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10 Articles in Volume 17, Issue #7
Abuse-Deterrent Opioids: Why Rush to Judgment?
Alcohol Screen Recommended to Reduce Opioid-Induced Respiratory Depression Overdose
Ehlers-Danlos Syndrome: An Emerging Challenge for Pain Management
Guide to Laboratory Testing in Patients With Suspected Rheumatic Disease
Letters to the Editor: Arachnoiditis, Hormone Testing, Ehlers-Danlos Syndrome
Neurocognitive Disorders: Pain Expression in the Face of Mental Deficits
Preemptive and Preventive Analgesia for Chronic Postsurgical Pain
The Effects of Religion and Spirituality on Coping Efficacy for Death and Dying
Topical Nonsteroidal Anti-inflammatory Drugs and Nephrotoxicity: Is There a Safer Option?
Transformative Care for Chronic Pain and Addiction

Transformative Care for Chronic Pain and Addiction

Healing the patient and the health care system through a health coaching model

Chronic pain is the big elephant in the room of health care. It is the top reason to seek care, the number one cause of disability and addiction, and the primary driver of health care utilization, costing more than cancer, heart disease, and diabetes.1-3

More than half of the patients who seek care for pain conditions at one month still have pain years later despite treatment, and up to 20% develop long-term disability.4-9 This delayed recovery occurs largely because practitioners do not address patient-centered risk factors, such as poor ergonomics, repetitive strain, inactivity, prolonged sitting, stress, sleep disorders, anxiety, depression, abuse, and many others that increase peripheral and central pain sensitization and lead to chronic pain.6-14

When usual care fails, clinicians and patients often escalate care to passive higher-risk interventions, such as opioids, polypharmacy, surgery, or extensive medical and dental treatment, resulting in devastating consequences including a high prevalence of disability, opioid addiction, and intractable pain.10-14

Yet, clinical trials have shown the long-term outcomes of these passive interventions are no better, and in many cases worse, than patient-centered approaches that activate and empower patients with self-management strategies such as cognitive behavioral therapy (CBT), therapeutic exercise, and mindfulness-based stress reduction.15-34

There is a need to apply an innovative model of pain care—transformative care—that integrates robust self-management training and health coaching with the best,  safest evidence-based treatments. This paper offers a discussion of the concepts and practical strategies associated with transformative care as implemented with a dynamic, new online self-management training program called Patient Aligned Care Team (PACT).

Integrating Training with Treatment

When transformative care with robust, patient-centered self-management strategies is added to evidence-based treatments as part of routine care for pain conditions, chronic pain and its consequences can be better prevented and managed.38-40 In addition, transformative care can improve long-term outcomes dramatically and reduce a patient’s dependence on the health care system, thus improving both the patient’s life and the health care system.

For this reason, healthcare leaders, including the Institute of Medicine, the National Pain Strategy, and the Institute for Clinical System Improvement, have recommended routinely integrating self-management strategies into clinical practice that engage, educate, and empower people to prevent chronic pain and addiction.1-3

With transformative care, the Institute for Healthcare Improvement (IHI) Triple Aim of improving the patient’s experience of care, enhancing the health of the patient, and controlling the cost of healthcare has the best potential to be achieved with pain conditions.

There are many barriers, however, for health professionals in implementing such transformative care. A lack of reimbursement, a significant time burden, and inadequate training, coupled with the lack of care coordination, fragmented care, poor communication, and conflicting treatments, all interfere with patient-centered transformative approaches in clinical practice. New approaches to implementing self-management as part of routine healthcare are greatly needed.

Personalized Activated Care and Training

The PACT program is designed to overcome some of these barriers and support health care providers to improve long-term outcomes of patients with pain disorders. PACT provides healthcare professionals with a simple solution to integrate evidence-based self-management training and health coaching with medical or dental treatments using an online platform (Table 1).40-56 Systematic reviews of randomized clinical trials of self-management with cognitive behavioral therapy (CBT), exercise, and lifestyle changes show significant improvement in chronic pain.17-24

Reviews of mindfulness-based stress reduction also demonstrate a significant impact in reducing chronic pain,25-28 as do reviews of meditation, relaxation, and resiliency training.29-32 In addition, reviews of social support and health coaching show that they can improve functional recovery from chronic pain.32-36 Furthermore, systematic reviews of online, self-management training programs for various conditions have shown excellent outcomes.37-41 By integrating all of these strategies within the web-based PACT training program, clinicians can better engage and empower patients to learn the skills of long-term self-management for chronic pain.

