Cyber Seminar:  Spotlight on Pain Management- 20 -Department of Veterans Affairs

**Department of Veterans Affairs**

**Cyber seminar:  Spotlight on Pain Management**

**March 6, 2012**

**Lessons Learned in Developing a CARF-Accredited Interdisciplinary Pain Rehabilitation (IPR) Program**

**Presenters: Dr. James Toombs and Dr. Adam Bank**

Moderator:  I’m delighted to welcome you all to today’s cyber seminar on Spotlight on Pain Management.  It’s my great pleasure to introduce our two speakers today.  These are Dr. James Toombs and Dr. Adam Bank from the St. Louis VA Medical Center.

Dr. James Toombs received his medical degree from the University of Missouri, School of Medicine, at Columbia, Missouri in May 2000.  Following his residency training at the Cox Family Residency program in Springfield Missouri, he completed an interdisciplinary pain medicine fellowship at the University of Iowa.  He is boarded in both family medicine and pain medicine.  Welcome Dr. Toombs.

Dr. Adam Bank completed his Ph.D. in clinical psychology in 2001 at Wayne State University in Detroit, Michigan.  Following his pre doctoral internship at the Miami VA Medical Center, he completed a post doctoral fellowship in clinical general psychology in 2003 at the VA Boston Healthcare System and Harvard Medical School.  He served as the clinical director at the St. Louis VA interdisciplinary pain rehabilitation program since December of 2009.  Welcome Drs. Toombs and Bank.  We look forward to your presentation.

James Toombs:  Okay.  Where to begin.  CARF.  I love CARF.  Several years ago, I think it was in 2009, the VA put out a mandate that every division would have a CARF accredited interdisciplinary pain rehabilitation program.  And we were very, very blessed as you’ll find out to get some funding and some very, very good support to start our program.  We were both Dr. Bank and I were pretty naïve about CARF accreditation and learned quite a bit through the process.  We’re going to try to navigate through our next slides here.  So on the standards, the standards are published and that the section 3k is where we’re really focused and the program that we develop is really outcome driven and with goal oriented team services and within all of those domains.  

Adam Bank:  And folks can go to the CARF website which is www.CARF.org and really get a good introduction to the standards and the requirements for getting this process started and section 3K is a part that really applies to interdisciplinary pain programs where the following domains need to be addressed:  behavioral, functional, medical, physical, psychological, social and vocational all need to be covered.

James Toombs:  And as I went through these initially, it seemed like an overwhelming task.  There were several pages and there were many, many things.  Policies.  Procedures that needed to be addressed.  Very fortunately we were able to get the expertise to help guide us through that and now we can provide some of that same expertise.  So the interdisciplinary team.  It sounds huge, but it really, there’s at minimum four components and the person that you’re serving, a physician, a psychologist and one other allied healthcare professional.  So and there’s no requirements out there that the physician be full time, devoted to the interdisciplinary program, nor the psychologist be full time to this program.  Only that they work within the program.  I don’t devote my full time practice to the interdisciplinary program.  Dr. Bank is probably much closer to that.  And I think we have a couple of .2’s in our PT and a .2 in our chiropractic care and that’s about what we provide in our services.  It truly is a—it’s focused around Dr. Bank’s clinic, but we have all the other allied health professionals in there.

Adam Bank:  CARF also talks about the importance of serving the stakeholders, so folks often wonder what does that mean.  The stakeholders are really just referring to anybody that is served by or affected by your inner disciplinary pain program.  The person to come to mind is the patients your serving, their families and the people supporting them, but it’s also your referral sources, it’s your primary care docs, your specialty care docs, and sometimes that also means the local community that you’re serving now.  So anybody that’s impacted by your program is really defined as a stakeholder.

James Toombs:  All right.  I understand CARF is cool.  Unlike some other organizations and JCAHO comes to mind, that are really inspecting you and guiding you, CARF I feel like they more assist you through this process.  They were very, very helpful to us.  The cookie cutter approach to building a program.  They don’t have a cookie cutter.  They won’t say your program has to look like this.  Outcomes are what help massage the format of your program and we discovered that on the way through how we were making program decisions and that outcomes would change the way our program was formatted.  And it’s really a dynamic program over dogmatic.  I think every month we have our pain team meeting here and we’re proposing some changes to the format or the content of our CARF program. 

What does a CARF accredited program look like?  You have to have two ears, four legs and one tail.  And Dr. Bank and I thought about that and you can build an awful lot of different programs, or an awful lot of different animals with two ears, four legs and one tail.  The idea is to build what you’re facility needs.  Some facilities need an elephant dragging logs out of the woods and other facilities need a sheep dog that are going to herd patients and referring providers.  I’m not sure what our program looks like.  We’ve got a little bit—a few more elements than that within our program.

How about our next slide.  Getting started.  Don’t reinvent the wheel, simply steal the wheel.  That’s what we did.  We went down to Tampa and we were welcomed into that facility.  I think we were down there for about four days.  Three or four days and we got to see their program in action, all phases of their program.  Now they were inpatient at that point in time and developing their outpatient program.  On the inpatient side of things we knew that that was going to come later on.  They helped give us guidance with program structure, the beginnings of our policies and such.  We’re also able to cooperate with San Juan in Puerto Rico and they have an outpatient interdisciplinary program that’s been going on for a long time and they gave us a ton of teleconferencing support.  And now we’re happy to be part of this resource list.  We have an outpatient program only at this point in time, but we have all of our policies and procedures, essentially our whole program available via CD that we’re willing to provide to anybody who wants this as some sort of boilerplate to look at to begin with our own policies and procedures.  And we’ve certainly welcome site visits from anyone who wants to come out and see how our program operates.

Adam Bank:  A big part of this is stealing the wheel and not reinventing it and communicating with these other CARF accredited programs including ourselves.  But you also find that you’ll learn a lot by doing and by making some mistakes on your own hat you just won’t learn until you actually get involved in doing this.  There’s a CARF 101 training session that’s also very helpful to attend where it helps you prepare for a CARF survey and they’ll review the standards that are required and you really get a chance to do some more networking.  You really have to do a little bit of everything to build your own program.  We’ll give you a little history of what happened here in St. Louis.

Before 2006, our pain services were spread across a lot of different specialty clinics.  So you could get pain services through medicine, through psychology, over an anesthesiology; go to chiropractic or physical therapy or neurology.  Everything was very disconnected.  Then in about—we also had a significant problem here with opioid prescriptions and not the best guideline based prescriptions going on here for a lot of patients.  So when this became more and more apparent, our associate chief of staff and spinal cord injury service, Dr. Florian Thomas in the middle of 2006 got together with Dr. Metsker our staff psychologist at the time, who’s now the chief of psychology and they got together and put together a proposal to establish a multidisciplinary pain management service.  And they fired off a couple of proposals to our executive council here to try and get that up and running.  So the first one, that didn’t go over too well.  The second one, they submitted.  That got a little more support.  And they had to go through a series of iterations before they could finally get some support to get the funding and get the space and get there staff to get this pain program up and running.

