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 Cynthia Townsend, PhD Staff Psychologist W. Michael Hooten, MD Medical Director Barbara Bruce, PhD, ABPP Clinical Director Jeffrey Rome, MD Former Medical Director Jaxon Hodgson, MA Program Coordinator Connie Luedtke, RN, MA Nurse Manager

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-basedtreatment with daily PT and OT • Open group (rolling admission) • Treatment goals: functional restoration and opioid withdrawal

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

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

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

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)

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%)

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%

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

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)

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)

16. 6. Frequent Administrative Meetings • Dedicated consultants (MD, PhDs, MA, RN) • Offices physically close • Weekly meetings and monthly financial reports • Flexibility is key

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

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

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