Publications
APS Bulletin • Volume 16, Number 1, Winter 2006
Innovations in Practice
Debra Gordon, MS RN, Department Editor
Veterans Health Administration National Pain Management Strategy: Update and Future Directions
Robert D. Kerns, John Booss, Martha Bryan, Michael E. Clark, Audrey C. Drake, Rollin M. Gallagher, Beverly Green-Rashad, Ruth Markham, Jack Rosenberg, Anne Turner
Editor’s note: The focus of the Bulletin’s innovations column is often some form of new assessment, diagnostic technique, or treatment strategy. However, I think most readers would agree that another important type of practice innovation involves fundamental changes in the healthcare system and day-to-day behaviors of healthcare providers, that is, how we coordinate and deliver high-quality pain management to all patients across all settings. In July, APS published updated recommendations for improving the quality of acute and cancer pain (Gordon et al., 2005). A critical message in these recommendations is that all care settings should formulate a structured, multilevel system approach (sensitive to the type of pain and setting of care) that ensures safe, high-quality pain management to all patients. A shining example of dedication and innovation to making this type of systematic change is the ongoing effort of the Department of Veterans Affairs (VA). The following article provides an update on the VA’s impressive quality initiative and is an excellent example that I believe we can all learn from and follow.
In late 1998, the Veterans Health Administration (VHA), one of the largest healthcare delivery systems in the United States, enacted its National Pain Management Strategy, designed to provide a system-wide standard of care to reduce suffering from preventable pain. This overarching goal of the strategy has served to elevate pain management as a top priority within the VHA and to spark enormous innovation in the planning and provision of high-quality pain management to veterans receiving healthcare in more than 163 VHA facilities nationwide. A prior report on the status of this broad and ambitious initiative was published in the September/October 2003 APS Bulletin (Craine & Kerns, 2003). That article summarized the goals and structure of the strategy and provided a brief update of its major accomplishments (see Table 1). The intent of this article is to continue to provide information on the status of the strategy and describe a few of its current initiatives and specific objectives. The provision of these updates can provoke discussion and inspire efforts to promote improved pain care for veterans and civilians alike.
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Overview of the VHA National Pain Management Strategy
An important strength of the VHA National Pain Management Strategy is the effective use of an organizational infrastructure that provides for policy and resource development, ongoing performance monitoring and improvement activities, and provider and patient education, among other key responsibilities at national, regional, and local facility levels. A multidisciplinary coordinating committee has been in place since the initiation of the strategy and continues to provide guidance and oversight at a national level. The committee has representatives from key areas of the organization, including relevant clinical disciplines such as internal medicine, anesthesiology, neurology, nursing, pharmacy, pain medicine, psychiatry, and psychology and representatives from other important partners within the VHA such as the Office of Information, the Office of Research and Development, the Employee Education System, and the Office of Quality and Performance. The chair of the committee also serves as the National Program Director Consultant for Pain Management and has national programmatic responsibility for policy development, coordination, and oversight of the VHA National Pain Management Strategy. Working groups comprised of members of the Coordinating Committee and others from the field have been particularly instrumental in advancing the goals and objectives of the strategy. A summary of accomplishments through 2003 was provided in the prior report (Craine & Kerns, 2003), and a brief summary of more recent activities is provided below.
The VHA is organized into 21 Veterans Integrated Service Networks (VISNs) or regions that comprise several VHA facilities that offer a broad array of inpatient, outpatient, and community-based service delivery settings. Each VISN has a pain point of contact (POC) and many have developed VISN-level committees. By VHA directive, each facility also has a local pain management oversight committee responsible for providing oversight, coordination, and monitoring of pain management activities and processes to ensure consistency with the VHA Pain Management Strategy. This decentralized approach encourages innovation and flexibility in meeting the needs of the VISN and local facilities given the diverse nature of these healthcare settings and more specific missions of each facility. Virtually all facilities have published their own policies regarding pain management, organized programs for education of providers and medical and associated health trainees, and developed effective systems for measuring outcomes and fostering performance improvements in pain care. Many have developed interdisciplinary teams for the provision of specialty pain care and developed systems for accessing specialty services, as needed.