It took from about mid 2007 to mid 2008 for us to get some space and get some staff here and by March 2009 we were actually able to start offering comprehensive pain management services when we had Dr. Toombs come on board—I, the pain psychologist came on board in January of 2009 and we started to plan for the IPR program as soon as we were both here.

James Toombs:  Wow.  so we took our first swing at this program in August of 2009, and we set this up for what we thought would be perfect, an eight week program with visits twice a week, that’s plenty of exposure time to visits lasting approximately four hours, and we secured two patients, one dropped out immediately and the second no showed or canceled and then dropped out as well. We—that program didn’t really work well for us and we couldn’t develop any outcomes except that we had a hundred percent failure rate, is that about right, Dr. Bank?

Adam Bank:  Yes.  That was pretty high failure rate with that first iteration.

James Toombs:  So we thought that program was just a bit too intense.  No one wants to spend eight hours a week in the hospital, so we thought, we’ll reduce the commitment to an every other week program that went on for six months.  Now.  Reducing the commitment also maintained our current no show and dropout rate.  So we were back to the drawing board, again.  Now I’m going to stop right there because the program—the six months, every other week program.  That is similar to what they use in San Juan.  They have a kind of an open ended program that is continuous.  Patients fade in and out of the program and go on forever.  For that population, their population served that works very well for them.  It doesn’t work very well for us.  Our current program, which seems to be a balance of commitment, meets once per week for three months. About fourteen visits and we provide about three to four hours of care at each of those visits.  

We have a catchment area of about 40,000 Veterans who may come from two or three hundred miles away at the furthest point away.  And we don’t catch many of those patients at this point in time and we’re working on changing at least a portion of that program to meet that need.  We catch more patients who fall within that fifty or sixty mile radius from our service center here, our hospital.

Adam Bank:  Our current interdisciplinary pain program is outpatient only.  It’s offered to Veterans with chronic non-cancer pain who are not candidates for operative or interventional services.  So by the time they’ve come over here they have already been worked up and seen by a specialty service to determine whether they would or would not benefit from surgery.  So they’re coming over here we kind of have a good idea of what’s going on with them and they haven’t been responding to a lot of the other treatments or medications that they’ve been trialed on so far.  So when they come here, they’re taught a wide variety of self-management skills to help them cope better with their chronic pain, help them improve their day to day functioning, help them improve their mood and try to decrease their reliance or in some case eliminate their pain medication, particularly opioid medication and try to reduce reliance on the healthcare system.

James Toombs:  These are our goals through this based on the CARF guidelines and standards, but eliminating pain medications.  There are some programs out there who won’t accept patients who are on opioid pain medications or who will anticipate that they will taper them off over the course of time.  While they’re part of the program.  We’ve elected not to make that a requirement here.  And I think I like Dr. Banks—he put the decreased pain intensity is kind of last on our list.  If that happens, that’s wonderful, but functioning and coping with pain are really the highest priorities that we have.

Adam Bank:  Absolutely.  So it’s definitely a change in mindset for many of the patients coming over here.  We have a long list of services that we provide here, so patients are being involved in physical therapy when they come here and they’re doing home based physical therapy exercises at home.  They’re getting chiropractic treatments here and they’re getting group psychotherapy which may include family and individual therapy as needed.  They’re working out at our gym and our pool.  So we have the luxury of having an indoor 93 degree swimming pool here where a lot of patients really benefit from the aqua therapy over there.  Those who choose not to be in the pool therapy will do gym based physical exercise at our gym which is about a ten minute walk from our pain rehabilitation center.

Patients will get nutrition education from our dietician.  They’ll get education about pain meds from our pharmacist.  They’ll have two follow-up visits with Dr. Toombs, our pain physician during the program, and those are two generally fairly brief visits during the program, where the heavy emphasis is really on these other components of treatment and the relatively less emphasis on meeting with the pain physician and changing medications and titrating things.  So it’s definitely a shift in focus and then last but not least is extensive homework with documentation.  So patients are required to have folders and to fill out paperwork every week and record and document what it is that they’re working on as they’re developing skills through the program.

The other key component of this is that it’s interdisciplinary.  So the team which is in this case pain physician, psychologist, chiropractor, physical therapist here are the core members.  We’re meeting every week and we’re talking about and revising and adjusting a treatment plan on a routine basis.  And that’s really what separates this from a multi disciplinary clinic is it’s definitely interdisciplinary in nature which is really the key that makes it so successful.

Goals of treatment for our program are number one to help patients develop a broad range of chronic pain self-management skills so oftentimes patients come in here and they’re primary coping skills are to take pain medication or to rest.  And when you ask them if they have any other things that they can do to manage their pain, they can’t come up with much.

James Toombs:  And I get to meet with the patients prior to admission to the program and early on in the program and my focus is not what surgery can we explore for you, what additional injections can we do for you, what medications can we add, but to try to remove some of these things.  We look at medications that are ineffective and we remove them without replacement and in hope to taper down on ineffective medications, but the gradual shift in thinking that I try to provide in talking with the patients is not what I can do for them, because I—it’s been tried and done and hasn’t really worked well for them, but what can they do for themselves and it’s a shift in thinking that occurs over the course of the entire program but when they’re not hearing the doc talk about adding a—well let’s send you back to the neurosurgeons or let’s try this different injection, then we’re looking at things—improving their own coping skills.

Adam Bank:  The functional status is really the overarching and the key goal besides everything else.  We look at what are they doing day to day.  Are they able to work?  Are they able to get outside and go to the mall or go to the bookstore?  Play with their grandkids?  Go to the park?   What are they doing day to day and try to increase that level of activity.  So we’re really targeting people who have a relatively low level of functioning and really trying to gradually build that back up.  Certainly decreasing emotional distress and negative thinking are key goals.  Most of our folks are becoming in here with major depressive disorder and anxiety disorders, post traumatic stress disorder.  So they have tremendous mood disturbance and anxiety problems. And while we’re certainly working on those issues as well.

