VISN 20 Residential Functional Restoration Pain Program A Supportive Model with MHRRTP Admission and Pain Clinic Programming

Presented By: Laura M. Tuck, Psy.D Rehabilitation PsychologistVISN 20 rFRPP Clinical Team Lead

Program Director: Timothy Dawson, MDMedical Director: Bernard Canlas, MDDirector, Community & Residential Care Services: Simon Kim, PhDNurse Coordinator/CARF Data Management: Pearl McGranaghan, RN

Scope of Service • The MHRRTP at VA Puget Sound is comprised of five (5) residential treatment programs (88 bed capacity, serving both male and female Veterans).

• PTSD Residential (18 beds)• SA Residential (20 beds)• DCHV (Domiciliary Care for Homeless Veterans) (18beds)• Pain Residential (8 beds)• CWT-TR (Compensated Work Therapy – Transitional Residences) (24 beds)

• Pain Residential Program• Joint collaboration with the MHRRTP and Pain Clinic providing a supportive model

where Veterans are admitted to the MHRRTP and engage in specialty treatment programming offered by the Pain Clinic staff.

• Program Duration: • Approximately 6 weeks, individualized to Veteran’s tx goals

• Program Objective: • Biopsychosocial approach, validation and “new” experience with the healthcare system • Enhance active self-management to increase functioning, values-based living, and quality

of life through reactivation, coping, and neuroplasticity.

Staff Roles: Seamless Patient-Centered Care

Pain Clinic DOM (MHRRTP)

• Medical Providers: PA-C, ARNP, MD• Groups and screens

• Nurse Coordinators• Triage consults and manage

data for CARF and facility• Psychology

• Administrative, screens, intakes, and group therapy (individual, as needed)

• Physical Therapy • Groups, screens/evaluation,

creating exercise program• Acupuncturist (PA-C) • Pharmacist• MSAs

• Scheduling and communication

• Medical Providers: PA-C• Intake and discharge history

and physicals and sick call• Nursing

• Triage sick call, medication management, groups

• Social Work • Case management and groups

• Recreational Therapy• Outings and guest lectures

• Chaplain • Elective group and guest

lectures• Vocational Rehabilitation

• Guest lectures

rFRPP Programming• Progress Review- Weekly Patient-Team Meeting (RN, Case Manager, Psych, MD)• PRN Treatment Team Meeting with Veteran and Repair Counsel- Troubleshooting• Mind-Body Medicine- Neuroplasticity, tai chi, qi gong, meditation, and hypnosis• Holistic Health- Confluence of Eastern and Western medicine for pain

management• Acupuncture- Group auricular (ears) acupuncture/ Battle Field Acupuncture (BFA)• Physical Therapy- Didactics and daily exercise (with PT or monitored by staff)• Motivational Enhancement- Values exploration to enhance adaptive health

behaviors/ self-management• Insomnia Treatment (CBT-I light)- Empirically supported treatment to address

sleep, tailored for chronic pain• Pain and Relationships- Explores Identity and role pain behavior in relationships

(including partners, family, and the healthcare system)• Yoga Nidra- iRest

*Relaxation Skills- Taught in sleep and mind-body groups. Guided imagery, diaphragmatic breathing, body scan, autogenic training, etc.

rFRPP Programming (continued)

• Wellness- Based on empirically supported programs for people with chronic illness and disabilities

• CBT/ACT- Cognitive Behavioral Therapy and Acceptance and Commitment Therapy are empirically supported treatments for pain management

• Quality of Life- Based on research on quality of life for people with acquired disability (Re-engagement in personally meaningful activities such as work, volunteering, or school; social support/relationships; spirituality; and positive psychology/resilience)

• Wellness Recovery Action Planning/Flare-up Management Planning (foundation for discharge planning and assists primary care provider with treatment planning upon return to community)

• Caregiver Support- Via telehealth or in-person • Co-Disciplinary Discharge Meeting- Case Manager and Psychologist/Team

Lead*Additional treatment options include individual therapy as needed, Graded Motor Imagery/Mirror Box Therapy, recreational therapy, pool therapy, smoking cessation, and substance abuse treatment (AA, NA, Celebrate Recovery)

Time Monday Tuesday Wednesday Thursday Friday Saturday/ Sunday0630-0800 Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast

0745-0830

RAC Officers & Team Lead Meeting

RAC Officers & Team Lead Meeting

RAC Officers & Team Lead Meeting

RAC Officers & Team Lead Meeting

RAC Officers & Team Lead Meeting

0830-0915

ALL DOM Community Meeting

Program Community Process Group

ALL DOM community Meeting

Program Community Process Group

ALL DOM community Meeting

ALL DOM community Meeting

0915-1000

Progress Review (Select Veterans)