Going Beyond Patient Education

More than a patient educational tool, the PACT online program is designed to be a well-defined therapeutic pain program with a goal of helping people understand how risk and protective factors in each realm of our lives can be improved with self-management strategies to relieve and prevent chronic pain.

Based on the Chronic Care Model (CCM), which has documented efficacy for chronic conditions in many healthcare organizations, the PACT Program can help transform the patient to health by practicing self-management daily.42-48 In addition, many studies of online self-management training have demonstrated the parameters used in the PACT program to be successful in achieving high levels of engagement and effectiveness in implementing online self-management training.55-65

The PACT program includes online tools for risk assessment, therapeutic CBT training, and telephonic health coaching that are easily integrated into a person’s daily life and personalized to their individual characteristics (Figure 1). The PACT program also leverages the benefits of a support team, including a social network for family, health care providers, and a health coach to enhance compliance and success. 49-54 PACT tracks patient self-efficacy, adherence, health care use, and outcomes with a dashboard to demonstrate change over time to the participant and health care provider and send alerts when problems exist.

Furthermore, since PACT is designed to be responsive to both smartphone and computers, it can be implemented anywhere at any time to be easily integrated into a person’s life. Web-based programs can also be secure, confidential, transferable, and scalable to be a cost-effective addition to care programs for health plans, health systems, and health professionals.

Comprehensive Pain and Risk Assessment

The PACT online program also includes a series of brief psychometrically derived assessments to evaluate pain location and severity; health care use; self-management engagement; readiness for change; and risk and protective factors in each realm of a person’s life.69-77

PACT holistically assesses the underlying risk factors for chronic pain and delayed recovery that occur in each of the 7 realms of a person’s life—the physical, cognitive, emotional, social, behavioral, spiritual, and environmental realms. In addition, the assessment identifies protective factors, including exercise, posture, balanced lifestyles, good sleep, healthy nutrition, safety practices, mindfulness, meditation, and others that patients can apply in each of those realms.

Personalized Self-Paced Training

Based on the assessments, practitioners may then develop personalized experiential lessons and train patients as to ways in which they may reduce their personal risk factors, which would otherwise cause delayed recovery and promote protective factors that encourage healing. The program consists of 9 online modules or tools designed for completion over several months (Table 2).

There are 3 tiers of lessons to simplify the process and include immediate self-care relief, gradual healing of sensitive tissues, and long-term recovery to health and well-being. Each module includes many 5- to 10-minute interactive lessons directed at self-management of specific factors involved in chronic pain. The lessons begin with an overall understanding of the patient’s individual condition and how it can be improved by balancing the risk and protective factors in each life realm.

Each subsequent training tool focuses on lessons within the 7 realms and the changes that can be made to improve the patient’s pain. The program includes guides for quick review, action plans for each realm, and worksheets to facilitate understanding of the lessons. The action plan for each lesson includes 3 main components: healthy habits, daily pauses, and calming practices.

Tips for overcoming barriers to change also are offered to share with patients to ensure that they are prepared to most successfully complete their action plans:

  • Establish healthy habits—Advising patients to dedicate time each day to work on enhancing protective factors and decreasing risk factors. This includes lifestyle behaviors such as exercise, sleep, healthful diet, healthy substance use, activity, optimism, positive emotions, and others, as appropriate for the individual.
  • Take daily pauses—Promoting mindfulness by taking brief time-outs helps patients to notice how they are doing in the present moment, in a non-judgmental way. This is essential to living a life fully and being highly aware of protective factors that will enhance overall health and well-being.
  • Exercise calming practices—Encouraging relaxation through brief meditation techniques that are employed a few minutes each day has many benefits, such as calming the mind, relaxing muscles and nerves, reducing stress, offering space for contemplation about the patient’s life, and reflection about how best to move forward.

Specially Focused Pain Health Coaching

Health coaches (HCs) are certified health professionals who are responsible for developing a coaching relationship with patients to review assessments and provide guidance in establishing goals and facilitating knowledge, understanding, and skills necessary for successful self-management of chronic conditions. Trained and certified HCs are provided through the PACT platform. It is important to note that health coaching for pain conditions is distinctly different from care coordination or health psychology counseling.

HCs undergo a shared training of a model that is holistic and integrative, in order to provide a consistent and congruent service to the patients. The coaching process supports the needs and life experiences of the individual patient to guide them in the successful care of their condition (Table 3). The coach assists the patient through the process of care, actively working toward improving a patient’s pain and health by helping them set and achieve their own identified goals.

