Integrated Models of Care: Pain Management Robert D. Kerns

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Integrated Models of CarePain Management

• Robert D. Kerns, PhD
• National Program Director for Pain Management,
  VACO
• Chief, Psychology Service, VA Connecticut
• Professor of Psychiatry, Neurology and
  Psychology, Yale University

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Integrative care
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Psychology, psychologists, and pain management

• Primary models of pain perception emphasize the
  central role of psychological factors
• Role of psychological factors in the development
  and perpetuation of persistent pain is
  universally accepted
• Psychological interventions for pain management
  are accepted as efficacious and cost-effective
• Approximately 20 of members of IASP and APS are
  psychologists
• Current president of APS is Dennis Turk, a
  psychologist
• Goal of VHA National Pain Management Strategy is
  to incorporate an interdisciplinary, multimodal
  approach to pain management

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Efficacy of psychological interventions for
chronic pain

• Meta-analysis of RCTs of psychological treatments
  for clbp
• Effect sizes were calculated from 22 RCTs
• Positive effects of psychological interventions,
  relative to numerous control conditions, were
  noted for pain intensity, interference, quality
  of life, and depression
• Cognitive-behavioral and self-regulatory
  treatments were found to be efficacious
• Multidisciplinary treatments that included
  psychological interventions had positive
  long-term effects on return to work

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Integrative model of pain care

• Stepped care approach to pain management
• Level one Primary responsibility rests with
  primary care providers
• Level two Living with Pain Class
• Patient education and rehabilitation model
• Review of common pain conditions
• Personal review of medications
• Discussion of self-management model
• Personalized exercise plan
• Practice of self-regulatory pain strategies,
  e.g., breathing, relaxation, activity pacing
• Level three Comprehensive Pain Management
  Center

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Comprehensive Pain Management Center at VA
Connecticut

• Integrative clinical, research, and training
  program
• Interdisciplinary staff
• Virtual Clinic
• Primary Care Clinic integration
• Primary roles of psychologists
• Conduct comprehensive pain assessments
• Development and enactment of integrative
  treatment plan
• Care coordination
• Primary clinician in delivery of psychological
  treatment
• Assessment of outcomes
• Education and training
• Research

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Targets for improvement

• Improved access
• Successful engagement
• Reduced drop-out
• Enhanced adherence to treatment
  recommendations
• Maintenance of treatment gains
• Relapse prevention

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Ongoing research

• Targeting these areas for improvement
• Refine CBT to promote engagement, adherence, and
  outcomes
• Refine CBT for special populations
• Elderly
• Women with vulvodynia
• Painful diabetic neuropathy
• MS-related pain
• Investigate treatment process variables
• Readiness for self-management of pain

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Refining processes of referral and engagement

• Education/Training of primary care providers
• Knowledge and attitudes about self-management
  treatments
• Patient-centered counseling/Use of motivational
  interviewing techniques
• Respond to patient concerns and beliefs that are
  incongruent with adoption of a self-management
  approach
• Endorse self-management treatment and goals
• Assure follow-up and continued coordination of
  care

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Training primary care providers

• Brief educational session
• Relevance of self-management and rehabilitation
  approaches
• Overview of multidisciplinary pain center
• Review of pathway for referral
• Group training followed by individual
  consultation
• Use of modeling (video) VIDEO_TS.IFO

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PRIME-CBT

• Based in a primary care setting
• Collaboration with primary care practitioner
  (PCP)
• Explication of referral process
• PCP education and training
• Modifications to CBT

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Refining self-management treatment

• Collaborative sessions involving primary care
  provider
• Explicit attention to readiness to adopt a
  self-management approach
• Use of stage-matched tasks and processes of
  change (e.g., consciousness raising with
  precontemplators, increasing support for
  strivers)
• Use of motivational interviewing strategies
  (expressing empathy, developing discrepancy,
  rolling with resistance, and supporting
  self-efficacy)

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Results of PRIME CBT study

• Both CBT (n33) and PRIME CBT (n33), relative to
  TAU (n23), demonstrated significantly greater
  improvements on measures of pain, disability, and
  emotional distress
• PRIME CBT, relative to CBT, resulted in
• significantly increased adherence to weekly
  homework
• and goals
• significantly greater goal accomplishment
• significantly greater patient satisfaction
• Mean percent intersession adherence for PRIME CBT
  was approximately 70

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Tailored CBT

• CBT as inherently flexible approach that
  accommodates to prescriptive treatment planning
• Assess patient preferences for learning specific
  pain coping skills
• Tailor CBT on the basis of patient preferences
• Employ motivational interviewing techniques to
  encourage forward stage movement or enhanced
  readiness to adopt specific pain coping skills