Foundations of Interprofessional Collaborative Practice - Mikes Journey

“Mike’s Journey” From Chronic Non-Cancer Pain to Interprofessional Chronic Pain Management at Shirley Ryan Ability Lab’s Pain Management Center MHA Case Prep Version, Spring 2020

Author: Frank Borgers, Chair, University of Illinois at Chicago, Pre-Licensure Curriculum Workgroup, April 20201 1

Note: This case was developed by the authors by adapting “Interprofessional Team-Based Learning Module: Chronic Non-Cancer Pain,” Steven Bishop, MD, Rachel Waller, MD, Brigitte Sicat, PharmD, Laura Morgan, PharmD, MEd, Bennett Lee, MD, June 3, 2015, 10.15766/mep_2374-8265.10112, accessed via MedEd Portal, January 20, 2019.

Mike’s Journey - Introduction: Mike Thompson is 65 years old. Mike worked for 30 years as a teacher, after working for 10 years in construction. He is married, and has 3 children, two sons aged 40 and, 38, and a 33 year old daughter, as well as three grandkids, a ten-year old grandson, and two grand-daughters, aged seven and four. While Mike has suffered lower back pain for much of his adult life, three years ago, things took a serious turn for the worse. Note: For a timeline of Mike’s Journey, see Appendix I: Case Timeline.

The Accident: While Mike Thompson has suffered lower back pain for much of his adult life, three years ago, things took a serious turn for the worse. It was a beautiful Sunday toward the end of March, and Mike was working on cleaning up and prepping his beloved yard, a passion he developed while in his forties. Mike was lifting a wheelbarrow full of debris when he felt a sudden and severe pain flare in his lower back. His left leg gave way, causing him to fall and to hit the left side of his jaw on a low brick wall, hard. After the accident Mike’s lower back pain subsided a little, but remained at a level that was much more severe than any time prior to his accident. Mike was now also experiencing pain in his jaw.

Mike Starts his Journey: A couple of days later, after visiting his long time primary care physician, Phil Smith, MD Mike was prescribed over-the-counter pain medications. These did little to relieve Mike’s lower back pain, which gradually worsened. His PCP then ordered imaging tests that revealed Mike had a herniated disk and he was referred to a surgery practice, MD Khan & associates that specialized in back injuries. Based on the MRI results MD Khan & associates recommended, and a few weeks later performed a lumbar discectomy. At that time Mike was still working and he was fully insured through his job as a teacher in the Chicago Public School system.

While Mike’s surgery appeared to be successful, he did not adhere to the follow up physical therapy recommended by his surgeon, in part because he was still experiencing significant pain a month after surgery. Six months later Mike was now experiencing increasing burning pain in his leg that radiated all the way down his legs as far as his calves. The pain was especially bad in his left leg. Mike’s surgeon at Khan & associates recommended a follow up MRI. However, the MRI results did not reveal spinal damage that would be amenable to further surgery.

Increasingly desperate, and feeling that neither Dr. Smith nor Khan & associates were properly responsive or seemingly able to help him, Mike sought help sporadically from different clinics and doctors over the next two years, including a psychiatrist for anxiety and depression. But, none of these visits consistently improved his lower back pain, which worsened to the point where it became debilitating, while Mike slowly sank deeper into depression and accumulated other medical conditions.

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Despite taking Percocet 5/325mg every four hours daily, Mike reports that his lower back pain is consistently at an “8 out of 10” level. Moreover, since the prescribed medication is expensive and sometimes not available to him, he has also been taking ibuprofen over-the counter. When the pain really flares, it has been so bad that Mike has checked himself in to his local ER where he has received short term prescriptions for stronger opioid pain medications.

Mike’s sleep is badly disrupted at night because of the pain, Mike suspects that his lack of sleep and his increased anxiety is causing him to grind his teeth at night, which in turn is exacerbating the pain in his jaw that never really subsided after his fall three years ago, but which seemed secondary to getting his back pain treated and for which he never sought treatment.

Mike is no longer able to participate in any of the activities he has enjoyed so much over the last few decades. His beloved yard work is out of the question. Fishing, another favorite pasttime, that also allowed him to spend highly valued time with his oldest son and grandson, has become painful to the point where he has stopped accepting invitations from his son to go fishing in Wisconsin. Mike’s reduced ability to actively play with his grand-daughters, who are very energetic and physical, as well as his slowly worsening mental state, has lessened his grand-daughters’ desire to spend time at Mike and Evelyn’s house, something that is deeply painful for Mike, but difficult for him to openly express to his daughter and wife.

