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Tiered approach to chronic pain targets suffering

Chronic pain, or pain that continues for at least three months, is a key driver of healthcare utilization. Yet there is little to show for much of this spending, because the individuals suffering from chronic pain often fail to receive the relief they are seeking, even after repeated visits to their provider and/or the ER. It’s a situation that typically leaves patients, providers, and payers frustrated with the results, even while the cycle of repeated utilization continues.

Part of the problem is that nonmalignant chronic pain, or chronic pain that is not associated with cancer, is tricky for the provider to pin down given that there are often few objective findings to rely on in diagnosing such a condition. Successful treatment of the condition may have more to do with alleviating a person’s suffering than actually removing the pain, a concept that may be entirely foreign to both patients and providers.

Despite these complexities, Oakland, CA–based Kaiser Permanente has developed a comprehensive, multilayered approach to chronic pain that developers believe offers all stakeholders a much better outcome than they have traditionally received. At the heart of the program is the idea that chronic pain should be viewed like the other major chronic diseases in the sense that self-management skills are critical to getting the condition under control.

A cure for pain is elusive

Speaking at a Webinar sponsored by Ann Arbor, MI–based HealthMedia on July 26, Andrew Bertagnolli, PhD, a care management consultant at Kaiser’s Care Management Institute, explained that both provider and patient education about the key differences between acute pain and chronic pain are critical to a successful outcome. “We know that immobilization and rest are actually counterproductive in the management of chronic pain. While they can be very helpful with acute pain, [with chronic pain] the muscles decondition, and this may end up causing the pain to flare up, so there is a lot of education that needs to happen at all levels,” he said.

Further, although acute pain tends to get better over a short period of time, he noted that some people must learn to manage chronic pain for the rest of their lives. “The way you would expect a person with diabetes to learn how to manage [his or her] diabetes through a number of avenues, looking at diet, exercise, medication, and monitoring, we would expect someone with chronic pain to learn to manage [his or her] condition as well.”

Given that a cure is often elusive for chronic pain, the approach that Kaiser has implemented focuses on what Bertagnolli referred to as the ripple effects of the condition. These include a diminished activity level, mood disorders such as depression and anxiety, sleep disturbance, and problems with relationships on the job or at home.

In fact, when working with patients, Bertagnolli uses a diagram that has a small circle in the center that represents their physical pain. Surrounding the central circle are outer circles that represent all of the ripple effects that enhance suffering, as represented by the enlarging circle.

When Bertagnolli explains to patients that he has interventions that can help them with all of the ripple effects, essentially diminishing their suffering to the small central circle that represents physical pain, he said they are almost always eager to go forward. “That is how I engage people to get into trying some different approaches to pain management that aren’t focused on alleviation of their physical systems,” he said. “What we know is that evidence shows that it is really about self-management and learning new ways of dealing with pain.”

Self-management is the key

Similar to the way that diabetics or asthma patients are often triaged into different treatment programs based on their acuity level, Bertagnolli explained that Kaiser has established three care management levels for the 12% of its population that has been diagnosed with chronic pain. For example, level one patients, who represent about 59% of the chronic pain population at Kaiser, have the least impairment in terms of physical and psychological functioning as well as lower self-reported pain ratings, so they receive care primarily through their PCPs.

Level two patients, representing about 35% of Kaiser’s population with chronic pain, are assigned to care managers, and they work with an interdisciplinary team of pain management experts focused on helping the individuals to manage their pain better. Typically, Bertagnolli noted that level two interventions last about six months, after which the patients are sent back to primary care.

Level three patients represent about 6% of Kaiser’s chronic pain population. These patients are usually so severely impaired by their pain that they are unable to work or are working very minimally, noted Bertagnolli. They too receive a care manager and work with an interdisciplinary team on a longer-term basis.

At all three levels of care, there is a core emphasis on developing self-management skills. Beginning in November, Kaiser will be adding a new Internet-based program developed by HealthMedia that is designed to stress this aspect, according to Ed Baas, HealthMedia’s director of product marketing, who also took part in the Webinar. “We have developed the technology to be able to deliver programs over the Web,” said Baas. “And we surround all those programs with engagement tools so that we can reach out to the members to get them [engaged]. And we have content libraries.”

Just unveiled in July, HealthMedia’s Care for Pain program follows the model established by many of the company’s other DM and wellness offerings in that it begins with an assessment that the patient can complete online and then automatically uses the information collected to produce and deliver a series of tailored messages and tools to the patient. For example, the program includes sections and resources related to the doctor-patient relationship, medication compliance, stress, and relaxation techniques.

Baas noted that the program draws from behavior-change science and evidence-based guidelines and that it is designed to carry out many of the same sorts of functions that a live counselor might do when working with a patient. However, the intervention is computer-generated, so there is no person-to-person communications.

Preliminary results are positive

Kaiser plans to use the HealthMedia program as an adjunct to the other components in its approach to managing pain. The idea is to reinforce the concept of self-management of chronic pain and to serve as an added resource to providers. “We have very busy PCPs seeing our members, and they tend to focus on the medication aspects of pain management,” said Bertagnolli. “We have tried to get our providers to emphasize nonpharmacological approaches, but this has been troublesome because they don’t often have the training in these areas, and it takes up time.”

Consequently, whereas PCPs might refer their level one patients to the Care for Pain program as one of their first steps, the program may be used as more of a refresher tool to level two and level three patients who have already undergone more extensive interventions.

One of the chief goals of Kaiser’s approach is to stop or slow the escalation of acuity in chronic pain patients, noted Bertagnolli. “We are hoping to not only address the needs of our level two and level three patients but also to do things to prevent folks from moving from level one to level two,” he said. “We know [that] if people adopt a lot of the strategies that we teach them in the more intensive programs earlier on in their pain experience, they are less likely to move up [to a higher acuity level].”

Because the Care for Pain program is just being introduced to the market, no long-term outcomes data are yet available. However, Baas noted that preliminary data from early studies conducted by HealthMedia indicate that the approach has a positive effect on self-reported pain symptoms as well as productivity at 30 days.

Whether these results will hold up over the long term remains to be seen, but Kaiser is one of four organizations planning to roll out the program to members in the next few months, and HealthMedia routinely provides follow-up reports about outcomes at 30, 90, and 180 days, so longer-term clinical and financial data should be available soon.