The Centre for Active Lifestyle Management (CALM)

1
The Centre for Active Lifestyle Management (CALM)

• Dr Stephanie Jarrett
• Consultant Clinical Psychologist
• Pain Management Unit
• University Hospital Lewisham

2
Setting the scene

• Chronic pain - British Pain Society definition
• continuous, long-term pain of more than 12 weeks
  or after the time that healing would have been
  thought to have occurred after trauma or surgery
• Diagnoses
• Osteoarthritis
• Degenerative changes/disease
• Spondylosis
• Wear and Tear
• Complex Regional Pain Syndrome
• Fibromyalgia
• Chronic widespread pain

3
Setting the scene

• People living with chronic pain 7.8 million
• Prescriptions for pain 584 million
• The cost to the NHS of chronic (long-term) back
  pain alone is estimated to be 12.3bn per year
• The management of chronic pain in primary care
  accounts for 4.6 million GP appointments, costing
  around 69 million per year
• Patients with chronic pain experiencing
  depression 49

4
Setting the scene
Comprehensive, multi-disciplinary group programme
is the most efficacious and cost-effective
treatment for patients with chronic pain
(Gatchel Okufuji, 2006 Guzmán et al
2001) Multidisciplinary group pain management
programmes (PMPs) are recommended for patients
with chronic non-malignant pain by The British
Pain Society European Guidelines The
International Association for the Study of
Pain Report by Dr Foster (2003) identified the
patchy provision of PMPs in the UK.
5
Lack of PMPs in South-East London
Northwick Park
National
Hillingdon
Ealing
INPUT
Chelsea
Wolfson
Kingston
COPE
Epsom
6
Lack of PMPs in South-East London
National
Northwick Park
Hillingdon
National
Ealing
Hillingdon
INPUT
Ealing
Chelsea
INPUT
Chelsea
15k Diameter
CALM
Wolfson
Kingston
Wolfson
20k diameter
Kingston
COPE
COPE
Epsom
7
Past

• 2001 Recruitment of Clinical Psychologist to
  Chronic Pain Service, University Hospital
  Lewisham
• 2002 Pilot Programme
• 2004 1st Business plan put forward
• 2009 Obtained 12 month funding
• 2010 6 month extension
• 2011 12 month extension until March 2012
• 2012 Mainstream funding

8
Present

• The CALM team
• Consultant Clinical Psychologist
• Clinical Physiotherapist Specialist
• Pain Nurse Specialist
• Psychology Assistant
• Administrator
• All 0.4 wte

9
The CALM Programme

• The CALM programme aims to help patients
• Develop strategies to reduce the distress
  disability caused by pain
• Decrease reliance on medical professionals
• Improve quality of life

10
Referral

• Referrers - secondary care pain related services
• Chronic Pain service
• Rheumatology
• Orthopaedics
• Musculoskeletal assessment and triage (MSK)
  service
• Physiotherapy
• Referral process
• Check patient is registered with Lewisham GP
• Check patient eligible for CALM programme
• No ongoing litigation
• No ongoing medical intervention (other than
  medication)
• No ongoing investigations
• No active psychosis
• Discuss referral with patient
• If patient in agreement send referral letter to
  CALM team
• Discharge patient to care of CALM team

11
Referral letter received
Programme suitable - offered place
Patient phones to arrange individual assessment
Patient phones to arrange date for group
information meeting
Attends group information meeting. Invited to
contact CALM team to arrange date for individual
assessment
Seen individually by psychologist,
physiotherapist nurse for assessment
Patient sent letter inviting them to phone and
arrange a date to attend a group information
meeting about the CALM programme
DNA group information meeting
DNA assessment
Programme not suitable referred to more
appropriate service
No contact to arrange assessment appointment
within 28 days
No contact from patient within28 days
Discharged inform referrer and GP
12
Weekly group sessions for 10 weeks
6 months later Second follow-up group session
Assessment offered place on programme
6 weeks later First follow-up group session
Open invitation to yearly booster session
13
Outcome Data Quality of Life

• Distress
• Depression (Beck Depression Inventory II)
• Catastrophising (Pain Catastrophising Scale)
• Fear of movement (Tampa Scale of Kinesiophobia)
• Disability
• Sit-to-stand (number per minute)
• Pain interference (British Pain Inventory)
• 96 patients reached 6 months follow-up
• Complete data available for 90 patients
• Bonferronis correction for multiple analyses
  plt0.008

14
Outcome Data Quality of Life
N 90 Patients who had completed programme and returned questionnaires Statistically significant improvement by end of 10 week programme Statistically significant improvement at 6 month follow-up
Distress p .008 p .008
Depression (BDI II) Yes Yes
Catastrophising (PCS) Yes Yes
Fear of movement (TSK) Yes Yes
Disability
Sit-to-stand (No. per minute) Yes Yes
Pain interference (BPI) Yes Yes
15
Outcome Data Health Care Use

• Computerised appointment system
• Secondary care pain-related appointments
• Physiotherapy appointment s
• Contacted GPs to get data on primary care
  pain-related appointments

16
Outcome Data Health Care Use
Total number of appts (N55 patients who finished programme gt1 year ago) 12 months pre-programme 12 months post-programme Reduction
Secondary Care Pain Appointments 142 13 91
Physiotherapy Appointments 206 20 90
NHS Lewisham Target 80
Primary Care Pain-Related Appointments (N25) 156 66 58
17
Outcome Data Health Care Costs

• Clinical coding department to get accurate costs
  for
• Secondary care pain-related outpatient
  appointments
• Physiotherapy appointments
• Interventions (e.g. Epidural, trigger point
  injection etc.)

18
Outcome Data Health Care Costs
Cost of appointments (N55 patients who completed the programme gt1 year ago) 12 months pre-programme 12 months post-programme Reduction
Secondary Care Pain appointments 21,115.46 2,328.20 89
Physiotherapy appointments 14,584.80 1,122.60 92
Secondary Care Pain Related Interventions 12,178.39 2,989.27 75
19
Happily Ever After?

• Pilot phase ended and taken into mainstream
  funding in April 2012
• But...
• Trust Special Administrators draft report
  Securing Sustainable NHS Services -
  Consultation on the future of South London
  Healthcare NHS Trust and the NHS in South East
  London (November 2012)

20
Thank you

• The CALM Team
• Sarah MacNeil Clinical Physiotherapy Specialist
• Tamzin Bunton Pain Nurse Specialist
• Ajay Clare Psychology Assistant
• Reuben Richards Administrator
• Lewisham support
• Dr Tom Smith Consultant in Pain Management
• Ashley OShaughnessy Head of PBC and Services
  Redesign, NHS Lewisham
• Lewisham Practice Based Commissioners
• Hilary Rankin, Consultant Clinical Psychologist
  and her team at COPE, Sutton Hospital
• INPUT