Mike’s wife, Evelyn, has “taken over” many of the household chores he used to do, while their yard has fallen into disrepair, further adding to Mike’s sense of powerlessness and loss of value as a husband. Again, while these developments are very painful to him, Mike is unable to openly express his feelings to his wife.

Mike Visits Evergreen Clinic: Two months ago, Mike and Evelyn visited a branch of a new Medicare Advantage primary care clinic chain, Evergreen Health. A family friend had enthusiastically recommended Evergreen over six months ago. However, Mike had had no interest in trying yet another provider. After seeing countless PCPs and specialists over the last three years Mike had become deeply skeptical that anyone could help him in his slow but seemingly inevitable physical and mental decline.

However, on a Saturday, two and a half months ago, Mike and Evelyn had a serious blow-up after Mike, once again, cancelled the couple’s plans to visit with their granddaughters, because he “wasn’t feeling up to it and wanted to spend the day watching re-runs in their bedroom.”

Mike’s wife, alarmed and angry at his retreat from everything he loves, and her loss of the husband she had known and loved all her adult life, had snapped. “Enough is enough… like it or not, we are going to try this new clinic” and, the following Monday Evelyn had called Evergreen and booked Mike’s appointment.

The Evergreen clinic has a great staff, is welcoming, and Mike and Evelyn really like the physician they are scheduled with, Dr. Samari Patel. Dr. Patel spends a solid hour talking to Mike and Evelyn, reviews the fragmented medical history documents Mike brought to the visit, and runs an array of labs. Two weeks later Mike and Evelyn are back at Evergreen to review the lab results and discuss next steps. After reviewing Mike’s labs Dr. Patel has paused and said…

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“Mike and Evelyn I am so glad you came in to see us. After talking to you and reviewing Mike’s labs, I have to say I am concerned. While none of your conditions, in and of themselves, could be considered life threatening, looking at your medical history since your accident three years ago, it seems you have been on a downward journey that no one has been able to help you escape.

I am also very concerned about your current pain medication use. While I understand that you are in severe pain, and the medications you take are helping you with that pain, these are highly addictive medications that used long term can pose a health risk and that, left uncontrolled, could easily escalate to a very serious and life-threatening addiction. I also believe, like you, that all of your conditions are connected and that they all relate back to the injuries to your back and jaw that you sustained three years ago, and that have gradually worsened over all these years.

So, I want to propose you try a very different approach. While I would love to be your primary care giver, Evergreen unfortunately doesn’t have the full range of services that I think can truly help you. Luckily though, I know a place that does, a place that I think is perfectly suited to help you and Evelyn, it is called the Shirley Ryan Ability Lab. You probably know it as the Rehab Institute of Chicago.

Anyway, Shirley Ryan has this great clinic called the Pain Management Center. They treat all kinds of pain, most commonly lower back pain like yours, and they have a really unique approach to treatment that I think will not only help treat your pain but also many of your other conditions that are, as I said, linked to your pain. Can I set you up with a referral? I think you are really going to benefit from this and, believe it or not, there is a path away from your current pain that could help you get back to the things you and Evelyn love.”

Mike Makes it to Shirley Ryan Ability Lab’s Pain Management Center: Evelyn schedules Mike (our Standardized Patient) for an intake appointment at Shirley Ryan Ability Lab’s Pain Management Center (SRALab PMC). The intake appointment is a standard 90 minute evaluative discussion between the patient and the team psychologist and doctor. Here are the last five minutes of Mike’s visit where Dr. Margolis is trying to close the meeting and engage Mike in their 4-week Intensive Outpatient Pain Management Program (see Appendix II).

Click Here: Mike Makes it to Shirley Ryan AbilityLab’s Pain Management Center

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Interprofessional Collaborative Practice: One of the key anchoring concepts for interprofessional education (IPE) is the “IPEC Core Competencies”, which, as the term implies, describe broadly agreed to core competencies for IPE (in the United States). Figure 1 provides a high level logic model of the IPEC core competencies relative to patient and family, and community and population outcomes.

Figure 1. IPEC Core Competencies Logic Model2

The four IPEC core competencies are: Ø Competency 1: Work with individuals of other professions to maintain a climate of mutual respect and shared values. (Values/Ethics for Interprofessional Practice) Ø Competency 2: Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. (Roles/Responsibilities) Ø Competency 3: Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.

(Interprofessional Communication) Ø Competency 4: Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/populationcentered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. (Teams and Teamwork)

Each of these competencies has more granular sub-competencies. You are going to use a set of these sub-competencies to evaluate the extent and nature of interprofessional collaboration amongst the SRALab PMC clinical team and Mike.

