A Successful Nurse-led Chronic Pain Program in Primary care - Présenté par / Presented by: Dr. Elizabeth Muggah, Isabelle Leclerc (RN), Dr. Hillel ...
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A Successful Nurse-led Chronic Pain Program in Primary care Présenté par / Presented by: Dr. Elizabeth Muggah, Isabelle Leclerc (RN), Dr. Hillel Finestone and Ms Metasebia Assefa (MSc candidate), January 17 2019, PHC Research Rounds , MOHLTC, Kingston, ON
Disclosures
• Speakers:
• Dr Elizabeth Muggah, MD MPH CCFP
• Ms Isabelle Leclerc, RN
• Dr Hillel Finestone, MD, CM, FRCPC
• Ms Metasebia Assefa, MSc candidate
• Relationships with financial sponsors:
– Grants/Research Support: none
– Speakers Bureau/Honoraria: Dr Muggah receives a small
honorarium from HQO IDEAS
– Consulting Fees: none
– Other: none
Chronic pain is a challenge to manage • Common in primary care • Comorbid mental health, trauma and addictions • High opioids use/misuse • Hospital based pain programs have long wait lists and are not well integrated with primary care
We asked: “COULD WE BETTER MANAGE CHRONIC PAIN PATIENTS IN OUR PRIMARY CARE SETTING?
Identifying the Solution: MDs need help
Embedded in
primary care
RN-led Addresses
comorbidities
Chronic Pain (addictions &
Program mental health)
Principles
Self-
management
Uses existing principles
resources
(FHT and
community)1. Aligns with Ontario’s Chronic Disease Framework Waterloo Wellington Diabetes Regional Coordination Centre November 2011 https://www.waterloowellingtondiabetes.ca/usercontent/documents/presentation%20on%20RCC%20November%202011.pdf
2. Aligns with Stepped Care Model Parliamentary Submission to the Standing Committee on Finance House of Commons 2017 Pre-Budget Consultations. Submitted by the Canadian Mental Health Association Revised Version https://www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR8398159/br-external/CanadianMentalHealthAssociation-e.pdf
3. Aligns with Patient Medical Home/Neighbourhood North East LHIN Subregions: http://www.nelhin.on.ca/subregions.aspx
A RN-led model of chronic pain care Setting: An urban Academic Family Health Team (FHT), in Ottawa, 17,000 patients Patients: Adult patients with chronic pain identified in EMR or referred by MD/NP Intervention: Two visits with the RN, more if needed, incorporating self-management principles, with referrals to FHT and community resources. Evaluation: 2016-2018
Outcome Measures •Numerical Rating Scale (NRS) •Brief Pain Inventory Interference score (BPI) •Confidence Scores •Opioid intake Morphine Equivalent (MEQ) •Goal Setting
Pain Explanation and Treatment “Tool”
Patient Characteristics: 2016-2018 Total participants: 125 (0.8% of clinic population) Sex: 23% Male, 77% Female Age: 19-91 yr (mean 59 yr) Baseline Pain score “intolerable” >5: 66/87 (75%) Program completion: 46% had 2+ visits with RN
Summary Statistics on Outcome Measures of Interest
Patients Improved (%) Across Outcome Measures
80%
72%
70%
60%
61%
Percentage of Patients
50%
46% 46%
41% 42%
40%
35%
30%
20%
10%
0%
With at least one On Opioids Decrease in total Clinically Significant Clinically Significant Improved Achieved Goals
Follow Up Visit Opioid Dosage Decrease in Pain Decrease in Confidence
Scores Interference Scores
Outcome MeasuresDetails on Opioids
N Mean SD +/-
MEQ 1st Visit 23 75.00 160.91
MEQ Last Visit 23 54.09 * 134.29
* (95% CI [1.69, 46.07])
•46 % had a decrease in opioid usage
•33 % decreased to 0 mg per dayQualitative Results Questionnaire, open ended Thematic analysis and SWOT Total: 36 Patients: 9 Administrators: 14 Clinicians (MD/NP/RN): 13
SWOT analysis
INTERNAL FACTORS
STRENGTHS (+) WEAKNESSES (–)
• RN Qualities • Weak collaboration:
• Professional, informed • Could integrate better with hospital