Decreasing pain related fear and anxiety—we also want to minimize their reliance on medication.  We want to reduce their overall reliance on their healthcare system.  Sometimes we see patients who are spending a lot of time just going to doctor’s appointments as part of their day to day life and they really don’t have much other things going on.  So we really want to reduce their reliance on  visiting health care providers to the extent possible and develop a lot of other interests and things that they’d like to spend their time doing and get them out of that sometimes professional patient role that’s sometimes folks adopt.  Certainly decreasing pain intensity is on the list; although it’s towards the bottom.  If we can help folks reduce their pain intensity we’d like to do that.  But it’s not the overarching goal.  We reinforce throughout the program that patients can benefit in all of these other areas even though sometimes we can’t decrease their pain intensity.  They can still get better functioning and they can still get better mood.  They can still decrease their reliance on pain medication and feel better.  They can function better but their pain might be the same.  Then we kind of conceptualize that overall as improving their quality of life and reducing their level of suffering.

Again, just to clarify, we do not focus on pain elimination. And we’re deemphasizing pain intensity.  So oftentimes when they’re coming over from a specialty care or from a primary care setting, oftentimes the focus of those conversations is I need my pain to go down.  I need to get rid of this pain.  What can you do to help me get rid of my pain and over here we’re really trying to shift the mindset to well, reducing pain intensity is one thing that we can work on but we’ve got a lot of other things we need to focus on too, and pain intensity is not the be all end all because when it is, oftentimes the patient gets worse or they stay the same.  They tend not to get better.  So again, we deemphasize that shift in thinking.  Family involvement is strongly encouraged.  And oftentimes we find that when family members are involved whether that’s a spouse, or a child or a caregiver, we find that’s a real synergistic effect and that helps folks make progress faster.

Again, to kind of think about this conceptually, we think a lot about suffering that patients are experiencing when their pain intensity is high.  Patients will report that because their pain is so bad, they’re suffering and their life is awful and miserable.  We teach them during this program that you know what we can actually teach you some ways that you can practice on your own so that your suffering a lot less even though you till have some degree of pain.

Who’s on our team here?  These are all our main players here.  Dr. Toombs our pain physician.  We have physical therapist is Dr. Keys.  Our chiropractor is Dr. Wakefield.  I’m the staff psychologist.  David Jansen is our pharmacist.  We have a dietician, which we borrow from spinal cord injury, Jackie Henderson.  We have a program manager that’s been tremendously helpful in getting us ready for CARF and doing a lot of the paperwork in organization to Takisha Lovelace, and then we have Jackie Caskanett, our nurse coordinator who’s a tremendous help to this program as well.

James Toombs:  And this looks like a heck of a team but when you put it down, Dr. Bank, you’re probably a .6 to .8 in this.  

Adam Bank:  Right.

James Toombs:  Our chiropractic physician is a .2.  Our physical therapist is about a .2-.4.  I’m probably a .1 or .2 in this program and the pharmacist is a .1.  So this is—this looks to be a—this is a robust program; however, none of us have full time dedication to the interdisciplinary program.  We’re all some fractional employee for this.

Adam Bank:  The other key point about this team is that we’re really always working towards this idea of a trans disciplinary approach which is different than the interdisciplinary.  When you think about disciplinary team is that everybody is working together and sharing their strengths, but with trans disciplinary interventions and approaches what we’re really doing is try to teach other members of the team to reinforce the same concepts that we’re telling our patients.  So when I work with patients, I’m trying to reinforce the ideas that our physical therapists are teaching them.  And when she talks—when our physical therapist or our chiropractor or our pain physician talk about pain management and the way that patients are thinking about it and the way that it means that they’re reinforcing the same idea that I am.  So—go ahead—

James Toombs:  And that was one of a—talk about lessons learned.  It took us a while to gel as a team to understand that we did need to do this reinforcement and in our pre-patient visit meetings and our post patient visit meetings, in our care planning conferences, how we could develop a similar approach or for cue off of Dr. Keyes would see a patient and she would notice things about that patient and how we can key off of that and use that to support their recovery and support their improvement in function.  Everybody brings a different set of skills to the table and we all bring a different set of observations to the table that—the team meetings were something that’s key for us in discussing patient care.  

Adam Bank:  If we look at the referral criteria for patients to be referred here.  Patients are experiencing chronic non-cancer pain despite having operative or interventional therapies or evaluated for those.  Patients have to be able to fully participate and follow the program rules that we have which are pretty lengthy.  And mostly relate to being responsible like showing up for appointments and calling in if you’re not able to make it in because you’re sick.  Just some kind of basic expectations.  Patients also have to be free of active substance abuse.  So oftentimes patients have a history of substance abuse but if they’re currently struggling with substance abuse whether that’s binge drinking alcohol or smoking marijuana or using crack cocaine or meth amphetamines, active patients that are struggling with active substance abuse are temporarily excluded and they’re encouraged to get hooked up with our substance abuse care programs here to work on sobriety and then they can certainly return for our IPR program.

James Toombs:  Dr. Bank, it seems like these people who are substance abusers could—they’re the ones who need services like this.  Why do we exclude these people?

Adam Bank:  That’s a great question.  Why don’t we take people into this outpatient program who are actively binge drinking as a coping mechanism or who are smoking marijuana and telling us, you know what, Doc, when I smoke marijuana, it’s just recreational.  It’s just like a glass of wine.  And it actually does reduce my pain intensity.  It does make me feel better.  One of the major problems of course with active substance abuse is that we know long term that’s not an effective coping skill.  That’s very maladaptive.  We know that there’s lots of mental health and health effects from smoking marijuana.  We know binge drinking alcohol is a—alcohol is a central nervous system depressant and contributes to the high rates of depression and problems with work and problems with the family. 

We know if people are using these very dangerous and maladaptive coping skills, we’re not really equipped right now on an outpatient basis to really manage those patients well.  And so we find that when we collaborate with our substance abuse treatment program, that those patients are a lot better able to integrate into our program when they’re actively working on their sobriety.  So that’s a good question.  We found that when patients are working on their sobriety and they’re actively involved in after care that they have a much better chance of making progress in our program.  

Another issue is psychiatric stability.  Most of our patients are struggling with depression and anxiety disorder, bipolar disorder, PTSD but if they’re so unstable that they’re acutely suicidal and they’re having active thoughts of wanting to harm themselves or they have a plan to do themselves in they’re probably not going to be safe in an outpatient program and they may need inpatient care.  So for patients, for example that have just been discharged from inpatient psychiatry a few days ago, we would not take them right away into the interdisciplinary program and we would want those patients to show thirty days of relative psychiatric stability where they can be managed safely as an outpatient.

James Toombs:  And Dr. Bank and I will often meet with these patients while they are inpatient to plan admission or at least evaluation through the interdisciplinary program after discharge.  So they’re not felt like they’re just hanging out there.  Well, I’m discharged from this program and they don’t know when they’re going to take me or if they’re going to take me.  We’ll be able to coordinate that for them before discharge.

