rx16 presummit 200_empower_veteransprogram

PowerPoint Presentation

Empower Veterans Program: Innovative Functional Restorationfor High Impact Chronic Pain

DisclosuresThe following presenters each have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.Michael Saenger, MD, FACP Ushvani Persaud, LCSW, MSWPaul Burholt, LCSW Beth Hammons, PhD Jennifer Gansen, DPT Lindsay Ballengee, DPT

All content represents the personal views of each presenter and does not necessarily reflect the views of the Atlanta VA nor of VHA

DisclosuresAll planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.The following planners/managers have the following to disclose:John J. Dreyzehner, MD, MPH, FACOEM Ownership interest: Starfish Health (spouse)Robert DuPont Employment: Bensinger, DuPont & Associates-Prescription Drug Research Center

Learning ObjectivesDescribe how the Empower Veterans Program provides intensive, integrated self-care coaching for veterans with chronic pain.Identify each of the bio-psycho-social-spiritual dimensions of real chronic pain.Advocate the value of integrated, multidisciplinary coaching for functional restoration and wellness in chronic pain.Explain how to implement similar intensive whole health interventions through clinical and business cases.

OverviewMichael Saenger, MD, FACPLead Physician, Pain Management, VISN 7Director, Empower Veterans, Atlanta VA Medical Center

EVP Workshop OverviewOverview ofNeed for large scale functional restorationEmpower Veterans Program (EVP)

Perspectives fromSocial Worker (then Q&A and Break) Whole Health facilitatorACT facilitatorMindful Movement facilitators

Q&A

The GoalSafe and thriving Veterans

Step 3Multi-Disciplinary

Step 2Subspecialty Consults

Step 1 PatientPrimary Care (Self Care desired)

OpioidsCurrent State of Pain Management

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No Change in Chronic Low Back Pain From 73mg MEDD vs NSAID or Placebo9

Evidence in Chronic Painfor Long Term Opioid TherapyNo strong evidence for effectiveness

Possible functional Sweet Spot with small infrequent doses

Strong evidence of harmWorsening of Migraines and Fibromyalgia Association with worsenedMoodSleepAssociation with increased deaths10Chou, AHRQ, 2014

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Risk of Accidental Overdose Death in Veterans

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More Effective Pain MedicineDuloxetine (SNRI)

Of clients with Diabetic Peripheral Neuropathy 30% may have 30% less pain

I.e. not all helped, and no pain curedGriebeler et al, Annals Int Med, 2014

Some Common Injections QuestionedEpidural Spinal Injections for Central Canal StenosisAfter 2 weeks to 2 monthsNo difference in pain or function forSteroids + temporary numbing medicine, versusNumbing medicine by itselfFriedly et al, NEJM, 2014

Common Surgery for Back QuestionedLaminectomy when done not for radicular pain but primarily for Low Back Pain3 studies, after 2-5 years after surgery, No difference in pain in those with surgery versus those who were randomized to waitE.g.: Chou et al, Spine, 2009

Towards therapies:Safe andModerately effective andActive / Self-efficacious:

Away from therapies:Dangerous orIneffective orPassive:

Saenger, APA PCSS-O Webinar Series, Evidence CAM LBP, 2013

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Deep BreathingProgressive RelaxationSelf MassageTENS self careMindful Movement:Alexander TechniqueYoga / Tai ChiPT Neuro-Muscular Rehabilitation Mindfulness TrainingCBT or ACT for PainAway from therapies:Dangerous orIneffective orPassive:

High Dose OpioidsBenzodiazepinesChronic Muscle RelaxantsChronic Sleep MedicationsSome InjectionsSome Surgery


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During Tapering or beginning Active Self-Care with temporary

Bridging Therapies(Passive, Evidence-Based):

Acupuncture orSpinal Manipulation orMassage orHypnosis


Deep BreathingProgressive RelaxationSelf MassageTENS self careMindful Movement:Alexander TechniqueYoga / Tai ChiPT Neuro-Muscular Rehabilitation Mindfulness TrainingCBT or ACT for PainAway from therapies:Dangerous orIneffective orPassive:

High Dose OpioidsBenzodiazepinesChronic Muscle RelaxantsChronic Sleep MedicationsSome InjectionsSome Surgery