Overview of Accomplishments
The goal of promoting a single standard of care for veterans with pain is advanced by attending to several more specific goals and objectives of the National Pain Management Strategy. Publication of VHA Directive 2003-021: Pain Management (2003) provides the policy and guidance for the strategy, including specification of these key goals. For example, the directive states that providers have responsibilities for conducting routine screening for the presence and intensity of pain, completing comprehensive pain assessments as clinically indicated, delivering timely and appropriate pain interventions, and including patients and families in the pain management process. The document emphasizes the importance of maintaining institutional commitments to multimodal and interdisciplinary approaches to pain management, establishing educational and monitoring programs to ensure that providers are competent to deliver appropriate pain care, and providing for a process of performance monitoring and improvement. The document further clarifies roles and responsibilities for promoting the goals of the strategy at each level of the organization. As noted above, pain management policies have been developed at both the VISN and local facility levels that, although consistent with the national VHA Directive, provide more explicit details about delegated roles and responsibilities.
Critical to the success of the strategy are efforts to promote the education and training of VHA staff. An array of resources continues to be important in an effort to promote provider competency related to pain management. In March 2005, the Fourth National Leadership Conference on Pain Management and End-of-Life Care was held. These conferences highlight dissemination of best practices across the VHA and offer lectures and discussion sections from professional, scientific, and policy leaders in the field of pain management. National satellite broadcasts on specific topics and aspects of the strategy are routinely held and made available to providers across the VHA. An increasing array of Web-based educational programs is also available. The VHA National Pain Management Teleconferences have been held monthly since 2000 to provide education and to encourage sharing of best practices and dialogue about current practice issues related to pain management among pain specialists and other care providers. A national pain management Web site and an active VA Pain Listserv are additional resources that support information sharing and discussion of problems, solutions, best practices, and areas for improvement. VISN and local provider education conferences and initiatives supplement these national programs. For example, most facilities now provide an overview of the principles of pain management and the VHA pain management strategy as a component of new employee orientation, and many require participation in additional annual training programs. Annual competency reviews have been implemented at many sites and are used to confirm knowledge and skill acquisition and acceptable standards of care.
Practice guidelines have been developed in collaboration with the U.S. Department of Defense for the management of pain in the postoperative care setting and for chronic opioid therapy, and toolkits supporting these guidelines have been developed and disseminated. These guidelines continue to serve as a focus for specific educational, performance improvement, and research efforts. The guideline for postoperative pain (2001) is unique in that it provides a specific procedural perspective and is intended as a tool to enhance the practitioner’s clinical skills by presenting therapeutic options with supporting information. As a Web-based guideline, it can be used in a variety of ways—providing information on algorithms, assessment, special needs, interventions, and planning for pain management at the chosen level of detail. Management of Opioid Therapy for Chronic Pain (2003) provides practical and theoretical advice to the practitioner, including a model opioid agreement, detailed descriptions of roles and responsibilities for providers including guidelines for managing medication-related behavior and drug/dosing tables, and supporting patient-education materials. Additional toolkits have been published to provide guidance in the VHA’s “Pain as the 5th Vital Sign Initiative” and for the assessment of outcomes.
A consensus statement focusing on the assessment of pain among cognitively impaired veterans has been published and has encouraged sensitivity to this issue, the adoption of a standardized approach to this problem, and, not surprisingly, additional discussion and research. Recently, collaboration with the VHA National Center for Ethics has yielded publication of a brief statement on the rights of persons to expect appropriate pain management, including the use of opioids for the management of chronic pain in certain clinical situations. The article delineates provider and patient roles and responsibilities in the use of chronic opioid therapy, and, in particular, describes a tool called an “opioid agreement” that reinforces the collaborative nature of the patient-provider relationship in this context.
An important advantage of the VA healthcare delivery system is the availability of advanced technologies for documenting and monitoring care, especially the computerized patient record system. One of the first goals of the strategy was to promote routine screening for the presence and intensity of pain, otherwise referred to as the Pain as the 5th Vital Sign Initiative. By 2003, systematic review of records revealed that approximately 98% of veterans receiving care at a VHA facility had a documented pain score within the past 12 months. More recently, similar data document that pain screening occurred at the most recent clinical encounter in 97% of the records reviewed. The availability of an electronic template for documenting a comprehensive pain assessment further encourages a more thorough evaluation and documentation of veterans’ pain complaints, a plan for pain care including both pharmacological and nonpharmacological interventions, assessment of the effectiveness of the interventions, and appropriate patient education. Systematic review of the available data similarly documents a growing rate of adherence to recommendations for this stepwise approach to effective pain management.
