Pain Management Innovations in the Primary Care Medical Home

Pain Management Innovations in the Primary Care Medical Home Ilene R. Robeck, MD

Faculty and Disclosures  Sondra M. Adkinson, PharmD, DAAPM, CPE – Nothing to Disclose

 Jeremiah C. McKelvey, PharmD – Nothing to Disclose

 Ilene R. Robeck, MD – Nothing to Disclose

 Robert S. Sproul, PharmD – Nothing to Disclose

Learning Objectives Describe the use of the pain school to improve patient education and safety Recognize how primary care-based pain teams improve access to a comprehensive approach to pain in the primary care setting Describe use of electronic consulting for provider to provider consultation and education

E-Consult: INNOVATIONS IN CONSULT MANAGEMENT

Robert S. Sproul, PharmD

VHA Innovations In Clinical Services Support Our Veterans and Their Providers

E-Consult Background  Access to specialty care from outlying and rural locations is challenging for Veterans and their primary care providers  Non Face-To- Face – E-Consults provide specialty consultation without face-to-face contact by the Veteran with the specialist

 Different way of delivering health care – Improve coordination of care for veterans – Increase collaboration between specialist and referring providers

E-Consult Pain Management

PCP

Bridging the Gap  OVAMC E-Consult Pain Management One of “Many” Formats

E-Consult PM Primary Care Daily PM Issues, Support

Specialty Care Pain Clinics Management Services

OVAMC E-Consult PM

E-Consult PM Fundamental Goals  This service can answer many “seemingly” routine but important questions/issues that often burden our PCPs  Many issues do not necessarily need to be shunted to a Specialty Pain Clinic  Provides “easy access” for the consulting provider – “Easy Access” equates with “Timely Support?”

– Paramount for addressing patient safety issues

 Typical concerns addressed by the E-Consult Pain – Opioid related

• Titration, rotation, conversions, tapering • Alternative treatment modalities

– Urine Drug Screen

• Interpretation, policy, provider recourse • Associate opioid tapering and ethical considerations

OVAMC E-Consult PM Limitations – No intent to replace existing Specialty Pain Clinic (SPC) services • SPC which “temporarily managed” until stable and then discharged back to the PCPs

– Conversely, the E-C Pain service does not manage but rather provide a one time evaluation – However, a provider may continue to follow up with additional consults as appropriate – E-consult team representative(s) will document the recommendations in CPRS – However, it is at the discretion of the consulting provider to accept and implement the team’s recommendations

Innovations in Consult (ICM)

Project Coordinator Pain Pharmacist

CPRS Provider E-Consult (Countable/non-Billable Clinic)

E-Consult

CPRS Review/Documented Recommendations

Provider Education Week Teleconference

Pain Pharmacist: Initial Responder Triage Based on Level of Complexity (LOC)

L1 Pharmacotherapy concerns L2 Pharmcotherapy /MH Comorbity Concerns a. Multidisciplianary L3 Complex Comorbitity/High Risk Patients: Teleconferencing a. Interdisciplinary VHAORL E-Consult Pain Management Outlook Provider Non-CPRS Follow up Contact Option

Triage Chart Review

MH Screen

Pain Psychologist +Screen-Comorbitity L2

CPRS Clinical Review Progress Notes

Primary Responder-Pharmacist

Pain Pharmacist 1.0 FTE Pain Psychologist % FTE Pain Physician % FTE

Outcomes Quarterly/Annual Data Pain Psychologist

Recommendations/Documentation What’s In A Name?  Intent – Is not to “paint a provider into a corner” – Is to provide guidance for / with options to the provider  Wording – How a recommendation is “worded” is crucial • Stipulates the recourse the Pain Service would take • Offers alternative to the Clinic’s stance (opinion) – Acknowledges provider's discretion

 Example – For the following patient safety issues detailed above a.b.c., the Pain Clinic would no longer prescribe opioids for this pt at this time – However, should the provider determine opioids will be continued, then the Pain Clinic would recommend the following • Frequent UDS • No more than a seven day supply, etc

VISN 8 E-Consult PM Provider Education  VISN 8 E-Consult

– Chronic Pain Audio Conference

 Weekly Case-Base Provider Education (CME) – Moderate to High Risk Patients – Complex patients with Comobitity

 Supporting didactics  Provides an Interdisciplinary Forum – Explore alternatives – Discuss controversies – Provider recommendations

Hidden Treasures Transcending the Routine E-Response Typical consults –Often directly address important daily issues, such as urine drug screens, opioids, and associated concerns

However, provider support is not limited to "treatment modalities" alone –May directly assist the provider in resolving difficult scenarios • Patient treatment and or ethically related issues • Assist in coordination of care

E-Case Study Ethical Considerations  Reason for Consult

– Terminally ill cancer patient – In the ambulatory care setting – Non-End of Life Scenario – On significant amount of opioids – Test positive for cannabis / alcohol

 Provider's Comments  "I'm concerned that the patient is going to overdose or hurt someone else”  “Is a second chance reasonable, or must I discontinue the opioids”  “I don’t want to cut the opioids”  “I know he’s in a lot of pain”  “What should I do”

E-Hidden Treasures PCP Doesn’t Have to Walk the Walk Alone  Ultimately it will be the provider's discretion that determines the recourse which will be taken  However, the provider can reach out to a "team" for support and or advice – Options with the supporting details – To address a controversial pain / ethical issue

 Means to avoid the unilateral decision process – An uncomfortable situation for many providers – Due to perceived scrutiny

• From oneself or from others • Laced in the form of legal, ethical, moral considerations/implications

VHA Pain Management Support of and Care for our Veterans

To All of Our Veterans Who Have Sacrificed

THANK YOU FOR YOUR SERVICE

(Roger-That)