Adam Bank:  And so those are two conditions also that we monitor throughout the program. We’re monitoring their psychiatric stability and sometimes patients during the program have a decompensate and they need to be hospitalized.  Sometimes patients relapse on marijuana or cocaine and we know that they’re relapsing because we are randomly drug testing them during the course of the program.  That doesn’t mean that we then deny services to those patients, but what we do is we hook them up with the most appropriate resource here and then they can be readmitted into the IPR program once they are more stable.

The targets of treatment.  I think the domains of treatment are pretty easy to agree upon.  The ways that you measure those domains, there’s not always a lot of agreement.  In terms of things that we try to measure, and things that interdisciplinary programs tend to measure, the impact recommendations from prior publications kind of talk about the domains to assess but the actual instruments to assess them tend to differ across programs.

James Toombs:  And CARF did not say you have got to use these five or six measures.  And in fact, I don’t think that Tampa, San Juan and St. Louis.  I don’t know.  We probably cross over on just a couple of different measures, but they don’t—outcome measures are appropriate for your facility and your patient population.  These are the ones that we’ve chosen to use.

Adam Bank: So pain intensity, we assess with the quadruple visual analog scales—zero to ten.  Depressive symptoms we assess that with the patient health questionnaire nine.  Catastrophic thinking with the pain catastrophizing in scale.  We also assess pain related fear and anxiety with the short form of the PAC, and we assess functional status and psychosocial functioning with the pain disability questionnaire.  Other people will use things like the Oswestry or the MPI.  So I don’t think there is any one particular best measure.  I think it depends on what your program wants to use and what your rationale is for assessing that in your population.  A lot of other outcomes that folks may want to assess may be weight.  A lot of these folks are coming in and they’re overweight and they need to lose weight.  Healthcare utilization, which may be number of emergency room visits or number of primary care doctor visits, and opioid medication use.  Oftentimes patients are on opioid medications and they’re not benefiting from them so one of the outcome measures that some programs will assess whether they’re able to taper folks down or off of opioid medication.

What’s our program path here to actually take patients through this whole process.  An initial consult comes through from primary care or specialty care and the pain physician and pain psychologist review that consult and determine whether this person looks like they’d be a good match for the IPR program and then that patient is brought in for a group screening and a methadone drug screen.  We want to assess right away is this person struggling with substance abuse or not.  And we also want to assess their interest and their goals.  So that’s what the group screening involves. Where the pain psychologist explains in great detail what does the interdisciplinary pain program involve and why would anybody want to be in an interdisciplinary pain program that involves so much effort and hard work on patient’s parts.  We talk a lot about the difference between the medical model of chronic pain and about how that differs from the biopsychosocial model or the chronic illness model of chronic pain.  And how approaching things from that biopsychosocial perspective tends to lead to a lot better outcomes.  We take patients who are then interested in the IPR program and meet the initial screening criteria, meaning they’re psychiatrically stable and they’re not actively abusing illicit drugs or alcohol, and then they come for a four hour evaluation.  And in that interdisciplinary four hour evaluation they’re seen by the pain physician, the chiropractor, the physical therapist and the pain psychologist.  They meet together as a team and then give the patient feedback about what we think will be most helpful for them.  Sometimes that is a recommendation for the IPR program.  Other times it’s referral to other services.  If we look at patients who are scheduled then for IPR admission and who agree that that’s what they want to do.  They will then start usually within about four to six weeks they can start our three month outpatient program which again is fourteen visits once per week over about three months.  That program also includes those really important weekly interdisciplinary pain team meetings.  Those are both formal and they’re informal.  So Dr. Toombs and Dr. Keyes and Dr. Wakefield, we are all talking to each other in our offices and throughout the week as patients are coming in to give each other updates on what is happening and any changes that need to be made.  At discharge from the program, there’s a post discharge assessment.  There’s also follow-up session when they’re completing the program.  So there’s booster sessions once a month.  There’s a support group that’s available.  There’s three month and there’s a twelve month assessment because those who want to track people over time and see how people are doing once they’re out of the program.  

Contents of the session.  What actually happens on the psychology end of things?  I use Dr. John Otis’ book which is just terrific, *Managing Chronic Pain - Treatments that Work.  Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach.*  That is very straight forward cognitive behavioral therapy for chronic non-cancer pain.  That’s a really wonderful manual that provides the basis for a lot of the things that we do here.  This is a list of the different sessions that I take patients through. 

Their first session is really an orientation to what’s going on here, what are their rules and responsibilities.  Do they really want to be involved in this?  So I certainly give them another option and opportunity to decide is this something I really want to pursue and commit to or are they having second thoughts and maybe they’re just not ready for this at this time and if I can pursue some other options.  We really emphasize the importance of self-management of chronic pain and the patient is the one who has the primary responsibility for pain management.  The other team members like the pain physician, the physical therapist, chiropractor, nutritionist, pharmacist, we are all guides to help patients through this path but it’s really the patient in the end who’s going to be the leader.  

Basic pain education in session two.  We talk about hurt versus harm.  Again, detailed explanation of the biopsychosocial model.  And how that compares to the medical model.  Take patients through activity pacing, relaxation exercises, hygiene, distraction, and we differentiate that from mindfulness, meditation.  We do a mid treatment assessment right around session six or seven to see how folks are doing.  And then they give us feedback on how they’re progressing.  We’re assessing them to make additional adjustments in the treatment and talk about depression management, behavioral activation, cognitive reframing.  And then kind of towards the end here, we get to discharge planning, relapse preparation as opposed to relapse prevention.  We assume that everyone is going to have a relapse at some point because their pain is chronic and then what are they supposed to do to get ready for that relapse.  How do they cope with it?  And the dietician and the pharmacy sessions usually those are happening within the first third or so of the program.  We’re also gathering information on how can we continuously improve the quality of this program.  So we’re always soliciting and looking for feedback from our patients, from our stakeholders and looking at our outcome results to adjust the program as we’re going through it.  So some of the things we’re adjusting in here is we originally we didn’t have mindfulness meditation as part of our program.  We added that on after about six months or a year.  We initially didn’t have a lot of nutrition resources here.  We had one session and now that’s been expanded and patients are offered a lot more nutritional counseling if they desire it.  So these are things that we adjust as we go through.

Sample day,  patients come in in the morning and they go to the pool or the gym where they begin their exercise program.  That’s about an hour.  We emphasize a gradient approach to exercise and cardiovascular training, slow but sure and they then come over to the pain rehabilitation center where they see the chiropractor or the physical therapist.  They’ll see the pain physician a total of two times during those fourteen weeks.  And they’ll see me, staff psychology from eleven to twelve in the morning.  They will do homework on the days that they’re not here.  So they’re expected in their homework folders to be documenting that they’re doing their daily walking, they’re doing their home based physical therapy exercises, their stretches, their relaxation exercises, etc.