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Source: Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.

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Mike's Case Reviewed by SRALab’s PMC Team: First we are going to watch the SRALab PMC team review Mike’s care plan at the end of week 1 of his program. For this video we want you to assess the extent of the interprofessional collaboration amongst the clinicians.

Click Here: Mike's Case Reviewed by SRALab’s PMC Team

Please complete worksheet 1 at the end of this case booklet Mike Makes Progress with SRALab’s PMC Team: Next, we are going to watch the SRALab PMC team meet with Mike at the end of his intensive four week program for his discharge meeting. For this video we want you to assess the extent of the interprofessional collaboration between the clinical team and Mike.

Click Here: Mike Makes Progress with SRALab’s PMC Team

Please complete worksheet 2 at the end of this case booklet

Next Steps: Please submit your worksheets to the course Blackboard site and have them available for the in-course group discussions.

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APPENDIX I: Case Timeline Mike’s Accident: Mike and Evelyn’s yard

Sunday, March 27, 2016

Mike visits PCP Phil Smith, MD

Friday, April 1 2016

First MRI Blue Sky Imaging - discover herniated disk Wednesday, April 13 2016 MD Khan & associates - lumbar discectomy:

Friday, May 6, 2016

Second MRI Blue Sky Imaging

Wednesday, November 7, 2016

Mike wanders, visits different providers

December 2016 to December 2018

Mike & Evelyn visit Evergreen Clinic

February 7, 2019

Mike Meets with SRAlab PMC MD (Video 1)

Monday, April 1, 2019

Mike Starts SRAlab 4 week program

Monday, April 8, 2019

SRAlab PMC Team Reviews Mike’s Care Plan (Video 2)

Friday, April 12, 2019

SRAlab PMC Week 4 Team Meeting with Mike (Video 3)

Friday, May 3, 2019

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APPENDIX II: SRAlab Pain Management Center Background GOALS: The Shirley Ryan Ability Lab Pain Management Center offers a supportive, motivating, and active care environment for individuals experiencing chronic pain. Pain is addressed in an interdisciplinary program format, with interventions designed to improve physical and emotional well-being. Common conditions that we address include chronic low back pain, chronic neck pain, complex regional pain syndrome (CRPS), fibromyalgia, neuropathy, radiculopathy, migraines, and other conditions leading to chronic pain. Our goal is to help individuals manage their own pain and improve their quality of life. Patients benefit from an interdisciplinary treatment program designed to: • • • • •

Develop long-term strategies for pain management, health maintenance and a balanced lifestyle Recover the ability to perform activities of daily living, occupational tasks and leisure pursuits Address the emotional and psychological consequences of coping with chronic pain Facilitate support from family to promote the patient’s continued participation in learned pain management strategies Maximize individual-based pharmacotherapy for pain management

THE PAIN MANAGEMENT PROGRAM: The program focuses on reintegrating patients into their usual family, social, vocational, and leisure activities. Patients will learn various relaxation techniques, coping skills, stress management skills, postural and body mechanics principles, and strengthening and stretching exercises that they can utilize for effective self-management of their pain. Vocational rehabilitation will help provide tools for a successful return to the workplace. The program will include individual and group-based sessions focused on learning the complexities of pain, mindfulness strategies, relaxation skills, movement based techniques, and applying these techniques to functional daily activities. Family meetings are also offered to help educate and empower families to support patients in their recovery and progress.

Based on the outcome of the assessment, recommendations will be made for the best treatment plan for the patient. The Pain Management Center has a full day outpatient program that takes place over four weeks.

KEY PROGRAM ELEMENTS INCLUDE: • • • • • •

Individually tailored program Interdisciplinary approach Tapering Services and Medication management Access to multiple physicians Outpatient medical treatment setting at one primary location Follow up visits at months 1, 3, and 6 following completion of 4-week program

SERVICES INCLUDED: •

Comprehensive Interdisciplinary Team Evaluation (physician, psychologist and vocational rehabilitation counsellor) to include expert recommendation and evaluation report including suitability for Pain Management Program 7

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4-week Intensive Outpatient Pain Management Program (Monday-Friday, 8am-4pm). All services during the 4 week program, including physical/occupational therapy, physician visits, psychology, vocational counseling, program supplies (i.e. books, backpack)

STAFF: • • • • • • • •

Physicians with a specialty in Physical Medicine & Rehabilitation and Pain Management Pain Psychologists Occupational Therapists Physical Therapists Relaxation/Biofeedback Therapists Vocational Rehabilitation Specialists Nurses experienced in pain management Case manager