This is a patient-driven, relationship-based experience in which the individual is supported as the expert in his or her own life. Information exchange and encouragement to complete the online modules comprises only a small portion of the coaching time, as the patient’s agenda and self-determined goals and timing are the focus of each session. HCs can work with patients by telephone or through the secure video-conferencing telemedicine portal within the PACT platform and are in a partnered relationship. While a minimum of 3 coaching sessions is recommended for participants, the remaining number and frequency of sessions are determined by the needs and desires of the individual patient.

It’s Time for Transformative Pain Care

The Institute of Medicine’s monograph emphasizes the need to transform our current passive model of physician-centered care into one that is patient-centered.1 The document stated, “Health care provider organizations should take the lead in developing educational approaches for people with pain and their families that promote and enable self-management.” The clinical application of transformative care will involve both identifying and reducing risk factors and enhancing protective factors as well as shifting the health professionals’ clinical paradigms so that patients understand their important role in care.

Since patients often expect to have only a passive role in care, these new paradigms need to be conveyed to the patient as part of the initial evaluation (Table 4). Embracing these patient-centered health care paradigms, including self-responsibility, education, personal motivation, self-efficacy, social support, strong provider-patient relationships, and long-term change, will create a shift from a passive, dependent patient to an empowered, engaged, and educated individual.1,2 Ultimately, these paradigm shifts will improve the quality of care, enhance pain and functional outcomes, and significantly reduce health care costs.

Engaging and Empowering the Patient

The key to the success of any self-management training program, particularly when it is online, is the ability to engage the participant in making needed changes to improve their pain.59-73

The PACT program maximizes engagement in various ways:

  • Accessibility using any device. PACT online training can be delivered through a responsive website that can be accessed by smartphone, tablet, or computer.
  • Make a pact with a health professional. The program employs a pact or agreement between the provider and patient to shift the clinical paradigms implicit in transformative care. The provider can follow up with the patient and use the dashboard to track and reinforce progress.
  • Support from health coaches (HCs). As noted earlier, HCs are well-trained and certified health professionals who can support the success of a participant’s self-management training using telemedicine portals. The coach helps the participant determine and understand their goals, risk factors, protective factors, barriers, and individual skills and talents to help them be successful in achieving their goals through the program.
  • Support from family and friends. Having a friend or family team member who can support participants and encourage them along their journey is an important component of PACT. Each participant can sign up any teammate at the beginning or at any time using the team link of the dashboard.

Focus On the Whole Person

In contrast to the limited scope or fragmentation of many pain training and treatment programs, the PACT program is intended to help people evaluate risk and protective factors in all realms of their life, including the body, mind, lifestyle, emotions, spirit, social life, and environment.

Engaging Characters

Several animated characters are designed to assist the participant in learning (Figure 2).

  • Professor James is a distinguished professor and pain specialist who presents lectures and tells stories of many patients he has helped over the years.
  • Action Annie is a perky plain-speaking trainer whose main job is to help the participant implement their action plan within their lifestyle.
  • Calming Kate is an experienced health professional who teaches calming practice using techniques of mindfulness-based stress reduction and indirect hypnosis for pain control. She uses a calm voice, enlightening dialogue, and guided imagery.
  • Barrier Bob is a no-nonsense barrier buster who helps participants identify and change barriers that they may confront on the way to changing their attitudes, behaviors, and relationships to support a healthy lifestyle.  

Interactive Content

To engage the patient in learning, there are various engaging interactive components including bursting the benefit bubbles, breaking barrier bricks, cases stories of people overcoming chronic pain, and acronyms of phrases to help patients remember relevant concepts.

Simple Action Plan

As noted, an action plan that is generated for each module includes 3 components: healthy habits, daily pauses, and calming practice. Strategies to overcome barriers are discussed to help participants complete the action plans.

Dashboard to Track Progress

A dashboard based on the pain assessments is provided to track participant engagement in the program, pain, functional status, action plan status, and risk factor assessment.

Smartphone Apps Can Enhance PACT

Smartphone apps can be used in coordination with the PACT program to track steps, blood pressure, pulse, weight, sleep, stress, and other biometrics.

Send Reminders and Provide Worksheets

The program sends out reminders to reinforce success and encourage completion of the program. The program also has many resources that provide written documentation for each lesson, including an action plan summary, a daily log, and worksheets for each lesson.

Implementing Routine Pain Self-Management

To implement self-management, health professionals need to ask their patients simple questions that will naturally shift the paradigm to a patient-centered focus of care. For example, this is easily accomplished by asking, “I am happy to provide treatment for your condition, but it is more successful long-term if we also train you to reduce the causes of your pain. Are you interested?” or “80% of your success in relieving the pain is based on your self-management while, 20% is based on the treatments. Are you willing to learn how to do your part?”

