Adolf Meyer Chronic Pain Treatment Program

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Adolf Meyer Chronic Pain Treatment Program

• Michael R. Clark, M.D., M.P.H.
• Associate Professor Director
• Department of Psychiatry Behavioral Sciences
• The Johns Hopkins Medical Institutions

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The Model
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Adolf Meyer

• I should like to see a clinic give one half of
  its beds to intensive work on a limited district
  and bestow the other half on intensive work on
  special clinical problems
• 1913

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Donlin M. Long

• The three principles of The Johns Hopkins
  Program are 1) accurate physical diagnosis, 2)
  accurate and comprehensive psychiatric and
  psychosocial evaluation, and 3) individualization
  of therapy in an eclectic mode.
• 1981

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Paul R. McHugh

• Medical errors of oversimplification and
  misplaced emphasis usually play themselves out
  for all to see. Psychiatric misdirections often
  share this intimidating mixture of a medical
  mistake lashed to a trendy idea.
• 1992

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Pain Treatment Program

• A patient-centered, systematic, organized, and
  rational approach for restoring the benefits of
  health and alleviating the consequences of
  sickness for patients with chronic pain
• A service dedicated to rehabilitation
• Restorative model (not curative)
• Active role for the patient (not passive)
• Function and independence (not comfort)

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Mission

• Restore Freedom Excellent Care
• Advance the Field Scholarly Work
• Educate Society Patient Advocacy

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Essential Elements

• Individualized evaluation
• Formulation-based treatments
• Participation in the structured program

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Conventional Medical Framework

• Pathogenesis initial tissue damage
• Pathophysiology changes in function
• Pathology loss of capacity
• Sickness inability to meet demands
• Illness Behavior actions of sickness/suffering

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Perspectives of Psychiatry

• Diseases abnormal structure or function
• Dimensions inherent trait vulnerabilities
• Behaviors problematic goal directed acts
• Life Stories interpretations of failure

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The Program
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Components of the System

• Inpatient Unit
• 8 inpatient psychiatry beds
• Psychiatry nursing
• PGY-II resident, Anesthesiology fellow, RN, OT,
  PT, SW
• Expense-based hospital budget
• Day Hospital
• 8 patients per day (M-F)
• Unstaffed domiciliary apartments on campus
• Staffing budget based on volume

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Components of the System

• Consultation Clinic
• 5 New patients per week
• PGY-IV resident, Psychiatry fellow, NP
• Referrals to inpatient unit and day hospital
• Recommendations to treating physicians
• Follow-Up Clinic
• 100 patients with monthly appointments
• Psychopharmacology
• Cognitive-behavioral therapy

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Components of the System

• Residential Unit (proposed)
• Co-morbid chronic pain and SUD
• 24/7 professional staffing
• Day-night billing rate in regulated space
• Pro-fee billing vs. subcontracting ?
• Interdisciplinary team
• Psychiatrist
• Psychologist
• RN, OT, PT, SW, Counselors
• Joint venture with SUD treatment program

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Admission Criteria

• Screening of records
• Medically stable
• Agrees to be admitted
• Someone pays the bill
• Reputational niche
• Psychopharmacology
• Psychiatric comorbity
• Refractory chronic pain
• Medically complicated

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Admissions Coordinator

• Referrals per month 60
• Waiting list 30
• Average LOS 20 days
• Occupancy gt90
• Discharges per year 150

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PTP Demographics

• Age 44.9 (12.5)
• Education 12.8 (2.5)
• Female 66.7
• Caucasian 85.7
• Marital Status
• Married 54.3
• Single 28.6
• Divorced 14.3
• Surgeries 3.1 (4.1)

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PTP Inpatient Revenues

• Average charge per day 1500
• Average annual charges 4M
• Average monthly pro-fees 30K
• Balanced payer mix (PI, MC, WC)
• Maryland is a single payer state
• Profitable net variable margin percent

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The Outcome
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Paradigm Shift

• The primary goal of people in chronic pain is to
  seek comfort in order to avoid distress (find
  relief)
• The primary goal of treatment on the PTP is to
  persuade these people to stop being disabled
  (change)

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Pitfalls in Rehabilitation

• Getting angry at the patients
• Defending the staff and program
• Being inconsistent or lacking persistence
• Doing the patients work
• Failing to provide any rationale

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Promoting Rehabilitation

• Predictable world
• Avoiding distractions
• Gaining experience
• Learning from mistakes
• Thinking independently
• Focusing on a goal

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Patient Beliefs

• Nothing can be done 21
• Not sure what to do 15
• Ready to learn to manage 29
• Actively begun to manage 32
• Sure about ability to change 3

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Stages of Change
Admission
Discharge

• Maintenance 3.7 3.9 ? plt0.0001
• Action 3.4 3.8 ? plt0.0001
• Contemplation 3.2 3.9 ? plt0.0001
• Pre-contemplation 2.8 2.3 ? plt0.0001

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Pain Intensity-Current
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Pain Intensity-Current
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Coping Strategies
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PTP Outcome at 9 Months
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PTP Outcome at 9 Months
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PTP Outcome at 9 Months
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PTP Outcome at 9 Months
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PTP outcomes at follow-up
r 0.436 p 0.014
Depression (BDI)
r 0.573 p lt 0.0001
r 0.500 p 0.001
Healthcare Utilization
Interference (MPI)
Pain severity (MPI)
r 0.842 p lt 0.0001
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Conclusions

• The Interdisciplinary Pain Treatment Center in
  the Department of Psychiatry benefits patients
  with chronic pain
• The patients most likely to improve are those
  with the most complicated cases
• Long term follow-up after discharge is needed to
  refine the individualized formulation of patients
  and optimize their outcomes

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Conclusions

• Whats not in the data ?
• Intangibles!
• In other wordsreal value
• Indirect revenues
• Miracle cures
• Citizenship
• Reputation
• Mission