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Traditional Multi-Disciplinary Pain Management Programs100 hours in 3-4 weeks

Effective

Costly, but cost effective in earlier age

Limited accessAetna, Chronic Pain Programs, accessed 3/1/2016

Back or Pain SchoolsA little bit of thisOften 60 min of weekly or monthly drop in didactic

Not enough and mixed resultsBrox et al, Spine, 2008

CBT for Chronic Pain8+ weeks of 50 minute individual or group

Mild to moderate effect size for pain interference, QoL, catastrophizing Stewart et al, Clin J Pain, 2015

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Step 1Veteran Client & Primary Care

Self-Care

Empower Veterans Program

Accessible

Functional Restoration

Intensive, Integrated Self-Care Coaching

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Why Groups?Effective

Efficient

Wheel of HealthVHA Office of Patient Centered Care and Cultural Transformation

EVP Transdisciplinary Coaching10 weeks of self-care training for WellnessGroup Coaching (30 hours)Whole Health and Well-BeingACTBased on what is most important to youLearning to mindfully not let thoughts, feelings nor circumstances derail one from their valued directionMindful MovementFeeling safe in and aware of ones own bodyUsing movement to retrain the brain

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Weekly Individualized Coaching

Whole Health and ACT weekly check-in call

Mindful Movement in person

Break-even Modeled in 20 Veteran groups

> 140 Veteran graduates (and some spouses)

Changes in Scheduling:8 Concurrent Training Cohorts

Going Forward with iterative improvements:Model for Improvement

EVP for Training ONLYDistinction of training and assessment of pharmacological pain management

Feedback from FacilitatorsLearning from one another Integrating training Transdisciplinary

Stories from VeteransMr. S1Before: to relieve stress, I get on my computer and shoot up things

After: Im not angry anymore Im using my breathing [skills] Now I appreciate my wifeEvery Veteran should come to this program

Stories from VeteransMs. SBurdened by stress and alcohol

The pain is not in control anymoreReconnected with my church family

Stories from VeteransMr. W23 years in misery from Chronic Pain with careMANY Inside VHA and outside providers

EVP is the best thing the VA has given meWrote letter to forgive man who killed his family in car accident

Stories from VeteransMr. S2Very depressed and isolatedSuicidal Ideations dailyCame twice to 10 week EVP

I dont need you all anymore. Im doing better.But can you help me quit smoking, because, I want to live!

Stories from VeteransMr. E

I helped my family with what I learned in EVP[in family argument] I sent my daughter to her room and I talked with my wife [about not screaming in anger or saying that their daughter was stupid]Thats the way I used to treat you

Feedback from SpousesMy husbands a new man[not isolating anymore]My husband went to church for the first time in two years, and now is spending time with family again Now he get dressed, has breakfast with me and goes to the park every dayHis anxieties are so much better [had been attending weekly PTSD support group without change for years]

Clinical Outcome Assessments(Preliminary Details to Come)Chronic Pain Acceptance QuestionnaireAcceptance Action Questionnaire IINRSMultidimensional Pain Inventory - InterferencePHQ9WHOQOL-BREFPROMIS 29 paper v2.0Pain Catastrophizing Scale

Next StepsAnalysis ofClinical outcomes (with sensitivity to change)Utilization outcomesStaff satisfaction

Empower Veterans Value CompassCostsUtilization of Emergency, Walk-in and PM&RSatisfaction Long Term Veteran SatisfactionBiological StatusHigh Dose OpioidsBenzodiazepine UseUrine Drug ScreenAnxiety / PTSDDepressionSelf-efficacyFunction Health StatusQuality of LifeAttainment of Personalized Functional GoalsDisruptive Behavior

Empower Veterans Balanced ScorecardFinancialUtilization of Emergency, Walk-Ins, PM&RUtilization of PACT routine appointments Other Personnel CostsPharmacy CostsSatisfaction vs NeedVeteran Accidental Overdose Deaths from OpioidsVeteran FunctionLong Term Veteran SatisfactionLong Term Congressional Office SatisfactionInnovation and LearningStaff Satisfaction and RetentionOperating at top of their licenseIncreased EfficiencyGroup VisitsSecure MessagingTeleHealth EncountersKey ProcessesIdentification of Veterans at RiskTraining Veterans in Self-Management

