| Honoring Multidisciplinary Pain Care | ||||
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After 30 years of leadership in pain management, the American Pain Society initiated a Clinical Centers of Excellence (CCOE) in Pain Management Awards Program to recognize and reward top-quality clinical care in pain management. This was an ambitious effort for APS and took the time and talents of many individuals. APS wishes to thank the CCOE program development committee—co-chairs Russ Portenoy and Deb Gordon, and committee members Christine Miaskowski, Judy Paice, Lori Reisner, Michael Byas-Smith, Robert Jamison, and Steve Weisman—as well the final review committee, co-chairs Judy Paice and Dennis Turk and committee members Michael Byas-Smith, Steven Weisman, Lonnie Zeltzer, and Mark Jensen. APS would also like to thank the staff for its administrative oversight and Endo Pharmaceuticals for providing the vision and financial support to create this program. APS is extremely proud to recognize its first group of CCOE award recipients. The following 2007 CCOE award recipients exemplify the many multidisciplinary clinical programs throughout the United States.
The NYU-HJD Comprehensive Pain Management Center may want to consider highlighting the word Comprehensive in its title because this integrated inpatient-outpatient program epitomizes all things comprehensive. In terms of patient care, the center’s evidence-based multimodal care targets both physical and psychosocial function by combining analgesics, physical therapy, psychological approaches, and pain interventions. Several times a day, pain physicians, psychologists, and pain nurses follow patients to treat pain and focus on physical and psychosocial function. No patients are overlooked. If they don’t speak English, communications sheets come in 40 different languages; if they are deaf or hard of hearing, there’s a sign language interpreter on staff. In terms of staffing, pain management consults are available 24/7 from a staff that includes physicians, psychologists, pain management nurses, a palliative care team, physical and occupational therapists, a holistic nurse practitioner, a pastoral caregiver, pharmacists, and clinical social workers. Meanwhile, complex inpatient and outpatient cases are presented at weekly interdisciplinary meetings. “Intradisciplinary and multimodal access is integrated into a spectrum of acute and chronic pain management to optimize pain control, clinical outcomes, and patient satisfaction,” says Christopher Gharibo, MD. “This is enhanced by clinicians’ ability to use the vast multidepartmental resources within our institution.” The center’s pain management policies and procedures are both “general and specialized.” They include
Last, the center outreaches to the community to provide comprehensive pain care to the indigent, addicted, and prison populations, as well as to a treatment center with a predominantly Asian patient base. It has also provided clinical and administrative consulting services to a local mental health center. Research programs center primarily on the mechanisms, effects, and treatments of pain. For example, clinical investigations include phase 2 and phase 3 analgesic drug trials, neurophysiological testing of patients with neuropathic pain, and assessment of cognitive behavioral techniques in postoperative and cancer pain. Laboratory investigations, meanwhile, focus on sustained hypersensitivity in rats’ DRG cells and developing a single neuron model for preliminary drug screening. The gathered knowledge is published in peer reviewed publications and is featured at CME conferences and media outlets such as the Internet, radio, and television. Faculty also share their knowledge with colleagues at local and regional meetings, as well as at APS, AAPM, and ASA meetings.
Since RCPC’s founding in 1974 by Dr. Hubert Rosomoff—a founder and former president of APS, past-president of AAPM, founder of the Southern Pain Society (SPS), and longtime champion of pain medicine—the center has developed a reputation of excellence nationally and internationally. Consider these developments:
The RCPC employs a full-time integrated team—including physicians, psychologists, physical therapists, occupational therapists, massage therapists, biofeedback technicians, ergonomic engineers, rehabilitation aides, case managers, an acupuncturist, vocational counselors, and nursing assistants—that interacts on a daily basis to provide treatment throughout patients’ stays, which average 4 weeks. The staff is multilingual, multicultural, and receives ongoing education and training in cultural sensitivity. Staff members address patients’ physical, functional, behavioral, socioeconomic, and medical issues concurrently. For example, patients are tapered from narcotics and other dependency-inducing drugs, and are provided alternative treatments and other medications, as needed. The medical director and clinical staff hold twice-daily multidisciplinary rounds to review and adjust care. Patients are team-conferenced on a weekly, if not more frequent, basis. Patients treated range in age from 14–103. They are barely functional mentally and physically, have up to 42 surgical procedures, and are taking up to 1000 mg of methadone per day. Evaluations and treatments at the RCPC are individualized to patients’ needs and conditions. The multidisciplinary evaluation process spans up to 3 days of assessments and screening by pain medicine physicians, nurses, physical therapy, occupational therapists, massage therapists, psychologists, and a vocational counselor.