• Takes adequate time to understand patient • RN-Led:
• Communicates with patient’s MD/NP • Too Few appointments
• Inability to refill opioids , focus on other issues • Increased burden on RNs on the floor
• Appointments
• Convenient for the patient (their own clinic)
• More availabilities→ quicker bookings
• Self Management Support:
• Increased accountability (goal setting & development of care plans
• Improved patient education
• Patient Empowerment
• Increased patient participation in their healthcare
• Patient Centered Care
• Continuity of Care
EXTERNAL FACTORS
OPPORTUNITIES (+) THREATS (–)
• RN inability to prescribe • RN inability to refill opioids
• Cost-effectiveness of having an RN as expert • Costs of program
• Opioids aren’t solving pain problem • Continued struggle with daily pain
• Positive experience with this support program • Negative experiences with other healthcare
providersQuotes from Patients
“I felt that I was not rushed,
that we had enough time to
thoroughly discuss the
issues.” --Patient
„… there was no
“This program (Chronic need to rehash
Pain Nurse) is such an previous things.”
important piece in dealing –Patient
with my daily chronic pain.
- very helpful”
--PatientQuotes from Clinicians
“Non-pharmaceutical
approach…”
“Ease of access
“The follow up doesn’t
and continuity of
have the dynamic of
care” --Clinician
refilling narcotics”
--Clinicians
“Reduced wait
times”
--ClinicianQuotes from Administrators
“ Having access
to the latest
evidence based
“Enabling communication tools”
between the team --Administrator
members involved in the
patient’s care, and health
navigation”
--Administrator
“…delegate(s)
the less complex
tasks to those
not specialized in
the chronic pain
field”
--AdministratorNext steps: Spread • 25% of Ontario patients/MDs in FHTs: can we spread the program? • Many virtual supports for chronic pain but we need “boots on the ground” • Chronic Pain funding needs to support local programs and be embedded in primary care
Next steps: Essentials of the Program
Training Tools
(conferences, local (EMR, outcome
experts, readings) measures)
no existing program
available RN (1d/week)
+ Primary Care
Team
Ongoing mentoring Link to Community
Resources
(LHIN Self-management,
(Echo, OCFP, HQO, pharmacist, Bounce
local experts) Back)Next steps: Spread we are already doing • Much interest informally from across Ontario • 1 day training program has been developed (March 2019) • Done without funding
Summary • RN led program is feasible and effective • Clinically significant improvements in pain, function and reduction in opioid use • Shifted focus from pharmacological therapy towards self-management • Health care team felt it was accessible, evidence based and patient-centered and patients highly satisfied
Conclusion This successful RN-led chronic pain program, helped some of the most complex patients. The program addresses components of the opioid crisis. The program is feasible, evidence based and cost effective and could be scaled up across Ontario
Work Cited 1. J.T. Farrar, J.P. Young, L. LaMoreaux, J.L.Werth, R.M. Poole. Clinical importance of changes in chronic pain intensity measures on an 11-point numerical rating scale 2. Farrar JT, Portenoy RK, Berlin JA, Kinman J, Strom BL. Defining the clinically important difference in pain outcome measures. Pain 2000;88:287–294. 3. Jaeschke R, Singer J, Guyatt GH.Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials 1989; 10: 407–15. 4. Mease, P., Spaeth, M., Clauw, D., Arnold, L., Bradley, L., Russell, I., Kajdasz, D., Walker, D. and Chappell, A. (2011). Estimation of minimum clinically important difference for pain in fibromyalgia. Arthritis Care & Research, 63(6), pp.821-826.
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