An additional tool for monitoring the impact of the VHA National Pain Management Strategy is the systematic collection of data from random samples of veterans following episodes of inpatient and outpatient care. In this context, data related to veterans’ experiences of pain and pain treatment are collected. For example, data document that more than 75% of outpatients report that “pain interferes with normal work” at least to a moderate degree. Of the sample of veterans who reported receiving care for their chronic pain by a VA provider in the past 12 months, just over 60% reported at least a “good” level of satisfaction with their care. Data from samples of recently hospitalized veterans yielded similar findings. These and other data can serve as important benchmarks for ongoing performance improvement efforts.
An explicit component of the strategy is a focus on pain-relevant research. Evidence of the strategy’s success in this area is the increase in the number of pain-relevant, investigator-initiated research projects funded by the VHA Office of Research and Development from approximately 10 in 2000 to 43 in the current fiscal year. In an effort to further promote networking among investigators, increased investigator-initiated and collaborative research, and the VHA research priorities, a VHA Pain Research Working Group has been developed. The current membership comprises 50 VA and nonVA investigators. A face-to-face meeting and twice monthly conference calls among the members has led to the development of several more focused groups of investigators who share interests in research in specific areas. Cluster groups have developed in the areas of diversity; assessment of pain in the cognitively impaired; pain and psychiatric comorbidities; and pain, opioid therapy, and substance abuse. Each of these groups has already developed specific projects such as conducting systematic reviews of the relevant theoretical, clinical, and empirical literatures and developing a research agenda. An agreement has been reached to publish a special issue of the VA’s Journal of Rehabilitation Research and Development, which will include peer-reviewed articles from many members of the working group. Finally, the VHA Office of Research and Development, partially as a function of the efforts of this group, has disseminated a request for proposals for investigator-initiated research on chronic pain treatment and management. This request supplements several existing announcements that have explicitly encouraged research on pain and pain-related disability.
Of growing concern to the VHA is the care of service members returning from deployment in Iraq and Afghanistan. In response to this growing need, a multidisciplinary expert panel has been organized to develop policy, guidance, and a comprehensive approach to address the pain care needs of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members. Particularly important are issues related to the seamless transition of pain care from military treatment facilities to VHA facilities, including four specialized VHA treatment facilities that have been established for veterans who have suffered traumatic injuries including blast injuries with head trauma and catastrophic injuries to the extremities. The existing infrastructure of the National Pain Management Strategy is being activated to specifically facilitate these transitions and to ensure that the necessary pain management resources are available to address the complex and serious array of problems experienced by these veterans.
The true strength of the VHA National Pain Management Strategy is manifest in the commitment and efforts of VHA staff in the field. An increasing number of facilities have developed specialized pain management services including multidisciplinary pain programs. Many facilities have reported on the development of pain resource nurse (PRN) programs that develop registered nurses as pain champions and resources for patients, families, and other staff at the point of care. Increasingly, teams have been developed to provide an additional resource to providers concerned about the use of chronic opioid therapy. These teams provide systematic review of specific cases to confirm adherence to recommendations from the VHA and Department of Defense’s Chronic Opioid Therapy Guidelines and to provide recommendations to providers that are designed to promote optimal and safe opioid therapy. Patient and family education programs are routinely offered, including multidisciplinary didactic programs and discussion groups designed to promote more effective use of healthcare resources and improved adjustment and adaptation to chronically painful conditions. These examples highlight an increasing array of innovative programs and initiatives that are the hallmark of the VHA Strategy.
Future Directions
The established goals of the VHA National Pain Management Strategy continue to serve as the guideposts for future efforts to promote effective management of pain for veterans receiving care in VHA facilities. At the Fourth National Leadership Conference on Pain Management and End-of-Life Care, held in March 2005, several broad objectives were highlighted to further advance the goals of the strategy (see Table 2).
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Consistent with these overarching objectives are several specific initiatives. For example, several steps have been taken recently to better utilize the VISN POCs in their role as liaisons between the national leadership group and facilities. Quarterly conference calls with the VISN Pain POCs have now been initiated, and the groups now serve as explicit conduits for communicating with providers in the field. Information about pain-relevant performance monitors is now disseminated to the field through this group to facilitate performance improvement activities at the VISN and facility level. Responsibilities of this group for ensuring VISN and local facility adherence to national policies have also been reinforced.
Another important initiative involves efforts to strengthen linkages between those involved in the National Pain Management Strategy and other groups within the VHA including the Pharmacy Benefits Management Program, the Office of Quality and Performance, the Office of Research and Development, the Office of Academic Affiliations, the Anesthesiology Field Advisory Committee, and the VHA Palliative Care Program, among others. These linkages have already facilitated discussions about such issues as the seamless transition of pain care for returning OEF and OIF veterans, the development of second generation pain-relevant performance monitors, and the development of the recent request for proposals for research on chronic pain. Partnerships with the U.S. Department of Defense will continue to be important in the development of practice guidelines, educational initiatives, and the development of effective and efficient plans for providing care for veterans as they transition from military treatment facilities to VHA facilities. The development of similar bridges to agencies and organizations outside the VHA are underway, for example, partnership with groups involved in patient education initiatives that specifically target veterans and their families.