Staff from BWH Pain Management Center say that patients who enter their facility get fully immersed in multidisciplinary pain assessment and treatment—not a surprising description from a staff that includes massage therapists and physical therapists. In fact, the center’s staff comprises experts from diverse backgrounds ranging from anesthesiology, neurology, orthopedics, internal medicine, pharmacy, psychiatry, psychology, and nursing to physical therapy, dentistry, acupuncture, and massage therapy. Together, they stress a unified approach to evaluation and management of pain problems. As such, the center serves as a model of interventional and noninterventional treatment approaches. These include psychotherapy; medication management; biofeedback; physical and occupational therapy; neural blockade procedures; radiofrequency lesioning and chemical neuroablation; and implantation of spinal cord stimulators, intrathecal pumps, and epidural portacaths. The center receives national and international referrals, including from other tertiary care center pain programs. Among its offerings
According to BWH Pain Management Center officials, the center is a model of innovation and excellence. The center, for example, uses longitudinal medical records, note scanning, and electronic diary technology, and implements a developed system of assessment of risk/benefit potential to tailor treatment to patient profiles. On the legislative front, BWH Pain Management Center staff was invited by its state governor to participate on a special commission on drug abuse. Staff representatives, meanwhile, are developing Massachusetts legislative policies favorable to pain management. The BWH Pain Management Center staff is committed to advancing scientific knowledge. Staff members contribute an average 15 publications a year, sit on editorial boards of four pain journals, and frequently grant interviews to local and national press, among other things. The BWH Pain Management Center offers a superb educational program in pain medicine, and maintains a highly competitive fellowship accredited by the American Council on Graduate Medical Education. Each year, eight fellows graduate from the program, which is a key teaching site for approximately 35 residents per year and has hosted trainees from other national and international educational programs. Upon completion of the program, many of the graduates of the BWH Pain Medicine fellowship continue as leaders in their field, both in academics and private practice settings. The center actively collaborates with other Boston-area healthcare systems, such as the Dana Farber Cancer Institute to provide state-of-the art pain and palliative care services, Partners HealthCare to improve access to pain services for all of its patients, and the BWH Spine Center whose aim is to bring evidence-based practice to a cost-conscious outcome-based model of care for patients with spinal and musculoskeletal disease.
Meet Pamela Pierce Palmer, MD PhD, director of PainCARE, UCSF's Center for Advanced Research and Education and Professor, UCSF Department of Anesthesia and Perioperative Care. An internationally respected physician and a leader in peripheral inflammation mechanisms and opioid receptor signaling research, Palmer became director of UCSF’s Pain Management Center (PMC), working with healthcare leaders worldwide to advocate for improvements in research, patient care, and pain education for healthcare practitioners. Five years later, with the help of a challenge grant from The Mayday Fund and other key supporters, she and her staff launched PainCARE to intensify these efforts. “The PainCARE-PMC collaboration is transforming the conventional treatment center by integrating state-of-the-art PMC clinical care with research, training for healthcare professionals and patients, and active community, media, and government outreach to foster true collaboration between patients, policymakers, and....healthcare providers." PMC faculty develop patient care policies and education programs for UCSF and teach “everywhere,” from community hospital grand rounds to major international conferences. David Lee, MD, has been the medical director of the PMC since 2005, and also heads the ACGME-accredited UCSF Pain Management Fellowship program and is a key part of the collaboration’s success. In 2003, Dr. Palmer and her staff began a significant expansion of UCSF’s continuing education offerings. At the request of the associate dean and associate chief medical officer at UCSF Mount Zion, they created the Challenges of Managing Pain Symposia, a live lecture series that has helped physicians across the San Francisco Bay Area to comply with California’s law requiring 12 CME credits in pain management and end-of-life care. Now also teleconferenced to multiple sites in California, this series will soon reach even further through streaming video. In 2005, Dr. Palmer and PainCARE staff also launched the only intensive web-based pain management education program of its kind in the country, the UCSF Postgraduate Certificate in Pain Management-Online. This program is part of an international pain education program developed with the Universities of Sydney and Edinburgh. PMC and PainCARE faculty, often with UCSF staff, educate patients and their families on disease processes, treatment options, and coping strategies. PMC staff also tap various UCSF facilities and resources, such as its Integrative Medicine center, to provide patients access to complementary therapies—acupuncture, biofeedback, massage therapy, and stress management—and services such as nutrition counseling, social work, and occupational therapy. Likewise, PMC patients are referred to healthcare consultants both inside and outside of UCSF, including UCSF's internationally respected migraine specialists, neurologists, orthopaedic surgeons, and internal medicine practitioners. PMC and PainCARE serve about 10,230 patients a year, of which 7,294 are treated for chronic noncancer pain. Each patient’s case is reviewed by a multidisciplinary staff to ensure that the best combination of therapies is provided. “Each patient is reviewed by our team…and patients are encouraged to attend free programs on pain and coping presented by treatment staff,” according to PMC officials. “PMC’s anesthesiologists, neurologist, psychologist, nurses and physical therapist have extensive experience with multiple pain conditions, from back pain to cancer, musculoskeletal, neuropathic, and post-surgical pain.”