In the current study of the PACT program, when health professionals ask these types of questions, nearly all patients consent to participate in the online training program and, more importantly, begin making the personal lifestyle changes needed to improve their pain condition in the long term.

Health plans are poised to reimburse risk assessment, therapeutic training, and health coaching provided as part of transformative care for chronic pain, similar to heart health and diabetes self-management. The reimbursement of the PACT pain program as a therapeutic service is a key to its success for both health care providers and health plans. Without transparent reimbursement for implementing self-management as a routine part of care, it will be undervalued, resulting in lower patient and health provider engagement. When the participant sees value in the program and makes a decision to participate based on this value, engagement and success are greatly improved.

The Health Care Provider as an Agent of Transformative Change

As part of all health care, the health care provider needs to recognize that he/she is part of the patient’s system of health and/or illness. Treatment in some cases, such as for dependency on medications, over-reliance on surgery, secondary gain from seeking care, disability, and rebound pain from drugs, can be part of the patient’s cycle of problems. If clinicians understand their integral role in the cycle of health and illness, they can be part of the solution and help initiate change. To do this, clinicians need to enter the experiential world of the patient and alter it.

Clinicians need to help raise their patients’ health consciousness by helping them reconstruct their world into one of wellness and not illness, and access their own resources for sustainable and significant personal change (Figure 3). They need to help patients achieve the deepest, most permanent order of change—transformative change—that alters their basic understanding of health and well-being and opens a window onto a new view of life.

Preliminary Study Results

Preliminary data from the initial offering of an online course that employed the concepts in the PACT program are presented in Table 5.35-37 The population consisted of 771 participants with pain, with 93% completing the online training program as part of the course on preventing chronic pain.

The most common areas of pain included the neck and back (26%), head, jaw, and face (21.5%), leg, knee, and feet (21.5%), arm, elbow, and hand (10.5%), shoulder, chest, and abdomen (9.9%), and pelvic and hip (6.6%). The severity of pain (0-10) scale was 8.2 and interference (0-10) was 7.1. In the past year, they had seen 9.2 visits for their pain, with many having surgery or emergency visits.

The results demonstrated that 93% of participants using the PACT training program changed their lives and decreased their pain levels, while 85% of involved providers changed their subsequent patient care plans to include patient self-management.

Conclusion

Chronic pain conditions are the primary reason for seeking care, the most common reason for disability and addiction, and the highest driver of healthcare costs, costing more than cancer, heart disease, and diabetes combined, not to mention incalculable personal impact.1 There are several areas of focus for health professionals regarding implementing transformative care to address the huge problem of chronic pain.

These include a transformative model of healthcare that:

  • Integrates robust self-management training with evidence-based pain treatments through a coaching-based team approach to care.
  • Provides self-management training with evidence-based treatments that can improve the outcomes of early pain management and reduce patients’ dependency on the healthcare system and healthcare costs.
  • Emphasizes the importance of understanding the whole person with chronic pain by understanding their risk and protective factors.

Unaddressed risk factors may be reasons that a biomedical treatment may fail. Thus, a shift to patient-centered clinical paradigms in the clinician-patient relationship will be crucial to success. The PACT program is one example of an approach that can assist in implementing transformative care. It includes online tools for risk assessment, therapeutic CBT training to reduce risk factors and enhance protective factors, and telephonic health coaching that is easily employed by health professionals, integrated into a person’s daily life, and personalized to their individual characteristics.

The PACT program also leverages the benefits of a support team, including a social network for family, health care providers, and a telehealth coach to enhance motivation, understanding, compliance, and success. This program was developed as part of the International MYOPAIN’s Campaign for Preventing Chronic Pain and Addiction with funding from National Institutes of Health.

The Campaign has 3 goals:

  • Increasing research on preventing chronic pain by developing strategies and tools that health professionals can use to improve the prevention and early management of chronic pain conditions through self-management and evidence-based treatments;
  • Expanding education of patients and health professionals about how to prevent chronic pain using a transformative care model; and
  • Advocacy to increase awareness and provide tools to health plans, businesses, government agencies, and communities to improve their efforts to prevent chronic pain.

By accomplishing these 3 goals, pain practitioners will have addressed the Institute for Health Care Improvement’s triple aim as it applies to pain conditions for improving the patient’s experience of care, enhance the health of the patient, and help to control the cost of health care.54

 

Last updated on: October 2, 2017
Continue Reading:
Abuse-Deterrent Opioids: Why Rush to Judgment?

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