Provider Education for VA Chronic Pain Management

Introduction

Today, the Department of Veterans Affairs (VA) is the largest healthcare provider in the United States and one of the largest in the world. In fact, fully half of the physicians in the United States receive their training at a VA healthcare facility. This paper provides a description and explanation of the complex healthcare system to provide a framework for enhancing VA medical support staff knowledge of chronic pain management via a monthly "pain management" newsletter designed to improve pain management outcomes for veterans.

In addition, an examination of the various levels of the interprofessional team required for the optimal operation of the multidisciplinary pain management delivery system is presented, along with supporting rationale for each level. This is followed by a discussion of the core abilities required for each team member, including suggestions for role responsibilities. Finally, factors that may positively or negatively impact the delivery of provider and nursing care are identified, along with an assessment of how they will be addressed.

Interprofessional Team Structure and Rationale

Because pain is a complex phenomenon that is highly subjective in nature, effective treatment requires a holistic approach that takes into account a wide range of factors that may contribute to or exacerbate the pain process. There is a general consensus that an interdisciplinary team approach is most effective for achieving optimal pain management outcomes (Woods, 2011). In this regard, Woods emphasizes that "interdisciplinary teams have been shown to improve patient care in complex clinical situations and also to deliver the best possible treatment to this challenging population" (2011, p. 15). The rationale for including additional healthcare professionals as part of an interdisciplinary pain management team is based on the premise that a single physician, irrespective of training and experience level, is unable to address all of the complex individualized needs of patients suffering from chronic pain (Woods, 2011). As Woods concludes, "The addition of a team of specialists partnering together in the best interest of the patient brings a more comprehensive treatment approach" (2011, p. 15).

Based on the recommendations provided by Clark and Norton (2009) for optimal interdisciplinary pain management teams, the core interprofessional team members needed for this initiative will include the following:

One full-time equivalent (FTE) pain psychologist: This physician will serve as the coordinator of the pain management training program and will be responsible for initiating and formulating interdisciplinary, transdisciplinary, and interprofessional practice.

One FTE pain RN: This healthcare professional will serve as the nurse educator, provide support, and be responsible for quality improvement.

Pain specialists in each discipline of the chronic pain rehabilitation program (CPRP) who will volunteer time to help educate training participants.

In addition, a dietitian, recreational therapist, social worker, and other specialists may be valuable additions to the pain management treatment team depending on the unique needs of the patient (Clark & Norton, 2009). Likewise, Kubotera and Fudin (2013) recommend that interdisciplinary pain management teams should also include a pharmacist. The addition of a pharmacist to the multidisciplinary pain management team is based on the rationale that "pain and related symptom management often involves complex polypharmacy, a keen understanding of pharmacotherapeutics across several drug classes, and collaboration with other healthcare disciplines" (Kubotera & Fudin, 2013, p. 37).

The full range of disciplines that may contribute to a chronic pain team includes medicine, psychology, psychiatry, occupational therapy, physical therapy, pharmacy, nursing, recreation therapy, social work, dietetics, pool therapy, and vocational rehabilitation. Although each patient's pain management requirements will be unique, the interdisciplinary pain management treatment team can generally facilitate the following:

Working toward a common goal; making collective therapeutic decisions; communicating and consulting with other team members in face-to-face meetings; possessing a combination of skills that no single individual demonstrates; and achieving more together than what individuals could achieve alone (Woods, 2011, p. 15).

VA Stepped-Care Pain Management Model

Beyond the foregoing team members, the VA's current National Pain Management Strategy also mandates "a comprehensive, multicultural, integrated, system-wide approach to pain management that reduces pain and suffering and improves quality of life for Veterans experiencing acute and chronic pain associated with a wide range of injuries and illnesses, including terminal illness" (VHA directive 2009-053, 2009, p. 1). For this purpose, the VA employs a stepped-care pain management model set forth in VHA directive 2009-053 (2009), described below.

Step One: Primary Care. Stepped care is instituted as a strategy to provide a continuum of effective treatment to a population of patients — from acute pain caused by injuries or diseases to longitudinal management of chronic pain conditions that may be expected to persist for more than 90 days, and in some instances, the patient's lifetime. This step requires the development of a competent primary care provider workforce (including behavioral health) to manage common pain conditions. To accomplish this, primary care requires the availability of system supports, family and patient education programs, collaboration with integrative mental health and primary care teams, and post-deployment programs.

Step Two: Secondary Consultation. This step requires timely access to specialty consultation in pain medicine, physical medicine and rehabilitation, polytrauma programs and teams, and pain psychology; occasional short-term co-management; inpatient pain medicine consultation; and the collaboration of pain medicine and palliative care teams.

Step Three: Tertiary, Interdisciplinary Care. This step requires advanced pain medicine diagnostics and pain rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).

The VA's stepped-care pain management model in primary care settings is supplemented by referrals to secondary resources including pain medicine, behavioral health, physical medicine and rehabilitation, specialty consultation, coordination with palliative care, tertiary care, advanced diagnostic and medical management, and rehabilitation services for complex cases involving comorbidities such as mental health disorders and traumatic brain injury (TBI) (VHA directive 2009-053, 2009, p. 1).

The VHA directive 2009-053 stipulates that the responsibilities for each pain management team member will be assigned by each regional VA office. The relationship among these interdisciplinary team members is depicted in Figure 1 (Clark & Norton, 2009, p. 7).

Conclusion

Many healthcare providers from all disciplines remain woefully unprepared to provide effective and responsive pain management care because of a fundamental lack of knowledge about pain. According to Boschert (2009), a survey of healthcare practitioners typically included on a pain management team — including physicians, nurses, and pharmacists — revealed several significant gaps and inadequacies: (a) many healthcare providers do not believe that pain is real in patients who report it, and a lack of knowledge about the appropriate use of opioids likely results in undertreatment of pain; (b) healthcare workers, despite their training, allow bias to influence how they address patients' needs; and (c) one of the main challenges is getting staff to be more accepting of what patients tell them. The most reliable indicator that a person has pain is their verbally expressing that they have pain (Boschert, 2009, p. 82).

Therefore, healthcare providers in general, and those assigned to pain management teams in particular, must be educated concerning appropriate pain management practices (Boschert, 2009). In sum, a monthly pain management newsletter represents a valuable tool for this purpose, as well as a means of keeping the need for effective pain management practices fresh in the minds of VA staff.

References

Boschert, S. (2009, February). Many health workers need to bone up on pain management. Clinical Psychiatry News, 32(2), 82.

Clark, M. E., & Norton, C. (2009). Interdisciplinary pain team training program. Tampa: Chronic Rehabilitation Program.

Gebhart, F. (2009, November). JCAHO to release more pain management measures. Drug Topics, 146(21), 41–44.

Gibbs, L. (2007, Summer). Identifying work as a barrier to men's access to chronic illness (arthritis) self-management programs. International Journal of Men's Health, 6(2), 143.

Kubotera, N., & Fudin, J. (2013, April). Pain management for pharmacists: Concepts and definitions. Drug Topics, 157(4), 36–39.

Turk, D. C., & Gatchel, R. J. (2002). Psychological approaches to pain management: A practitioner's handbook. New York: Guilford Press.

VHA directive 2009-053. (2009). Department of Veterans Affairs. Retrieved from http://www.va.gov/painmanagement/docs/vha09paindirective.pdf

Woods, B. (2011, January–February). A comprehensive approach to pain management: A team of professionals can successfully address any and all comorbidities. Addiction Professional, 9(1), 14–19.