Outcomes-driven and interdisciplinary: This approach to pain treatment allows the CPRP to maintain “a proactive, responsive, and constantly evolving program.” It’s so proactive, in fact, that CPRP officials believe they were the first pain program to routinely implement clinical pathways to guide treatment and to measure pain treatment satisfaction as a primary outcome. To treat returning Iraq and Afghanistan soldiers, the CPRP recently implemented three innovative programs to provide comprehensive symptomatic and prophylactic treatment to those injured in combat or during deployment. Meanwhile, the CPRP developed a pain outcomes instrument requested by more than 800 clinicians and researchers in 36 countries and initiated a preliminary validation of actigraphy as an objective pain outcomes measure. “Consistent with the military actions in Iraq and Afghanistan, our latest research efforts focus on the assessment and treatment of pain in returning military personnel who experienced combat-related polytrauma or other deployment-related injuries,” says Clinical Director Michael E. Clark, PhD. He adds that current research funding of CPRP principal investigators is in excess of $1.4 million. Since its opening in 1988, CPRP has treated more than 32,000 active duty, veteran, and veteran family members for pain. Each year it serves about 3,900 patients, mostly on an outpatient basis. This evidence-based
program has for 17 years systematically collected outcomes data
to monitor its success and guide its program development. “We
utilize an active rehabilitation strategy with a strong cognitive-behavioral
focus to treat pain, and our success in this area is reflected in
our multitude of national awards… and continuous CARF accreditation,”
Clark says. CPRP’s core team comprises physicians (neurologists, physiatrists, an anesthesiologist, Pain Fellows, and medical residents), pain psychologists, ARNPs, RNs, LPNs, a registered dietician, rehabilitation therapists (physical therapists, occupational therapist, kinesiotherapist, vocational therapist, and recreational therapist), and a social worker. Extended team members include a chiropractor, acupuncturist, and pharmacist. Moreover, key members of the CPRP also
Kenneth R. Goldschneider,
MD FAAP, director of the Division of Pain Management, knows why
his pain management program, which last year made about 11,000 visits
to children suffering from acute pain, gets consistent high marks
in patient satisfaction. “We simply have the most wonderful
team of inspired, compassionate pain practitioners, who are creative
as well as focused on the kids and their families,” he commented. Another reason is innovation. The division’s Procedural Management Program (a sedation service) undergoes regular reassessments by families, physicians, and the nursing staff with the goal of improving its current care models. Among other things, the program aims to lower the distress suffered by children with cancer, hematologic diseases and other chronic illnesses by
An interdisciplinary approach to care is also seen in its Chronic Pain Clinic, where core staff comprises pain APNs, pain physicians, psychologists, and physical therapists. Patients and families at the clinic receive an initial assessment by the entire team as well as follow-up care which remains integrated via weekly team meetings. The clinic collaborates closely with the orthopedics, GI, Neurology, and PM&R departments, and is integrated with Hemangioma and Vascular Malformation and Epidermoloysis Bullosa clinics, both which are themselves interdisciplinary. The division’s accomplishments have captured the attention of others, from other divisions within their own hospital, to other institutions and media outlets. For example, Children's Healthcare of Atlanta, which has recently begun their own pain program, visited the division to observe its structure, philosophy, and operations. Meanwhile, the hospital’s director of palliative care has been working with programs nationwide to glean the best ideas for providing palliative care. Division APNs design many of the the nursing pain education efforts at the Cincinnati Children’s Hospital. Division members also consult on or design hospital policies on pain assessment, treatment, and side-effect management. Meanwhile, several Division members have been featured in segments and articles on pediatric pain in USA Today, The Washington Post, ABCNews.com, and local newspapers, radio, and television shows. Members also are editing an upcoming book on practical pediatric pain management, which provides practical recommendations to help primary care physicians better treat and advocate for their young patients.
APS also recognizes the following programs as 2007 CCOE Honorable Mentions:
CCOE Gala, Smithsonian Museum of Natural History APS believes that a special award deserves a special celebration. To mark this milestone and honor the 2007 award recipients, APS will host a gala at its Annual Scientific Meeting in May. On Thursday, May 3, a gala celebration will take place at the Smithsonian National Museum of Natural History. During the evening recipients and hundreds of guests will enjoy a cocktail reception and dinner and countless wonders of the Smithsonian, such as the Hope Diamond. Guests will be served cocktails and hors d’oeuvres in the Gems and Minerals Halls, whose walls are lined with some of the finest jewels in the world. A harpist will play soothing background music, as time for dinner approaches. Guests will then be escorted by a strolling string trio to the Rotunda for dinner. The evening’s presentation will include remarks from the APS leadership, an award presentation, and acknowledgement of industry partners who have supported this magnificent program. The evening will commence at 7 pm and conclude at 10:30 pm. Please show your support and commitment to multidisciplinary pain care by attending this prestigious event. Tickets can be purchased online for $100 per person. The funds collected are for cost recovery. This is not a fundraising event. Transportation to and from the museum will be provided.
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