SAMPLE SRAlab PMC Week 1 of Week 4 Care Plan Monday 7/15 TOUR

Tuesday 7/16 PT 1:1 12th Floor

Wednesday 7/17 Feldenkrais Studio

Thursday 7/18 OT Lecture Kitchen

Friday 7/19 Relaxation Group Studio

9:00 AM

Intro to Pain Management Conf Rm

Intro to OT Kitchen

OT 1:1 12th Floor

OT 1:1 12th Floor

PT 1:1 12th Floor

10:00 AM

OT 1:1 12th Floor

Psychology Group Conf Rm

Stretching Studio

Psychology 1:1 12th Floor

Intro to Relaxation Conf Rm

Relaxation 1:1 12th Floor

12:00 PM

LUNCH

LUNCH

Intro to Mindfulness Conf Rm LUNCH

LUNCH

LUNCH

1:00 PM

PT PT 1:1 12th floor

Psychology 1:1 12th Floor

Psychology Group Conf Rm

Psychology Group Conf Rm

Art Therapy Multi-purpose room

Nursing Lecture Conf Rm

Intro to PT Studio

Tai Chi Studio

PT Group Studio

Relaxation 1:1 12th Floor

Relaxation Group Studio

Intro to Conditioning Conf Rm

PT 1:1 12th Floor

Relaxation 1:1 12th Floor

Weekend Preview Group Conf Rm

8:00 AM

11:00 AM

Conditioning Gym

POOL OT 1:1 12th Floor

2:00 PM 3:00 PM

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APPENDIX IV: Michael F. Thompson’s SRAlab PMC Medical Record Date: Monday, April 1, 2019 Patient’s Name: Michael F. Thompson Patient’s DOB: October 3, 1953 Gender: Male Status: Married Vital Signs: Ht: 5’ 9”; Wt: 162 lbs; BMI 23.9; Afebrile; BP 140/88 mm Hg; Pulse: 90; HEENT, CV, Pulmonary, GI examinations are WNL. Bloodwork: FBC, PV, Bone profile – all normal.

Labs: TSH 2.5 General appearance: Walks with a limp and uses a cane. Speech is curt, patient makes poor eye contact.

Musculoskeletal: There is a well-healed surgical scar along the lower lumbar spine. Back exam demonstrates some exaggerated lumbar lordosis, and pt. reports tenderness to palpation in the bilateral lumbosacral area. Back demonstrates full range-of-motion (FROM). Neuro exam is intact other than 1+ L ankle jerk and 4/5 L foot dorsiflexion Patent’s spine is straight with no apparent scoliosis. His ability to flex his spine is limited. SLR reduced to 40 on left and 60 on right. You think his ankle reflex is less brisk on L. There is no sensory impairment. MRI lumbar spine report – facet joint and inter vertebral disc degenerative changes. No evidence of nerve root compression. On clinical examination, tenderness was noted over the spinous process of L5. Flexion in standing was reduced by greater than 50%, with slight reduction in extension noted. Motor, sensory, and deep tendon reflexes were normal. Straight leg raising was limited only by hamstring tightness bilaterally. Radiographs (plain) were obtained and revealed normal alignment, without abnormal motion in flexion or extension views.

Pain Rating: 8 out of 10, pain level consistently “not tolerable.” Patient localized his LBP at 8 out of 10, midline in the L5/S1 region with referral in the right gluteal/posterior thigh region.

Some notable leg weakness no paresthesia was noted. Pain increased with prolonged sitting greater than 30 minutes, leaning forward positioning, and occasionally when lying prone. Pain seemed to be improved by standing or walking.

Current Medications: Percocet 5/325mg 2 tablets every 4 to 6 hours Note: Patient just obtained #30 at his last ER visit 9

Background Notes: Percocet is a brand name for the combination of 5 mg oxycodone and 325 mg acetaminophen (APAP). It is an opioid analgesic used for moderate to severe pain.

Dosage should be adjusted according to the severity of the pain and the response of the patient. It may occasionally be necessary to exceed the usual dosage recommended below in cases of more severe pain or in those patients who have become tolerant to the analgesic effect of opioids. If pain is constant, the opioid analgesic should be given at regular intervals on an around-the-clock schedule. PERCOCET tablets are given orally. The usual adult dosage is one tablet every 6 hours as needed for pain. The total daily dose of acetaminophen should not exceed 4 grams.

