This designated evaluation team approach is helping fix the “no show” rate and maintain an steady census – it is an easy fix to a million dollar problem (literally – not an exaggeration). Using a call-cancel list to fill “holes” in the census when someone cancels, reschedules, or is denied helps maintain an even census. When patients are scheduled for the program which is out for a few months, we ask if they are interested in being placed on the Call/Cancel list to see if they are able to have an earlier admission. Outside referrals – patients who have completed medical evaluations and do not need further diagnostic clarification are reviewed by MD and sent a letter and detailed program brochure to consider admission to PRC. If they are interested, they call and we answer questions over the phone and they are scheduled for admission or invited to come visit the clinic.30 to 40 pre-candidacy evaluations per week (one hour each – 45 min with allied health and 15 min with PhD who has already reviewed record and met with allied health. For efficiency, two simultaneous evals are scheduled and PhD supervises both). We’re not trying to conduct a full psychiatric evaluation but instead develop a treatment plan to address pain and depression, assess suicidality and get them into rehabilitation or other treatment. Most of the patients that are sent in our direction are medically and psychiatrically complex and need the intensive rehabilitation treatment. High volume of evals per week and availability to see “checkers” allows us to meet referring providers needs and see patients when they are “teed” up to sign up for the program and to offer hope after completion of diagnostic appointments without the “cure”. This designated evaluation team approach is helping fix the “no show” rate and maintain an steady census – it is an easy fix to a million dollar problem (literally – not an exaggeration). Using a call-cancel list to fill “holes” in the census when someone cancels, reschedules, or is denied helps maintain an even census. When patients are scheduled for the program which is out for a few months, we ask if they are interested in being placed on the Call/Cancel list to see if they are able to have an earlier admission. Outside referrals – patients who have completed medical evaluations and do not need further diagnostic clarification are reviewed by MD and sent a letter and detailed program brochure to consider admission to PRC. If they are interested, they call and we answer questions over the phone and they are scheduled for admission or invited to come visit the clinic.

16. 6. Frequent Administrative Meetings Dedicated consultants (MD, PhDs, MA, RN) Offices physically close Weekly meetings and monthly financial reports Flexibility is key With our offices in the same hall we have a lot of informal hallway meetings throughout the week. Our MD is 50% dedicated to PRC and PhDs are 100% dedicated to clinical practice in PRC. RNs may rotate between rehabilitation and Fibromyalgia Treatment Program.With our offices in the same hall we have a lot of informal hallway meetings throughout the week. Our MD is 50% dedicated to PRC and PhDs are 100% dedicated to clinical practice in PRC. RNs may rotate between rehabilitation and Fibromyalgia Treatment Program.

17. Other Examples of High-Impact Solutions Enlarge rooms, change table configuration Add one hour to meet Medicare guidelines of 6 non-PT/OT treatment hours per day Designation of evals for Fibromyalgia Treatment Program patients List of lower-priced hotels, lodging Increase longitudinal study response rate by giving individualized graphs and phone call Reimbursable family programming Workman’s Comp – pre-paid Monthly all-team lunches Rooms – although we changed to HB codes, we couldn’t enlarge groups because patients were uncomfortable around a long oval table. Solution was to make the rooms slightly larger from unused corner space and use five small rounds tables with 3 chairs around each. This allowed us to increase census without compromising patient’s comfort. Although we were concerned about extending our day, we are able to add another relaxation treatment group at the end of the day to ensure that we continue to meet Medicare guidelines by providing 6 hours of non-PT/OT treatment groups per day. Designated Fibromyalgia evals - Fibro patients generally are young and have insurance and clinically do very well with rehabilitation - we have 4 evaluations slots per day designated for patients in the Fibro Treatment Program (FTP) to learn about the interdisciplinary program. The 3-week rehabilitation program is discussed in the FTP and patients receive our detailed brochure that includes program description, expectations and treatment outcomes. Having a mix of payors in the program is key. Patients express concern of not being able to afford hotels- we compiled a list of cheaper options, religious homes, etc. to help but we are not able to endorse a specific hotel due to clinic policy. We increased our response rate for our longitudinal study from 30% to 70% by including individualized pre-/post- graphs of several treatment outcomes for each patient and promise to send again with updated graph when the patient completes the survey; Also use study coordinator to call patients if not return survey in 2 weeks. Our manuscript on longitudinal findings of rehabilitation that incorporates opioid withdrawal is under review. We want/need to publish this research for our own survivorship as well as that of IPRPs nationwide. We learned insurance not reimbursing family group if patient not present (can bill but it does not get reimbursed) so we restructured some of the groups for patients to attend with family members (e.g., discussion about pain behaviors) in order to have a clinically meaningful discussion with patient in family group treatment. With all of the clinical activities increases need for open lines of communication for staff and morale. We now schedule monthly all-team lunches to discuss treatments, changes, research, quality concerns so everyone is one the same page, problem-solve, concerns, etc.Rooms – although we changed to HB codes, we couldn’t enlarge groups because patients were uncomfortable around a long oval table. Solution was to make the rooms slightly larger from unused corner space and use five small rounds tables with 3 chairs around each. This allowed us to increase census without compromising patient’s comfort. Although we were concerned about extending our day, we are able to add another relaxation treatment group at the end of the day to ensure that we continue to meet Medicare guidelines by providing 6 hours of non-PT/OT treatment groups per day. Designated Fibromyalgia evals - Fibro patients generally are young and have insurance and clinically do very well with rehabilitation - we have 4 evaluations slots per day designated for patients in the Fibro Treatment Program (FTP) to learn about the interdisciplinary program. The 3-week rehabilitation program is discussed in the FTP and patients receive our detailed brochure that includes program description, expectations and treatment outcomes. Having a mix of payors in the program is key. Patients express concern of not being able to afford hotels- we compiled a list of cheaper options, religious homes, etc. to help but we are not able to endorse a specific hotel due to clinic policy. We increased our response rate for our longitudinal study from 30% to 70% by including individualized pre-/post- graphs of several treatment outcomes for each patient and promise to send again with updated graph when the patient completes the survey; Also use study coordinator to call patients if not return survey in 2 weeks. Our manuscript on longitudinal findings of rehabilitation that incorporates opioid withdrawal is under review. We want/need to publish this research for our own survivorship as well as that of IPRPs nationwide. We learned insurance not reimbursing family group if patient not present (can bill but it does not get reimbursed) so we restructured some of the groups for patients to attend with family members (e.g., discussion about pain behaviors) in order to have a clinically meaningful discussion with patient in family group treatment. With all of the clinical activities increases need for open lines of communication for staff and morale. We now schedule monthly all-team lunches to discuss treatments, changes, research, quality concerns so everyone is one the same page, problem-solve, concerns, etc.

18. Challenges A LOT of Department leaders to answer to (Psychiatry/Psychology, Nursing, PMR, Financial Office Staff) Rotating financial administrators Difficulty preserving research time High evaluation waiting-list despite 40 slots per week (4 weeks) High admission waiting-list (currently Sept) Lacking knowledge of IPRPs similar to our program We would like to help develop a network of IPRPs to help identify other similar programs, learn of challenges and how programs are meeting those challenges and to identify contact information to help refer patients This will begin by identifying which programs are IPRPs and the treatments offered in each program.We would like to help develop a network of IPRPs to help identify other similar programs, learn of challenges and how programs are meeting those challenges and to identify contact information to help refer patients This will begin by identifying which programs are IPRPs and the treatments offered in each program.

19. Contact: Townsend.cynthia@mayo.edu (507) 255-5921 www.mayoclinic.org Search “pain rehabilitation”