Progress Review (Select Veterans)

Progress Review (Select Veterans) OR PT Intake

(week 1 Admits Only)

Progress Review (Select Veterans)

1000-1100

Open Gym / Case Management

Open Gym / Case Management

Practice Activities(Worksheets & Logs)

Open Gym / Case Management

Open Gym / Case Management

1100-1200

Holistic Health Group Motivation GroupPain Program Orientation

Group/ Open Gym / Mindfulness on your own

Mind-Body GroupDOM Orientation (week

1 veterans only) / Wellness Group

1200-1300 lunch Lunch Lunch Lunch Lunch Lunch

1300-1400

Group Acupuncture Pain & Relationships Group Sleep/Relaxation Group CBT/ACT group WRAP Group

1400-1500

PT groupPhysical Therapy Group OR Psychology Intake

(week 1 Monday Admits Only)

Mindful Movement OR Psychology Intake (Week 1 Tuesday Admits only)

PT Group Quality of Life Group *Rec Therapy optional outings

1500-1600 DOM Women's Support Spiritual Tools Group Fly Tying Guitar Class

t1600-1700

DOM Peer Support Group Meeting

1630-1830 Dinner Dinner Dinner Dinner Dinner Dinner

1830-1930

DOM Community Meeting

DOM Community Meeting

DOM Community Meeting

DOM Community Meeting

DOM Community Meeting

DOM Community Meeting

1930-2300 Celebrate Recovery NA/AA Meeting NA/AA Meeting NA/AA Meeting NA/AA Meeting

Lights Out

Lights Out Lights Out Lights Out

Lights Out

Lights Out

Sche

dule

Admission Criteria Summary• Is it the right time? • Has complex chronic pain and below 120 MED (or most recent CDC guidelines)• Is the veteran medically and psychologically stable? • Acute medical concerns have been addressed- safety first, limit risk of adverse

events with increased activity level • Able to complete ADLS and has mobility to navigate campus (with adaptive

equipment, as needed)• Stable in terms of suicidal ideation with no plans or intent• Stable and well-managed psychosis so able to attend to programming and interact

with staff and peers collaboratively • Cognitively able to attend to and remember programming and navigate the

environment • Substance abuse is not the primary focus • Psychosocial state permits admission • Veteran is invested in the philosophy of care for active self-management skills for

reactivation, coping and remodeling/neuroplasticity• Agreeable to 6 weeks in a residential treatment setting

Consult ProcessPain Clinic rFRPP consult placed by provider

Pain Clinic Nurse Coordinator reviews chart

Yes: DOM/rFRPP materials shared with Veteran

Comprehensive multidisciplinary screen in-person or via telehealth. VA Puget Sound Pain Clinic and DOM team members, as indicated. Medical provider, PT (if available), Veteran, and their support person at the remote site.

Yes: Pain Service submits DOM consult. DOM Admission Coordinator completes chart review and phone screen.

Yes: Schedule admission. Option to participate in programming via phone or telehealth until admission date.

No: Complete recommended work-up/treatment. Will provide treatment recommendations to meet individual needs.

No: Complete recommended work-up /treatment to meet admission criteria and resubmit consult when appropriate.

Consult Placement: 3 Easy Steps

1. Go to Notes Tab --> New note 2. Select location and Date/Time of visit

3. Enter note title RESIDENTIAL PAIN PROGRAM (FRPP) REFERRAL

Dem

ogra

phic

s

Outcome Measures• VA standardized measures nationally for CARF accredited programs

• Remember to use measures validated to your patient population. See the APA Guidelines for Assessment of and Intervention with Persons with Disabilities , the SCIRE Project, and Rehab Measures

• CARF programs measure percentage change nationally• Locally, will complete analysis for statistical significance when a greater “n” is achieved

• Measures• Pain Outcomes Questionnaire (POQ)

• Includes measures of pain history (descriptive information, pain experience, employment, disability status, and opioid use), average pain intensity, pain interference, emotional distress, pain-related fear, satisfaction with treatment, and medical use.

• Tampa Kinesiophobia Scale (TKS) • Assesses the level of fear related to movement/activity level.

• Insomnia Severity Index (ISI)• Evaluates the nature, impact and severity of insomnia in adults.

• Pain Catastrophizing Scale (PCS)• Assesses tendency to ruminate, magnify and feel hopeless about pain. Level of catastrophizing is a

primary predictor of pain-related disability level. Decreased catastrophizing is associated with decreased depressive symptom and improved pain related outcomes.

