A Case Management Model For the Ambulatory Care Patient Experiencing Chronic Pain

AAACN Viewpoint, Jan/Feb 2007 by Brooks, Esther, Younce, Julia

Abstract

This article describes the development and implementation of a Case Managed Opioid Program managed by an ambulatory care section nurse at the James A. Haley Veterans' Hospital, Tampa, FL. The authors will discuss the program from a historical perspective and the positive outcomes that were achieved.

Historical Overview

The Primary Care Section of the James A. Haley Veterans' Hospital in Tampa, FL, had approximately 100 patients a day who would walk in without an appointment. Many of these patients needed new medication or a refill of medication for relief of chronic pain. The practice had been to schedule appointments every 30 days for patients who required narcotic refills; however, the schedule could not accommodate the need. High numbers of unscheduled patients affected the ability of providers to see their scheduled patients in a timely manner.

In addition to inadequate parking and extensive travel time for veterans commuting long distances, lack of available appointments resulted in low levels of satisfaction for this population of patients with chronic pain. Furthermore, many patients expressed inadequate pain relief.

An interdisciplinary task force was developed to explore and problem solve the issue of patients walking into the Emergency Room without an appointment and in need of pain medication refills. One suggestion was to explore the advantages of caring for these patients using an RN case management model. The goal was to help decrease the number of unscheduled patients seeking relief from their chronic pain and/or seeking refills on their medication, and to provide better relief of pain.

Other RN case management programs within the Veterans' Integrated Services Network (VISN) were explored as possible models for implementation. A common feature of many chronic pain case management programs is the use of an interdisciplinary approach with the nurse in a pivotal position to manage and coordinate the care of the veteran in chronic pain. The nurse performs a pain assessment and evaluation, and orchestrates the process for the patient to obtain his or her prescriptions. Positive outcomes of the RN case management programs that were evaluated in the satellite clinics and implemented at the James A. Haley VA include the following:

* Better pain control.

* Enhanced customer satisfaction, due to decreased wait times to obtain medications.

* Decreased walk-ins and unscheduled visits to the provider.

* Increased cost effectiveness.

* Increased nurse participation in the veteran's pain management and increased role satisfaction for the nurse.

* Enhanced quality of life for the veteran with the ability to engage in a more normal lifestyle.

Opioid Case Managed Program Implementation

With support from providers, the Tampa VA implemented a nurse case managed clinic in ambulatory care in March 2003. The clinic was initially implemented in one of the primary care teams and was then expanded to the rest of the ambulatory primary care clinics at the Tampa VA.

The following are criteria for enrollment into the nurse case managed program for chronic pain at the Tampa VA:

* The program is intended for veterans on Class II control substances (oxycodone, morphine, methadone, fentanyl patches, and Percocet�).

* A veteran must be under the care of a primary care provider 3 to 6 months prior to enrollment into the program.

* The veteran needs to have been on a stable dose of analgesic for at least 3 months.

* The veteran consents to a pre-enrollment urine drug screen and a drug screen every 6 months. The veteran can also be tested at random.

* If the veteran is found to be using an illicit substance (marijuana, cocaine), he or she is tapered off the pain medication and referred to a drug/alcohol drug rehab program.

* The provider agrees that the veteran is a candidate for the program.

* The veteran agrees to abide by all the terms of the Pain Agreement, which is an agreement that details the responsibilities of the veteran while enrolled in the Opioid Program.

* The veteran must have a permanent home address available because the pharmacy will not deliver opioids to a Post Office Box.

* Prior to enrollment in the program, the provider determines that appropriate referrals have been made (physical therapy, occupational therapy, or the pain clinic) for the veteran to assure that other optimal treatments for relief of chronic pain have been considered.

Program Operation

The nurse case managed pain clinic program at the Tampa VA operates as follows: each primary care team has a pain resource nurse, who is assigned his or her own panel of patients who have been referred to the clinic by the provider. In the absence of the pain resource nurse, staff nurse colleagues, trained and oriented to the Opioid Program, manage the panel. Once the patient has been accepted into the program, the nurse conducts an initial baseline in-depth patient self-screening evaluation, provides the patient with extensive pain education describing the pain program, and obtains the patient's consent to enroll in the chronic pain program. On a monthly basis, each veteran submits a self screening pain evaluation. These are mailed to the pain resource nurse (in a preaddressed and stamped envelope provided) about 10 to 15 days prior to the monthly renewal due date for their narcotic prescription(s).The nurse enters the patient selfscreening tool data into the Computerized Patient Record System (CPRS) for the provider to view. After the provider has viewed the self assessment, the nurse collaborates with the provider and obtains the pain medication prescriptions, which are delivered to the pharmacy. Any change in the patient's condition or any problems with this process triggers a referral by the nurse to the primary care provider. The pain medication is mailed by the pharmacy monthly via certified mail to the veteran, thereby minimizing the veteran's need to come to the facility. The veterans see their primary care provider and the pain resource nurse every 6 months, where a face-to-face interview is conducted to review the treatment plan.