Social Worker PerspectiveUshvani Persaud, LCSW

Bio-Psychosocial & Financial assessmentPlanning & InterventionCrisis Intervention Pt & Family Education Counseling & Advocacy Resource Brokering & Referrals Quality Improvement & Systems Integration Case Facilitation

Social Work Services:

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Stories of Veteran success with Social Work Intervention (Part 1 of 4)

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Q & A

10 Minute Break

Understanding Pain video link:http://www.dvcipm.org/clinical-resources/joint-pain-education-project-jpep

EVP WHOLE HEALTH

NEW PERSPECTIVES AND SKILLS FOR VETERANS LIVING WITH CHRONIC PAIN

Paul Burholt, LCSW

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Personal Health InventoryFuller Life

Well-Being

Values

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BASIC PREMISE:

I can create a fuller life for myself, in spite of my pain and limitations !

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The goal posts have been moved-- but that does not mean I am out of the game

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Regaining lost ground

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Whole Life IssuesPoor DietPoor SleepSpiritualityloss of meaning and purposeIsolationAnger and resentmentThe challenge of suffering

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I cant have a fuller life until I am pain-free!

Paradigm Shift is always hard

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Mindful Practice

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SEQUENCE OF CLASSES

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Question this!

Someone with chronic pain and disability is of no value and has nothing to offer

And this!

You are only of value if you are young, healthy and pain-free

Week 2: FoundationalCan someone with chronic pain and disability have a life which is fulfilling and meaningful?

Can I live a fuller life, in spite of my pain and the tendency toward an ever more constricted life which my pain seems to imply?

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Week 2 (Contd.)Viktor Frankls witness

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Week 3: Foundational

Empowerment by Values

Personal Values clarification and Goal setting

Reinforces ACT

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Weeks 4-6Food and Drink

Sleep

Spirit and Soul

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Weeks 7-9More Personally Challenging and Existential Themes

Re-building Relationships

Forgiveness

Meaning in our Suffering

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Because many Veterans are in Crisis

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Dont believe everything you think!

Observer Self

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Empowered to Live a Fuller Life

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Acceptance and Commitment Therapy (ACT)Beth Hammons, Ph.D.Clinical Psychologist

ACT Overview: ValuesGoal of ACT is to create a rich, meaningful life

Personal Values

What you want to be doing with your lifeWhat you want to stand forChoices you make about what you want your life to be about

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ACT Overview: ActionEmphasis on taking effective action

Action is directed by personal values

Acceptance is an essential part of committed action

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ACT Overview: Barriers

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ACT Overview: MindfulnessMindfulness is an essential facet of ACT

Completed mindfulness practice during Whole Health presentation

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ACT Overview: Empirical DataBased on empirical data supporting its effectiveness

Overview of EVP ACT program evaluation dataIncreased activity engagement regardless of painIncreased psychological flexibilityNo changes in pain willingness

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ACT OverviewNot about getting rid of unpleasant feelingsAbout living a meaningful life

Use of metaphor and experiential exercisesWhat is your experience telling you?

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The Passengers on a Bus: An ACT metaphor

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EVP-Mindful MovementJennifer Gansen, DPTLindsay Ballengee, DPT, RYT

Jennifer Gansen, DPTEVP-MM developer and trainerRelevant background/experience:Hospital-based multi-disciplinary Chronic Pain Program (1993-95)Research Physical Therapist in Neurorehabilitation to improve walking and use of arm after stroke.Awareness Through Movement instructor (Feldenkrais Method)6 years VA Outpatient clinic and Pain School

EVP-MM: Important role of the Nervous SystemPain is a protective output of the brain that reflects a best guess perceptual inference of threat/danger.

