Pain Management at the VA Literature Review

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Provider Education for Chronic Pain Management

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 health care 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 interprofessional team that would be required for the optimal operation of the multidisciplinary pain management delivery system and supporting rationale for each level is followed by a discussion concerning the core abilities required for each team member of the interprofessional pain management team, including suggestions for role responsibilities of each team member. A discussion concerning the factors that may positively or negatively impact the delivery of provider and nursing care and how they will be addressed and an assessment of other important aspects of the system is followed by a summary of the research and important findings concerning enhancing provider education at the VA are provided in the conclusion.

Review and Discussion

Levels of interprofessional team needed for the optimal operation of the delivery system and supporting 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 in support of including additional health care 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 conclude, "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 who will be responsible for initiating and formulating interdisciplinary/transdisciplinary and interprofessional practice.

One FTE pain RN: This health care professional will serves as the nurse educator and provide support and will 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).

Beyond the foregoing team members, the VA's current National Pain Management Strategy (2009) also mandates a "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) as described in Table 1 below.

Table 1

VA's Stepped-Care Pain Management Model

Step

Description

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 diseases and disorders that may be expected to persist for more than 90 days, and in some instances, the patient's lifetime.

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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-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 the following:

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 co-morbidities such as mental health disorders and traumatic brain injury (TBI) (VHA directive 2009-053, 2009, p. 1).

The relationship between these interdisciplinary team members is depicted in Figure 1 below.

Figure 1. Interdisciplinary Pain Management Team Relationships

Source: Clark & Norton, 2009, p. 7

The VHA directive 2009-053 stipulates that the responsibilities for each pain management team member will be assigned by each regional VA office. 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).

Identify factors that may impact (positively or negatively) the delivery of provider and nursing care. How will these factors addressed?

With the veteran population aging at a rapid rate, the potential for negative outcomes in a pain management program are significant for a number of reasons. For instance, misperceptions concerning aging can result in problematic support when health care providers believe elderly patients are on an irrevocable path to a painful death which can cause overly solicitous behavior and introduce unnecessary worry for family members (Turk & Gatchel, 2002). Educating health care providers concerning these issues can help reduce these types of problematic behaviors and result in more appropriate pain management support and minimized worry (Turk & Gatchel, 2002).

In other cases elderly pain management patients may be reluctant to request pain management assistance even when they are in severe pain due to worries about being a "burden" to their health care providers and family members (Turk & Gatchel, 2002). In these types of pain management cases, the provision of timely support by health care providers is essential because family members and other supportive associates may lack the training needed to recognize the severity of the problem and the pain levels being experience by the patient may adversely affect qualify of life considerations and even become life-threatening (Turk & Gatchel, 2002). According to current guidance from VHA directive 2009-053 and the Joint Commission, these types of issues must be factored into a pain management treatment program. For instance, VHA directive 2009-053 stipulates that, "Quality of life is now accepted by the medical field as a standard outcome measure of effectiveness of treatment, including treatment of pain. The concept includes such factors as level of physical and psychosocial and treatment satisfaction" (2009, p. 2).

Likewise, there are some significant religious, gender and cultural differences in the experience and management of pain that must be taken into account when formulating treatment interventions (Gibbs, 2007). In addition, all patients need to fully understand their treatment plan and remain active participants in its execution in order to achieve optimal outcomes (Turk & Gatchel, 2002). In addition, health care providers should remain vigilant for pain management patients that attempt to present a "good patient" status (i.e., "Don't worry about me. I'm doing fine, doc!") because these types of responses may be an effort to please the provider rather than being a legitimate account of their condition (Turk & Gatchel, 2002). In these types of situations, health care providers may fail to accurately and timely identify patients' needs because of self-reports that they are doing so well (Turk & Gatchel, 2002).

A typical pain management problem cited.....

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