• Pain Self-Efficacy Questionnaire (PSEQ)• This measure is an estimate of one's self-confidence in their skills and knowledge to cope with pain.

Higher scores indicate higher levels of self-efficacy.

****Lower scores are desirable, with the exception of the PSEQ

Outcomes:

Pain Outcomes Questionnaire *Target is 20% change, current change 9.1%Mild 0-57 Moderate 58-114 Severe 115-171 Extreme 172-190

N=15

Outcomes:

• Average Pain does not change, which is consistent with the literature • Mobility from the severe to the moderate range • ADLs improve and fall within the mild range at admission and DCN=15

Outcomes:

• Vitality decreased from the severe to moderate range • Negative Affect remained in the moderate range • Fear decreased from the moderate to mild range

N=15

Outcomes:

• Insomnia Severity Index remained in the moderate range, starting in the upper limits and falling to the lower limits

• Tampa Kinesiophobia Scale (fear of movement) remained in the moderate range • Pain Self-Efficacy Scores showed an increase while remaining in the moderate range• Pain Catastrophizing Scores are clinically relevant at over 30 with improvement at discharge.N=15

ISI (0-28)

Kinesiophobia (17-68)

PSEQ (0-60) Reversed score

PCS (0-52)0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

18.2

39.5

28.226.0

14.7

35.933.4

16.5

Additional Outcome Measures

Pre-CoursePost-Course

Outcomes:

N=15

Overall

Satisfa

ction

Provid

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Provid

er Ski

lls/Compete

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Sched

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ase

Recommen

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Accurac

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Med Use_

Pre

Med Use_

Post0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

8.8 9.1 9.38.8

9.49.1

4.0

7.4

Course Satisfaction

Veteran Perceived Benefit of Each Class

Future Programming Considerations• After enough surveys are completed, analyze class satisfaction

feedback for quality improvement • Caregiver Support• Currently provided in progress review and case management with

as needed couples therapy (or caregiver and Veteran) . Consider formal group, possibly combine oFRPP and rFRPP caregivers.

• Increase Relaxation/Mind-Body offerings • Likely 2017

• Add additional PT educational module per week • Late 2016

• Formalized Nutrition Class • Currently anti-inflammatory diet module, then as needed with

various staff (nursing, SW, and psychology). Menu key for “chow hall”. Case Manager is creating a cookbook.

Future Considerations Continued…• Medications/Pharmacy Class • Late 2016

• Formal Aftercare group in addition to individual follow-up• Potential redesign with “Majors” and “Minors”• Class example- relapse prevention class co-facilitated with a psychologist

from the Substance Abuse Track and a Psychologist from the Pain Track • Enhanced aftercare for diagnosis of comorbid substance use disorders • See if collaborative addictions and pain program appointments can be

scheduled closer to discharge date (schedule these upon admission so there is no wait time).

• IRB• Telehealth offering at National Level• Increase access to care with complex medical comorbidities and acquired

disability

How can this be used outside of a formal Pain Clinic?• Referrals to VISN 20 rFRPP as an added resource• Implementing aspects of programming in stepped model of care • Pain PACT clinic offerings • Understanding pain as a “hidden disability” and advocacy • Role/identity redevelopment • Disability as a social issue • Rehabilitation model of care

• Enhance autonomy for community reintegration

• Validation • “New” experience with pain/functional management • Biopsychosocial model and neuroplasticity “buy-in”

• Increased Engagement in Care • Active self-management, less focus on biomedical approaches and opioid

use • Motivational Enhancement

Thank you• VA Puget Sound Pain Team • Special acknowledgements

• Lauran Hollrah, PsyD for creating a strong outpatient model to guide the residential program

• Pearl McGranaghan, RN for administrative support, particularly data management

• Leadership support

• VA Puget Sound MHRRTP • Joining a “well oiled machine” • Skilled, enthusiastic, and empathic providers • Leadership support and collaboration across services

Questions about MHRRTP admission:

Questions about Functional Restoration Pain Program:

Laural Tepper, LCSW Admissions Coordinator

VA Puget Sound MHRRTP (253) 583-1169

Laura Tuck, PsyDClinical Team Lead

VA Puget Sound Pain Clinic(253)583-2890

*Services are provided at the American Lake Campus

ADDENDUM Admission Criteria and Class Modules

Admission Criteria 1.Pain of at least 6 months duration with some consistent physical signs.2.Pain that has not responded to prior conservative treatment efforts.3.Diagnosis of chronic pain syndrome in addition to the presence of chronic

pain. 4.Veteran does not meet criteria for acute medical admission.5.Other medical interventions (e.g., surgery, nerve blocks, and control through

medications alone) either have been ruled out, declined , or have been completed with limited success.