Ibuprofen 200mg 2 tablets every 6 hours prn pain Background Notes: Tablets contain ibuprofen, which belongs to a group of medicines called Non- Steroidal Anti-Inflammatory Drugs (NSAIDs). These medicines work by changing how the body responds to pain, swelling and high temperature. Anti-inflammatory / pain-killer medicines like ibuprofen may be associated with a small increased risk of heart attack or stroke, particularly when used at high doses. Do not exceed the recommended dose or the duration of treatment.

Gabapentin Note: Patient tried once but did not like it and stopped taking it Background Notes: Neuropathic pain is a chronic debilitating pain syndrome that is complex to treat. ... The established therapeutic dosing for gabapentin in neuropathic pain trials is 1800-3600 mg/day in 3 divided doses in patients with normal renal function. This means the minimum effective dose is 600 mg 3 times a day.

Notes: The physician who saw the patient at his last visit prior to going to Evergreen clinic started him on OxyContin 20 mg every twelve hours with Percocet 5/325mg every 6 hours for breakthrough pain and set him up for a one-month f/u visit. A review of the Prescription Monitoring Program (PMP) prior to going into the room reveals that the patient filled his prescriptions from the clinic as well as another prescription for hydrocodone under the name of a local orthopedic provider, and a Percocet prescription from his original PCP. Smoking: NA Alcohol/Drug Use: Has history of heavy alcohol use, although stopped drinking at age 43.

Denies illicit drug use. Has not had contact with the legal system, and specifically denies any prior DUIs. Family/Social History: Father was an alcoholic and died at age 66 of cirrhosis. Patient indicates this was trigger for him to quit drinking. His mother died in an accident when he was 12 years old. Because he begins to tear up after he tells you this, you decide not to pursue this. He has 2 living sisters but has lost touch with them. He has 3 grown children and three young grand-children.

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Prior Medical Records: Note: Records sourced from Evergreen Clinic (Faxed Thursday, March 28, 2019) and collection of patient’s paper records covering parts of patient’s medical history over previous three years.

Hypertension, osteoarthritis and some hx depression. (Philip Smith, M, Date): A diagnosis is confirmed of disc degeneration and early facet joint osteoarthritis. No surgical treatment indicated. (Khan & associates Date: Psychology/Psychiatry: Date: Sometime between December 2016 to December 2018 Patient was referred for symptoms of anxiety and depression.

Score of 19 on the GAD-7 indicated severe anxiety and his score of 18 on the PHQ-9 indicated moderately severe depression.

Patients wife reports patient grinds his teeth at night and is clenching which causes jaw painrefer patient to dentist for assessment and possible night guard to improve positioning.

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WORKSHEET 1: Please fill in the table below to rate the degree to which you felt the clinicians displayed these \IPEC sub-competencies during their patient case review meeting, as well as any observations about your assessment or other things that struck you.

Interprofessional Communication

Teams and Teamwork

Roles/Responsibilities

Values/Ethics

Degree to which clinicians displayed sub-competency VE9: Act with honesty and integrity in relationships with … other team members.

VE10: Maintain competence in one’s own profession appropriate to scope of practice Observations:

RR6: Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan...

RR9: Use unique and complementary abilities of all members of the team to optimize health and patient care.

Observations:

TT5: Apply leadership practices that support collaborative practice and team effectiveness.

TT7: Share accountability with other professions… for outcomes relevant to prevention and health care.

Observations:

CC3: Express one’s knowledge and opinions to team members… with confidence, clarity, and respect.

CC4: Listen actively, and encourage ideas and opinions of other team members.

Observations:

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LOW 1 2

3

HIGH 4 5

WORKSHEET 2: Please fill in the table below to rate the degree to which you felt the clinicians displayed these IPEC sub-competencies during their discharge meeting with Mike, as well as any observations about your assessment or other things that struck you.

Interprofessional Communication

Teams and Teamwork

Roles/Responsibilit ies

Values/Ethics

Degree to which clinicians displayed sub-competency VE1: Place interests of patients… at center of interprofessional health care delivery…

VE6: Develop a trusting relationship with patients, families, and other team members.

Observations:

RR1: Communicate one’s roles and responsibilities clearly to patients, families,… and other professionals.

RR9: Use unique and complementary abilities of all members of the team to optimize… patient care.

Observations:

TT4: Integrate the knowledge and experience of health… professions to inform health and care decisions, while respecting patient… values and priorities/ preferences for care.

Observations:

CC2: Communicate information with patients, families, … and health team members in a form that is understandable, avoiding discipline-specific terminology when possible.

CC6: Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict.

Observations:

13

LOW 1 2

3

HIGH 4 5