So there’s a lot of accountability that’s placed on the patient’s part.  What do our patients look like here?  Our demographics in our first two years—we had forty eight patients complete this program with an average age of fifty one years.  Twenty one percent of those folks were working full or part time.  Fifty percent male.  Forty percent female.  Mostly Caucasian.  Thirty percent African American.  And if you look at the types of pain conditions, we have the typical variety that I think you’ll see in a lot of pain programs.  A lot of back pain.  A lot of diffuse pain.  Some headache.  Some neck pain.  And if you look at the average length of time since people have had problems with chronic pain, 14.8 years.  So these are patients who have been struggling for an awfully long time by the time they get to us.  These are mostly the most treatment refractory and challenging folks that are coming over here for treatment in our program.  

Our outcomes for the first two years, we’ve had seventy four folks who were admitted.  Five percent of those were involuntarily prematurely discharged because they were abusing illicit drugs and they were referred over to a substance abuse residential treatment program.  Another 30% dropped out during the program.  So drop outs caused by lots of different things.  Sometimes people are no show in their appointments.  They’re cancelling repeatedly their appointments.  They may have significant problems with transportation that they can’t overcome.  Sometimes they go to jail and they can’t participate because they’re in jail and maybe they were using the IPR program as one of their ways to avoid interaction with the judicial system.  So we see all kinds of different reasons for drop outs.  55% actually completed the program and if you look at our overall improvement rate in the five domains here that we have.  They’re actually pretty good.  You can see 65% of folks improved and again, we’re talking about clinically significant improvement from baseline to discharge is what we’re measuring here.  65% of folks improve significantly in their pain related fear and anxiety.  Two thirds improve in their degree of catastrophic thinking and 63% improvement in functional status, 58% improved in terms of depression or clinically significant symptoms of depression on the PHQ-9.  And 36% reported an average decrease in their pain of greater than one point was defined as clinically significant improvement.  So about one third got better pain intensity, but you can see in the other domains, they’re making marked improvement, despite the fact that we only had one third that improved in their average pain intensity.

Once we go to three months out, you can see again our rates of improvement here, holding up here with pain related fear and anxiety and catastrophic thinking dropping a little bit in terms of their functional status and depression and interestingly in average pain intensity that may just be a blip in the data there were 49% reported an improvement.

As you would expect as you get further out from active treatment, you would anticipate that patients would tend to relapse and tend to struggle.  And that’s what these findings show as we get a little bit of a decrease here in improvement rates for pain related fear and anxiety, catastrophic thinking and certainly average pain intensity.  So we follow people up to one year in terms of actually assessing them.  In terms of treatment, we’re offering treatment once a month for as long as they want for booster sessions to try to help them from a clinical standpoint.  Patient satisfaction, we’re also measuring that.  That’s another important piece of CARF.  We want to know what do patients think of our program.  Do they think they’re getting treated with warmth and respect and kindness from our staff?  Is it easy to get appointments here?  Would they recommend this treatment to somebody that you know that has a pain problem?

We’ll give you a success story here of a patient who completed this program several months ago.  This was a morbidly obese gentleman, 331 pounds in his early sixties.  He was 100% service connected with chronic depression, diabetes, degenerative disk disease and reported a fifteen year history of chronic pain in his low back, hips and shoulders.  And he reported that he knew what to do to get better but he just didn’t do it.  This was a guy who was on disability.  He was on social security disability as well as VA disability.  He had been in our move program but had not done well in that and he was actively engaged in psychology and psychiatry treatment and had good relationships over there.  so this man in our program really was an enthusiastic participant and really seemed to buy into the things that we were teaching him and working with him on and just with involving his family in particular, his daughter was somebody who was in her mind really trying to help him by cooking for him, by shopping for him, by really doing things that she thought would be helpful that were actually potentially serving to enable him to continue his current pattern of struggling with pain.  So we definitely were able to involve the daughter.  Fortunately she came to several sessions and we taught her about what is it that you’re doing that may be unwittingly contributing to your dad’s struggling with pain and so got her to ease off of shopping and cooking and getting the Veteran involved in nutrition classes, teaching him how to cook, how to shop on his own and he made pretty dramatic improvement as you kind of look through these figures here from baseline to post treatment and for the three month follow-up that we scheduled, he was not able to come in for that because he had fractured his left ankle, which I had thought, wow.  That’s really going to be a big setback.  He’s making good progress, but now he’s got a broken ankle, but sure enough he continued to use the skills that we had taught him and despite having the broken ankle he was able to continue to make progress and keep the gains that he had made.  He lost quite a bit of weight, about thirty two pounds during the program.  And his daughter then moved out of state and he was not as fazed by that as he could have been because now he had the skills to cook and to shop and do things much more independent.

Future goals:  I want to talk about a couple of things here.  Dr. Toombs you want to talk about the lodger program and inpatient program a little bit.

James Toombs:  Yes.  The lodger program is essentially we’re trying to invite folks in from that outlying area from the far reaches of our VISN here so they can come and get treatment and we envision this as a two day program where they’ll come from two days every other week and lodge on the hospital or nearby the hospital so they won’t have to travel quite so much.  An inpatient program, self-explanatory.  We’re looking for some of these more complicated folks who may have ongoing substance abuse where we can provide them pain and substance abuse treatment at the same time.  

Adam Bank:  We have an ACT group that we currently run at our sister hospital that is downtown St. Louis.  We’re in the countryside here at Jefferson Barracks where we have more of the cogitative behavioral interdisciplinary pain program, but there’s a lot of emerging evidence over the past ten or fifteen years for acceptance and commitment therapy for chronic pain which I know is already used in several different or many different VA hospitals for treatment of chronic pain with the idea of promoting psychological flexibility and not focusing so much on controlling thoughts and feelings which cognitive behavioral therapy would promote more of that but really focusing on acceptance of pain, acceptance of other unpleasant emotions and trying to behave in ways that are consistent with your goals and values.

So that’s something that we’re going to try to develop here also at Jefferson Barracks in addition to we already have a group over in our downtown campus.

James Toombs:  And we’ve recently started working on the telehealth services for our rural population and that’s really a proof of concept mode right now, just the very beginnings of that.  And we would like to export what we do to other VISNs. Other facilities within our VISN and then outside the VISN as well.

Adam Bank:  Questions you can certainly e-mail Dr. Toombs or myself.  Or you can e-mail our program manager which is Takesha Lovelace who’s been instrumental in helping us prepare and get things ready for CARF and maintain our CARF accreditation.   There’s a fair amount of paperwork and preparation involved but I think one of the hard parts is really thinking about what you want your program to look like and how you want to implement your interventions and as you’re doing that you’re also working on the CARF side and the preparation side of things and kind of simultaneously.  They really do go hand in hand.  