6.Completion of needed medical work up prior to admission.7.If prescribed opioid analgesics or muscle relaxants, medications must be at

a safe and stable dose prior to admission. Morphine Equivalent Dose (MED) must align with practice guidelines (currently below 120, likely to decrease in the future). Medication recommendations may occur during the screening. Medications will not be adjusted during this program unless there is a medical emergency or side effects. Consult the Opioid Safety Review Board if guidance is needed prior to admission. 8. Veteran does not meet criteria for acute psychiatric admission.

Admission Criteria (Continued)

9. Veteran is not assessed as a significant risk of harm to self or others. 10. Veteran has cognitive capacity sufficient to benefit from program

components.11. Veteran does not have an active substance use disorder that would limit

benefit from program components. 12. Veteran is assessed as requiring the structure and support of a residential

treatment environment. 13. Veteran is lacking a stable lifestyle or living arrangement that is conducive

to recovery. 14. Veteran is capable of self preservation and basic self-care. 15. Willing to be admitted for a six-week residential stay and willing to

adhere to program rules and requirements during their participation.16. Expectations of treatment and outcome are consistent with program goals.17. Veteran has identified treatment and rehabilitation needs, which can be

met by the program.

Programming: Modules

Holistic Health (S. Hedt, PA-C) Pain philosophy; Physiology of pain; What medicine can and can’t do; Neuroplasticity; Healthy Lifestyle ; Open topic

Mind-Body (S. Hedt, PA-C) Seated meditation; Mantram meditation ; Guided Imagery ; Self-Hypnosis ; Autogenics; Mindful Movement

CBT-Insomnia (L. Tuck, PsyD) Cognitions and Sleep ; Pain and Sleep; Sleep “101” (drive, architecture, medical dx & nightmares) ; Sleep hygiene ; Creating a bedtime wind-down ; Troubleshooting and relapse prevention *each session discusses sleep consolidation, restriction and stimulus control, troubleshoots issues from past week, and focuses on requested topics.

Motivation (L. Tuck, PsyD)*modified from Dr. Glynn’s manual

Values exploration (card sort) ; Personal Narrative (timeline) ; Roadmap ; Successful Change (reflecting on strengths) Lifestyle ; Planning for the future

Pain and Relationships (L. Tuck, PsyD)

Communication Skills ; Intimacy and Romantic Relationships ; Identity Exploration; Roles and Actions (sick role); Trauma, Pain, and Relationships (central sensitization/neuroplasticity); Interacting with the Healthcare System

Quality of Life (S. Zajac, LCSW) Rec Therapy and Personally Meaningful Activity ; Finding flow in activity; positive personal qualities (Positive Psychology/Resiliency); Caring for and maintaining relationships; Humor; Productivity (Voc Rehab)

Wellness Recovery Action Plan (WRAP) (S. Zajac, LCSW)

Recovery and valued living, Flare-up management plan (FUMP); Problem Solving, FUMP; Breaking Down, Staying Motivated, FUMP; Triggers, Early Warning Signs, FUMP; Crisis Planning, Developing a Wellness Toolbox, FUMP; Building Support and Finding Resources, FUMP

Clas

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Programming: Modules

Health and Wellness (R. Carroll, RN)

Nutrition (anti-inflammatory diet and energy conservation/adaptive cooking); General Medication Management Interacting with the HCS; Making Treatment Decisions ; Pain Medications ; Planning for the future

ACT/CBT (L. Hollrah, Psy.D) Life Manual and Control Agenda ; Values ; Cognitive Defusion ; Mindfulness ; Willingness & Acceptance ; Hurt vs. Harm

PT Didactics (P. Froehlich, DPT) Rotating topics/ As indicated for group at the time: Posture; Pacing/FUMP; Exercise with Comorbidities (other health conditions); Biomedical Model (Treatment of Acute vs. Chronic Pain); Benefits of Exercise – identifying important life goals; Kinesiophobia; Body Mechanics part I Body Mechanics part II; Physiology of Exercise; Physiology of Pain; Communicating with Health Care Providers; Creating and Exercise Program; Exercise Equipment

DOM Process Group (J. Ault, RN and S. Zajac, LCSW)

Open Format

Pain Clinic Orientation (J. Ault, RN)

Overview of program and materials

Process Group (J. Moore, PhD) Open Format

Acupuncture (M. Muth, PA-C) Acupuncture and information about Eastern Medicine while needles are placed, then relaxation.

Yoga Nidra (L. Hollrah, Psy.D) Similar to i-rest

Clas

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