Chronic Pain as a Chronic Illness Self Management Support Strategies

1. Chronic Pain as a Chronic Illness Self Management Support Strategies David Nowels MD, Marc Grushan MD and Samantha Monson, MA UCHSC Family Medicine Grand Rounds June 3, 2009

2. After this session participants will be able to… • Articulate why chronic pain management can be aided by following the chronic care model • List the components of self management support • Help patients set self management goals with greater confidence

3. Chronic Pain is a Chronic CNS Disease • Long term pain can remodel CNS on both micro-and macro-structural levels and modify long-term function • Chronic pain can cause/ augment psychiatric disease, just as psychiatric disease can cause/ augment pain • We all have differing abilities to cope with pain, and thus for some, it becomes a chronic illness

4. When Chronic Pain is a Chronic Illness • Individualized, ongoing treatment and re-evaluation • Aim is to control, not cure • Psychosocial interplay • Improvements and relapses • Frustrations

5. Usual Chronic Illness Care • Oriented to acute exacerbations • Focus on physical findings and lab results • Focus on physician’s treatment, not patient’s role in management • Not designed well for the commonalities of chronic illness • “The patient won’t do what I say!”

6. Chronic Pain Affects All Aspects of a Patient’s Life • Functional Status • Physical functioning • Ability to perform activities of daily living • Work • Recreation • Psychological Morbidity • Depression • Anxiety, anger • Sleep disturbances • Loss of self-esteem Social Consequences • Marital/family relations • Intimacy/sexual activity • Social isolation Socioeconomic • Consequences • Healthcare costs • Disability • Lost workdays Used with the permission of Professional Postgraduate Services

7. The Chronic Care Model Early 1990’s – MacColl Institute for Healthcare Innovation partners with Robert Wood Johnson Foundation, Chronic Care Model synthesized, refined. Published 1998

8. The Chronic Care Model Designed to transform health care from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible Designed to maximize the length and quality of life for patients with chronic conditions and to satisfy patient and caregiver needs, while maintaining or decreasing the total cost of care

9. The Chronic Care Model Community Health System Resources and Policies Health Care Organization ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes Used with permission from Wagner’s Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1998 (American College of Physicians)

10. A Proven Model of Care • 1.5-2 times as many patients with major depression have been recovered at six months • Average HbA1c of type II diabetics 1%+ lower • Readmission rates of patients hospitalized with CHF cut nearly in half • Inner city kids with moderate to severe asthma have 13 fewer days per year with symptoms

11. Early 1990’s – MacColl Institute for Healthcare Innovation partners with Robert Wood Johnson Foundation, Chronic Care Model synthesized, refined. Published 1998 • 2000 – Dissemination • Breakthrough Series Collaboratives with the Bureau of Primary Health Care / IHI • 2001 – The Institute of Medicine issues report, “Crossing the Quality Chasm: A New Health System for the 21st Century”, chronic care model emphasized • 2002 – Future of Family Medicine Project • 2002 – WHO publishes “Innovative Care for Chronic Conditions: Building Blocks for Action”

12. Health Care Organization • Senior leaders visibly support improvement in chronic pain care • Organization's business plan includes measurable goals for chronic pain Delivery System Design • Define roles and delegate tasks amongst team members • Planned visits • Assure continuity and follow-up

13. Decision Support • Embed evidence-based guidelines into daily clinical practice • Use standardized assessments in evaluating chronic pain • Integrate specialist expertise into the care plans • Inform patients about guidelines pertinent to their care

14. Clinical Information Systems • A registry includes clinically useful and timely information on all patients • Registry can identify relevant patient subgroups for proactive care Community Resources and Policies • Identify effective programs in the community and encourage patients to participate • Understand the expectations of the Board of Medical Examiners, DEA

15. Self Management Support • Emphasize the patient's central role and responsibility in managing their illness • Recognize and validate the patient’s expertise in what they can and cannot do • Assess patient self-management knowledge, behaviors, confidence, and barriers • Collaborative goal setting • Provide effective behavior change interventions and ongoing support • Support healthy coping

16. Chronic Pain Affects All Aspects of a Patient’s Life • Functional Status • Physical functioning • Ability to perform activities of daily living • Work • Recreation • Psychological Morbidity • Depression • Anxiety, anger • Sleep disturbances • Loss of self-esteem Social Consequences • Marital/family relations • Intimacy/sexual activity • Social isolation Socioeconomic • Consequences • Healthcare costs • Disability • Lost workdays Used with the permission of Professional Postgraduate Services

17. The Chronic Care Model Community Health System Resources and Policies Health Care Organization ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes Used with permission from Wagner’s Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1998 (American College of Physicians)

18. How would I recognize a productive interaction? Prepared Practice Team Informed, Activated Patient Productive Interactions • Tailoring of clinical management by guidelines • Collaborative goal-setting and problem-solving • Shared care plan • Constant re-assessment • Active, sustained follow-up

19. When Chronic Pain is a Chronic Illness • Individualized, ongoing treatment and re-evaluation • Aim is to control, not cure • Psychosocial interplay (patient and provider) • Improvements and relapses • Frustrations