James Toombs:  And I think that was something that we learned early on.  Your program has to be established for a period of time before CARF will come out—six months.  Before CARF will come out and evaluate.  So we put our program in order, ran the program and gathered some numbers and we actually made some changes throughout that as well.  Takesha Lovelace, if you send her an e-mail and request a CD of the policies and procedures for the CARF program, she’ll get one sent out to you.  I think we probably sent out fifty or sixty disks already.  And if there’s four hundred people on this call and all four hundred of you all want a copy of this, she’ll get them out to you eventually.  We just have to find a way to get the disk and get them copied.  That’s all available as well.

Heidi, how do we go to questions?

Heidi:  I’ve got the questions up on my screen right now, so I’m going to be reading them to you over the phone if that is okay.

James Toombs:  That is just fine.  People can see the download is complete here.

Heidi:  Yes, they can.  Okay we’ll just start in with the questions here.  The first question we received.  It used to be a CARF requirement that interdisciplinary pain programs have a nurse case manager.  It looks like that is no longer the case.  Can you clarify?

Adam Bank:  There may be certain CARF programs that do require a nurse case manager, this program did not.  The pain requirements did not.  And I would suggest that anyone—the first place to start is to get yourself a CARF manual and—

James Toombs:  Going to the CARF website and obtaining the standards which are updated once a year.  The new ones come out. At this time, my understanding is you have to have one other healthcare professional and they do not specify that that has to be a physical therapist or that has to be a nurse case manager.  So my understanding at this time is it’s much more of an open ended kind of a slot.

Heidi:  Perfect.  Thank you.  The next question, when the patients come in, are they then seen for three to four hours in a treatment center where the providers are all under one roof so to speak?  In other words, most of the service are provided in a proximal space and providers appear to share proximal offices so as to increase communication among the team.

James Toombs:  Yes.

Adam Bank:  We are all located in the same hallway and our services are provided on that same hallway.  The only thing that’s provided off site is our physical—is our pool and our gymnasium and that’s about a ten minute walk from here and we have a tunnel system to get the folks there.

James Toombs:  So all our services are on campus and the core services for our program which is physical therapy, chiropractic, pain medicine, pain psychology.  Those are all provided in the same hallway.  So it’s a matter of sixty feet and we’re all next to each other.  That’s correct.

Heidi:  Great.  Thank you.  The next question is, are you using any psychological measures to prescreen the patients into most potential success in your program?

Adam Bank:  One of the measures that’s been offered to—been looked at is the pain stages of change questionnaire.  We used to use that early on when we first developed this program and we tried to take a look at what things did we absolutely need to keep in our assessment battery and what were some things that we would like to keep in but there just wasn’t enough room.  There’s a lot of things which are important to assess, and there are a lot of things we would like to assess, but there may be logistically and in terms of time limitations there may not be room for it.  The short answer to that question is at this time, we do not have a formal measure where we assess readiness for treatment which is probably like that same stages of change questionnaire or something similar to that.  It’s much more heavily based on what’s their level of distress?  What’s their level of functioning?  What’s their level of interest and motivation in trying to learn some new skills and if they are open to talking about that and able to make it to that screening group which is usually their first contact with the pain clinic.  It’s usually in that screening group where people will start to think about is this something I want to try out or not.  Then in the interdisciplinary evaluation when they meet with the entire team they’re getting that idea reinforced that a self-management approach to chronic pain is what we offer here and it’s a voluntary program and so patients really have a lot of say in determining yes, this is something I want to try or you know what, I just want to go back to trying different medication or I really want to go back to just hanging out.

Heidi:  Okay.  Great.  Thank you.  The next question is could you explain how you utilize the part time participants of the pain team?  Do you have scheduled meetings or appointments or do the team members meet on an as needed basis?

James Toombs:  We’re scheduled and we do have ad hoc meetings walking down the hallway to a HIPPA compliant area but we are scheduled, so when we have a .4 chiropractor and a .2 pain physician, we’re scheduled into those blocks of times and if you looked across our schedule you would see, like Wednesday morning devoted to the interdisciplinary program and—Friday mornings devoted to the interdisciplinary program, Friday afternoons devoted to the interdisciplinary programs.  So we’re scheduled, our patients are scheduled into those blocks.

Adam Bank:  Even with the folks that are just .1, we still meet with them as well as informally.

Heidi:  Great.  Thank you.  The next question is when you are considering criteria for admission, do you do lab tests for alcohol or go by patients self-reports?  Do you have a urine screen for alcohol or do you order a serum alcohol test?

James Toombs:  The alcohol, when they come in for a screening visit, they will provide a urine drug sample and that tests for alcohol as well that’s in our methadone panel.  So it’s a urine test for alcohol, but we also rely on patient self-report and a review of their chart.  So if they’re reporting to their primary care doc that they’re drinking or they’re just coming out of an alcohol treatment program or so on and so forth or that’s been recommended, then we’ll use that information as well.

Adam Bank: The length of time that alcohol stays in your system is about how long, Dr. Toombs?

James Toombs:  Oh my gosh.  I couldn’t answer that question, but I would say probably about twelve hours or less.

Adam Bank:  Not very long.  So for folks that are abusing alcohol on a daily basis.  That’s fairly easy to pick up, relatively speaking but for folks that are binge drinking only on the weekends or once a week, that is much more challenging to detect and so we do rely on screening measures like the audit C and on patient self report and we don’t really have a reliable lab test I think that we can detect folks who are drinking just periodically rather than on the day that they happen to come in for evaluation.

James Toombs:  And on that—in that same vein, people might think that we’re pretty harsh by excluding folks for marijuana use.  The literature shows that marijuana lasts in the system quite a long time, and it may be a proxy for other drugs that may not last quite so long like meth amphetamine or cocaine.  So there’s some co-morbid abuse with those medications.  So if they’re positive for marijuana, we assume that they’re going to be—they’re actually using some other substances as well.

Heidi:  Great.  Thank you.  The next question we received, are significant others and family members identified?  How are they involved?  Are there weekend or evening hours for family members to participate?

Adam Bank:  Good question.  At this time there are no weekend or evening hours for participation.  Some of the clinics that we have here like the PTSD clinic offer evening hours.  Or they’ve experimented with that and have not found, at least here at the St. Louis VA for those slots to be filled, so they’ve kind of done away with that.  For the IPR program, we don’t have evening hours or weekends at this time.  We identify significant others and family members really through the patient. So when the patients come here for their screening group and for their initial evaluation, we’re asking them questions about that and encouraging the involvement of family members in the support system to the extent that the patient wants.  Sometimes patients have very conflictual relationships with family members and they are not interested in having family members come and participate.  We talk about that. We try to work with that, but we always respect the patient’s final decision and if they choose to have family members involved we applaud that and if they choose not to then we revisit that, but we respect it.