A continued focus on the broadest possible spectrum of pain disorders is critical to the overall success of the strategy. Revision of the existing post-operative pain guidelines is scheduled to incorporate the rapidly growing empirical literature that should inform practice in acute care settings. Collaboration with colleagues in oncology is ongoing, and efforts to promote increased attention to pain management in the context of cancer care are a high priority.
Other special populations will require focused attention including veterans returning from Iraq and Afghanistan, especially those with multiple traumatic injuries including brain injuries. Not surprisingly, given the advancing age and multiple medical comorbidities and health risks of veterans, problems such as painful diabetic neuropathy, other neuropathic pain conditions, and arthritis will require special attention.
Issues related to the appropriate assessment and management of pain among the elderly will continue to be an important focus. At the same time, given the VHA’s emphasis on promoting a model of primary care, the development of a VHA Pain Primary Care Working Group is underway. The development and dissemination of relatively simple algorithms for the assessment and management of some of the most common pain conditions is one particular focus of this group.
Guidelines for referrals to specialty pain services including interdisciplinary pain centers, commonly called service agreements, are increasingly being developed at the facility and VISN levels. Not surprisingly, consideration of costs, as well as demonstrated effectiveness, of pharmaceuticals and other procedures and interventions for pain need to be taken into account in the development of these algorithms.
Improving access to appropriate pain care will continue to be a particular challenge for the VHA. The VHA has invested substantially in the development of an increasing number of community-based outpatient clinics. At the same time, the VHA must find ways to provide for timely and appropriate specialty services, particularly interdisciplinary pain centers, pain medicine specialists, and rehabilitation medicine services. The recent decisions to provide chiropractic care and support for complementary and alternative medicine services and research are important expressions of the VHA’s commitment to promoting innovative, interdisciplinary pain care.
References
Craine, M., & Kerns, R. D. (2003). Pain management improvement strategies in the Veterans Health Administration, APS Bulletin, 135, 1–9.
Gordon, D. B., Dahl, J. L., Miaskowski, C., McCarberg, B., Todd, K. H., Paice, J. A., Lipman, A., Bookbinder, M., Sanders, S. H., Turk, D. C., & Carr D. (2005). American Pain Society Recommendations for Improving the Quality of Acute and Cancer Pain Management. Archives of Internal Medicine, 165,1574–1580.
Veterans Health Administration, Department of Defense. (2001). Management of acute post operative pain (Office of Quality and Performance publication 10Q-CPG/Pain-01). Washington, DC: Author.
Veterans Health Administration, Department of Defense. (2003). Management of opioid therapy for chronic pain (Office of Quality and Performance publication 10Q-CPG/OT-03). Washington, DC: Author.
Robert D. Kerns is the national program director for pain management of the VA Central Offices; chief of psychology service at the VA Connecticut Healthcare System; and professor of psychiatry, neurology, and psychology at Yale University in New Haven, CT.
John Booss is former national program director of neurology service for the VA Central Office and professor emeritus in the department of neurology at Yale University School of Medicine, New Haven, CT.
Martha Bryan is assistant director in health services, research, and development at the VA Central Office in Washington, DC.
Michael E. Clark is clinical director in the Chronic Pain Rehabilitation Program and associate professor in the department of psychology at the University of South Florida, Tampa, FL.
Audrey C. Drake is deputy chief nursing officer in the VA Central Office in Washington, DC.
Rollin M. Gallagher is director of pain services for the Philadelphia VA Medical Center and clinical professor in the department of psychiatry at the University of Pennsylvania, Philadelphia, PA.
Beverly Green Rashad is chief nurse executive at the Overton Brooks VAMC, Shreveport LA.
Ruth Markham is senior business analyst, Office of Information Field Office, Salt Lake City, UT.
Jack Rosenberg is the coordinator of pain management services, VISN 11, at Ann Arbor VA Medical Center and assistant professor in the departments of physical medicine and rehabilitation and anesthesiology, University of Michigan, Ann Arbor, MI.
Anne Turner is the instructional systems specialist and national projects manager at the Employee Education System, Birmingham Employee Education Resource Center, Birmingham, AL.