20. When Chronic Pain is a Chronic Illness • Individualized, ongoing treatment and re-evaluation • Aim is to control, not cure • Psychosocial interplay (patient and provider) • Improvements and relapses • Goal setting, with focus on function and quality of life

21. Self Management - components • Engaging in activities that promote physical and psychological health • Interacting with healthcare providers and adhering to treatment recommendations • Monitoring health status and making associated care decisions • Managing the impact of illness on physical, psychological, and social functioning

22. Self Management – tailoring to meet individual needs • Factors to target in a tailored, personalized, intervention • Education • Skill development • Medical/social support • Environmental modifications • Relationships with healthcare providers • Medication effects management • Lifestyle changes

23. Self Management – tailoring to meet individual needs • Patients often have several self-management needs – making prioritization and goal setting critical • Selecting wrong or too many targets lowered adherence • Long-term benefits may require ongoing collaborative relationship/process Bayliss, et al. Chronic Illness. 2007

24. Re-frame Self-Management Strategies Re-frame treatment as geared toward quality of life happy = pain free happy = sitting through kid’s baseball game

26. Self-Management Strategies Identify how pain interfereswith valued action legs hurt with standing cannot cook back aches with sitting cannot sit through kid’s baseball game hands hurt with typing cannot work

28. Self-Management Strategies Prioritize valued action working sitting through kid’s baseball game cooking

30. Self-Management Strategies make dinner M,W,F active spouse/ partner take pill at same time daily make b-fast T,R walk to mailbox M,W,F learn how to set alarm order groceries online Installation of hope in gradual improvement

32. Goal Setting – improves performance in 90% of studies • Goals affect performance by: • Directing attention • Mobilizing effort • Increasing persistence • Motivating strategy development • Goal setting improve performance when: • Goals are specific and challenging • Goals are attainable • Feedback and Rewards are provided • Manager is supportive • Goals are accepted by individual Locke et al. Psych Bull. 1981

33. Goal Setting in Chronic Pain Management • As part of collaborative multidisciplinary interventions, development of individualized functional goals has been associated with improved outcomes in at least 3 studies in patients with chronic pain • Improvements have been modest • National pain organizations and National Federation of State Medical Boards recommend development of individualized functional goals in the management plan of patients with chronic pain.

34. Goal-Setting Strategies Specific Measurable Aligned with values Realistic Target date for completion Scale importance & likelihood Problem-solve around barriers & follow-up

35. Goal-Setting Strategies Specific Measurable Aligned with values Realistic Target date for completion Scale importance & likelihood Problem-solve around barriers & follow-up

37. Goal-Setting Strategies Specific Measurable Aligned with values Realistic Target date for completion Scale importance & likelihood Problem-solve around barriers & follow-up

39. Goal-Setting Strategies Specific Measurable Aligned with values Realistic Target date for completion Scale importance & likelihood Problem-solve around barriers & follow-up

41. Goal-Setting Strategies • Specific Measurable Aligned with values Realistic Target date for completion • Scale importance & likelihood • Problem-solve around barriers & follow-up

43. Goal-Setting Strategies Specific Measurable Aligned with values Realistic Target date for completion Scale importance & likelihood Problem-solve around barriers & follow-up

45. Goal-Setting Strategies Specific Measurable Aligned with values Realistic Target date for completion Scale importance & likelihood Problem-solve around barriers & follow-up

47. References Affleck, G., Tennen, H., Urrows, S., Higgins, P., Abeles, M., Hall, C., Karoley, P., & Newton, C. (1998). Fibromyalgia and women’s pursuit of personal goals: a daily process analysis. Health Psychology, 17, 40-47. Bayliss EA, Bosworth PH, Noel JL, et al. Supporting self-management for patients with complex medical needs: recommendations of a working group. 2007.Chronic Illness; 3; 167-175. Dobscha, S.K., Corson, K., Perrin, N.A., Hanson, G.C., Leibowitz, R.Q., Doak, M.N., Dickinson, K.C., Sullivan, M.D., & Gerrity, M.S. (2009). Collaborative care for chronic pain in primary care. JAMA, 301, 1242-1252.

48. References Filoramo, M.A. (2007). Improving goal setting and goal attainment in patients with chronic noncancer pain. Pain Management Nursing, 8, 96-101. Hurn J, Kneebone I, Cropley M. Goal setting as an outcome measure: a systematic review. 2006. Clinical Rehabilitation. 20: 756-772. Locke EA, Shaw KN, Saari LM, and Latham GP. Goal setting and task performance:1969-1980. 1981. Psych Bull. 90(1): 125-152.

49. References Platt, F.W., & Gordon, G.H. (2004). Field guide to the difficult patient interview (2nd ed.). Philadelphia: Lippincott, Williams, & Wilkins. Rollnick, S., Miller, M.R., & Butler, C.C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: The Guilford Press. Von Korff M, Balderson BHK, Saunders K, et al. A trial of an activating intervention for chronic back pain in primary care and physical therapy settings. 2005. Pain. 113:323-330.