I would say in our program we have probably twenty percent—fifteen to twenty percent of our patients will bring in family members or other significant others.  And a large number of them will not.

Heidi:  Okay.  Thank you.  Would it be possible for you guys to put the slide back up with Takesha’s e-mail address on it?  We just got a question in wondering who to contact and it may just be easier for you guys to put that back up that to try and say it over the phone.  While you’re pulling that up, I’m going to move onto the next question here.  Do you provide patients with education for a portable profile?  I am unsure whether it’s required for an outpatient program, but previously MyHealtheVet was not acceptable for IP rehab units.

James Toombs:  Portable profile is something that is required and that we do provide patients with.  So that’s something that is relatively new.  But if you look at the CARF standards and the requirements for that, it kind of will go into detail about what’s involved in the portable profile and what the requirements are for that.  So yes, that is a requirement.

Adam Bank:  Is this helpful how I’ve structured this?

James Toombs:  Can you see the e-mail there.

Adam Bank:  Can you see the e-mail now?

Heidi:  We can see the e-mail now.  For anyone looking for the CD that they were mentioning a little while ago, it’s the last e-mail address on the screen.  Here’s Takesha Lovelace.  E-mail her and she will be able to help you out with that.

And the next question that we received in here.  We still have about a dozen pending questions, so I’m trying to move through these quickly so that we don’t run over on time here.  The next question, do you monitor reduction in opiates as an outcome?

James Toombs:  Yes, but not formally measured.  That’s something that I always ask about their visits with me.  But we don’t prescribe opiates.  We make recommendations about tapering or quitting.  And the primary care docs or the prescribing providers are copied on these notes as well.

Heidi:  Great.  Thank you.  The next question, do you admit patients as a cohort or do you admit individuals on a running basis?  If you admit a cohort, how many do you admit into each group?

James Toombs:  We admit as cohorts.  And it varies.  The smallest group we have is one.  The largest group we’ve had is about seven.

Adam Bank:  Yes.  Our largest group has been closer to eight.  We do admit in cohorts.  Sometimes we have a small group depending on our patient flow.  We may have four or five people.  Other time we may have eight folks.  But they’re relatively small contained groups.

Heidi:  Great.

Adam Bank:  I know from inpatient treatment, for example at the Tampa VA, they have what I believe is a running program where folks can kind of come in throughout the groups, so they do not have the cohort for their inpatient.  But for our outpatient we run a cohort.

Heidi:  Okay.  Thank you.  The next question, what exactly do you mean by clinical significance when you are examining your programs outcomes?  Are the values themselves significantly different using stat analysis between initial, three month, twelve month outcome data?  Or are you simply indicating whether or not there is an improvement in the original score?

Adam Bank:  Great question.  So and that’s one I’m—I think I’m prepared to answer.  We know that tests of statistical significance like P values and T test are relatively meaningless and that a difference of .05 might be statistically significant but may not be clinically significant and why is it?  It’s really just convention that people use .05 instead of .04 or .06.  so that’s why when I thought about how to put this together in terms of measuring improvement and looked at what would be the what I thought would be a better way to assess improvement, effect size and confidence intervals are certainly some of the better ways statistically to look at outcomes.  We don’t have a very large N here of patients so up to this point what I had developed was a priori before even starting this I looked at each measure and determined based on the psychometric properties of the measure and the range—the point range for each measure what would be a what did I think would be a clinically significant difference in a change score—so for example, and again, this is before looking at the outcomes.  So it wasn’t like I looked at the outcomes and I said, yes, that’s close enough.  It was done before we looked at whether people were improving or not improving.  So for example on the PHQ-9 which is a nine item measure of depressive symptoms.  There’s twenty seven points possible, with a cutoff of twenty or greater is considered severe—one to four is considered normal and five to nine is considered mild and so on the PHQ-9 I determined *a priori* that okay, I thought that a score of—a change score of greater than four points so five or more points on the PHQ-9 would be clinically significant.  On the pain intensity scale there’s agreement in the literature that a change score of one is not clinically significant and that a change score needs to be greater than one, so I adopted the greater than one score.  I kind of did that for each measure and determined what those scores would be and then looked at the percentage of patients who were demonstrating improvements on each individual measure at that cut off.

I thought and I also looked at how patients were doing just kind of clinically in terms of their self-report and looked at whether or not that was related to what I was seeing in terms of how I was rating them in terms of improvement or not and then it seems to have been very consistent over time.  So it seems like that’s so far has been working out as a good way to assess change and I think as our numbers get bigger we can look at affect size and things that are more reliable.  I’m not a big fan of T tests or P values.

Heidi:  Okay.  Thank you.  We are just past the top of the hour.  We do have about eight pending questions.  Do you two have time to stay on the call to take a couple of more questions or would you prefer to answer them off line we can—

James Toombs:  Let’s just go on.

Adam Bank:  I think we’ve got enough time to do eight more questions.

Heidi:  Okay.  Sounds good.  The next question we have who pays for the CARF accreditation?

James Toombs:  St. Louis VA Medical—the St. Louis VA Medical Center pays for the CARF accreditation. 

Adam Bank:  I thought you paid for that, Dr. Toombs.

James Toombs:  No.  St. Louis pays for the program and they pay for the accreditation as well.

Heidi:  Great.  Thank you.  The next question, do you check the homework to make sure that it is completed.

James Toombs:  Yes, we do.

Adam Bank:  Absolutely.  So that’s part of every weekly session is accountability.  And so during the program while they’re coming for visits there’s a lot of external accountability where we are checking their homework and we’re signing their folders for attendance and we’re seeing whether or not they’re actually doing the homework and when they’re not documenting, then we’re talking about what are the barriers to them documenting and what are the barriers to them practicing the things that we’re asking them to do.  And how can we overcome those barriers.  The flip side of that is we’re encouraging and talking at each session about the shift from external accountability to internal accountability with the long range goal, of course as being they’re not going to be coming here every week for the rest of their lives so during this program they need to keep working on developing more and more internal accountability and internal motivation and not relying entirely on us.  Certainly when they start out, usually there’s not a whole lot of internal accountability there.  That’s what we’re trying to help them build up.  We also have a lot of spiraling curriculum meaning that each week when I am teaching a new skill or a new strategy that the next week after that I always go back and review that skill that they learned last week or two weeks ago or three weeks ago to review that and reinforce it and make sure that they’re still working on things that we taught them earlier in the program because this is a cumulative exercise here.  It’s not just learn one thing and put it off to the side.  So yes, there is accountability and there is homework checking.