Objectives:Relate Activity to values & goalsMinimize nociceptive input from tissuesPromote feeling safe, competent, and in controlPromote enriched learning environment

Need to design structured approach to rehab that reconciles Tissues AND Nervous SystemStructural Pathology Paradigm(Tissues)Learning/Neuroplasticity(Nervous System)ContentAerobic Exercise guidelinesEmphasize mindfulness & variety of movementContentOverload Principle(no pain, no gain!)Weber-Fechner Law and ability to perceive changeContentStretch tight tissues & Strengthen weak tissuesDynamic systems and Re-set buttonContentWhole Body Movement systemsLearning principles like chunking

Need to design structured approach to rehab that reconciles Tissues AND Nervous SystemStructural Pathology Paradigm(Tissues)Learning/Neuroplasticity(Nervous System)StyleSMART or FITT goalsGoals reflect Values

StyleRole as ExpertRole as Coach

StyleAvoid Diagnostic UncertaintyMinimize perceived threat value of diagnosisStyleHurt HarmMinimize perceived threat value of stimulus

EVP Mindful Movement (EVP-MM) Overview:ContentUnderstanding Pain and natural tendencies of the nervous systemContent5 Minute walking (movement) break/ 3x per dayContentNeuromuscular Reeducation (NMR) or Movement Awareness LessonContentMotion is Lotion Exercises (MILEs): Functional progression of movement patterns with emphasis on mindfulness & context varietyContentNeutral Spine and Re-set Button: Experiential and problem-solving approach emphasizes guidelines applied to daily activities

EVP Mindful Movement (EVP-MM) Overview:StyleActive Listening: Non-judgmental, empathic, convey a positive regard

StylePromote Autonomy

StylePromote Self-Efficacy

StylePromote Social-Relatedness/ Values

POWER TOOL: MINDFULNESS when EXERCISINGIf you notice increased pain with exercise, ask yourself 2 questions:

Am I safe?

If I continue, will I pay for it later?

1) Is my breath calm?2) Is my body calm?3) Am I staying in touch with my body?

Source: 6 minute video on YouTube NEIL PEARSON: EXERCISE GUIDELINEShttp://youtu.be/gN-WwxfPIZo

Lindsay Ballengee, DPT, RYT: Mindful Movement Experience

SpreadManualized EVP is coming!

Cheers for GREAT EVP Team:Paul Burholt, LCSWChaplain Curtis Williams, D MinChaplain Drew Tomberlin, D MinBeth Hammons, PhDJenna DelVentura, PhDJennifer Gansen, DPTLindsay Ballengee, DPT, RYTGeorge Shaw, PTUshvani Persaud, LCSWNatasha Ewell, MSA; Bevelyn Porter, MSAFaye King, Administrative Officer

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2

Step 1Veteran Client & Primary Care

Self-Care

Empower Veterans Program

Accessible

Functional Restoration

EVP for a Fuller Life!

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Special Thanks to:Atlanta VA Healthcare SystemLeslie Wiggins; Director (now Director, VISN 7)David Bower, MD; Chief Medical Officer (now Acting Director of ATL VA)Sandy Leake, MSN, RN; Associate Director, Nursing/Patient Care ServicesTom Grace; Associate Director; Bob Evans; Assistant DirectorAnne Tomolo, MD, MPH; Quality Scholars ProgramDavid Fishman, MD; Chief of Anesthesia Service LineCedrella Jones-Taylor, MD; Deputy Chief of Primary Care Service LineKathy Davari, Pharm D, Supervisor Pharmacy SpecialistsVHA Pain Management Mac Gallagher, MD; Director and teamVHA Office of Patient Centered Care and Cultural TransformationTracy Gaudet, MD; Executive Director and teamVHA PACT Pain CoP (Community of Practice); PDICI CoP; Ilene Robeck, MD

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Q&A

Thank you!

Key ReferencesACT Manual:1Vowles, K.E., Sorrell, J.T. (2007). Life with Chronic Pain: An acceptance-based approach.

EVP-Mindful Movement:1Lotze, M., Moseley, G.L. (2015). Theoretical considerations for chronic pain rehabilitation. Phys Ther (95):1316-1320.2Pelletier, R., Higgins, J., Bourbonnais, D. (2015). Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders 16:25. DOI 10.1186/s12891-015-0480-y.3Zaman, J., Vlaeyen, J.W.S., Van Ourdenhove, L., Weich, K., Van Diest, I. (2015). Associative fear learning and perceptual discrimination: A perceptual pathway in the development of chronic pain. Neuroscience and Biobehavioral Reviews 51: 118-125.

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