Heidi:  Great.  Thank you.  The next question how are you addressing vocational and social needs of your Veterans involved in the pain program?

James Toombs:  For all the folks that are coming in here, we ask them in the interdisciplinary evaluation about what are their goals for work or for school and where do they want to end up.  Some of our folks have very little interest in pursuing work or school.  They may be in their late fifties or early sixties.  They may be on SSD and SSI and maybe 100% service connected and not real interested in pursuing work.  So for those folks—we’re not going to refer them to vocational rehab or to other resources.  The folks though who are kind of on the edge or who are considering that, we will facilitate referral to vocational rehab and compensated work therapies and the resources we have here to get them going with getting back to school or getting back to work.  We integrate and interact quite a bit with voc rehab and CWT.

Heidi:  Great.  Thank you.  The next question, what types of motivation do you use to get patients to move?  In my exercise programs primarily stretching and walking I get a tremendous amount of resistance based on it hurts.

James Toombs:  Great question.  That’s 99% of our patients here as well.  And our physical therapist, Dr. Keyes is really an expert at that, and has kind of worked with this over time with the idea of the graded approach to exercise that I’m sure most folks use.  The idea is that exercise does hurt.  Exercise does cause an increase in discomfort and in the short term patients need to think about is that worth it or not because in the short term, they’re going to have pain anyway whether they exercise or they don’t, but in the long term we tell them that their pain is most likely going to get worse if they don’t exercise and that when they do exercise over a period of weeks, what happens is a lot of that discomfort goes away and the likelihood of their pain intensity decreasing is much higher.  So short term, right.  There is going to be an increase in discomfort and we try to control that and minimize that and keep that to a reasonable extent, but it’s not possible to get better if patients don’t experience a slight increase or a modest increase in their discomfort.  And they will often find that once they are exercising, if they suddenly stop that they’ll miss exercising because their pain will get worse.  So we really teach them and talk with them a lot about short term and long term.  And if they want short term strategies, those are strategies that are going to tend to not be very helpful for a chronic condition like chronic pain.  Chronic conditions like chronic non-cancer pain need long term solutions and so that’s what graded exercise is all about.  Short term it’s going to be challenging.  We help them work through it, but in the long term, most folks will feel better.  So there’s a lot of that kind of feedback  and talking and encouragement going on and for some folks, they’re not willing to experience that discomfort and they may not be—they may not be ready to engage in the fourteen week program. 

The other issue that we address with that is looking at modalities that actually feel good when they do it.  For example, the aqua therapy and the pool therapy patients with very severe pain will report that that’s one of the easiest ways to get started because they’re buoyant and they’re in that water, they’re in the pool.  It feels good and that really helps get them started.

Heidi:  Great.  Thank you.  The next question we have here is we are in communication with CARF regarding our program.  We have a physician psychologist and nurse case manager and we were told that this would not meet the intent of the standards.  We are currently restructuring our program to include physical therapy.  Do you have any advice on how to keep our current structure with the nurse case manager?  Perhaps we are not clarifying the nurses role adequately?

Adam Bank:  We have a nurse case manager that’s part of our team as well, Jackie Caskanett.  We call her a coordinator.  She is a case manager.  And it seems as if they have the physician, the psychologist and they’ve added a physical therapist.  They’ve met their core requirements.  It should not be an issue.

James Toombs:  And it also kind of makes us wonder about what are the goals of your program.  Because again, if we look at the original goals of any IPR program it’s addressing those functional and those behavioral and those physical outcomes.  Really, I would think that a physical therapist would be a key part of that because the patient really needs to be getting someone to take them through some of those exercises that they’re doing to get those physical and functional outcomes.  So it makes sense to me to have a physical therapist and virtually all paid programs that are out there because that’s really where the straw stirs the drink.

Heidi:  Great.  Thank you.  The next question we received, for patients who do not meet admission criteria for the IPR program, do you have other program alternatives?  If so, what are they?

James Toombs:  Oh my gosh.  We certainly have other alternatives and sometimes that is for someone who is more functional and has less pain, distress or intensity, we’ll do a custom IPR where we’ll provide them brief visits with the psychologist, brief visits with physical therapy and the pain doc and use that.  Other times we’ll triage them to the most appropriate service.  If we find someone who is just distressed over severe degenerative joint disease in the knee and they need a knee replacement, we’ll get them there.  So we use the whole VA system to get them into appropriate care including OATPR, our opioid addiction treatment program, and our substance abuse rehabilitation program and all of our other behavioral health services. 

Adam Bank:  We also have an acceptance, commitment therapy group for chronic pain folks that want to focus more on the psychological and the coping side of things, but they’re relatively doing okay on the functional side of things.  It really kind of depends on the patient when we’re going to make that recommendation for them.  Interdisciplinary pain rehabilitation is really geared towards the most distressed and the patients that are functioning the lowest and really struggling.  It is not for every patient who has chronic pain because that’s not a really good use of resources.  We really have an intensive program that’s focusing on the most challenging patients and folks that have more of a mix of symptoms or more of a higher functioning or less distressed, we’ll refer them to a more psychology based program or a shortened version of the IPR or the other services that Dr.  Toombs has described.

Heidi:  Great.  Thank you.  The next question, can you delineate exactly what is CARF accredited in your pain program?  Does it just incorporate the IPR program or a larger pain service/clinic?

James Toombs:  We operate—I’m the director of the Pain Rehabilitation Center which is the overarching pain organization on the St. Louis campus and the IPR, the Interdisciplinary Pain Program is one small part of that and that is the part that’s CARF accredited.

Heidi:  Thank you.  The next question—this is the last question is what resources do you have regarding shifting from external to internal accountability and motivation?

Adam Bank:  Well that’s part of the group psychotherapy process.  So when we’re meeting as a group and we’re drawing on people’s strengths and weaknesses and why some members of the group are making good progress and some of the other members of the group are struggling. Those are all topics for discussion throughout the twelve psychology sessions that we’re meeting on.  Some folks are able to adopt that very quickly.  Other people tend to struggle with it.  But there’s a real encouragement to step away from this conceptualization that I’m a patient and I’m sick and shifting to I’m a person that has strengths and weaknesses.  I’m a person that has chronic pain.  I think that’s really incorporated into many of the sessions that we run and it often comes up as a topic when patients are describing at the beginning of each session what was their best day since I saw them last.  And so instead of talking about well, how are you doing?  Which kind of opens the door for a lot of complaining and describing of symptoms, the question I pose to them is tell me about your best day in the past week?  And then patients are kind of cornered into describing, well, I guess one day I had a relatively good day and these are the things that I did that seemed to make it good.  I really try to draw upon that and then tie in how it’s what they’re doing that’s making it better and it’s not something that I’m doing to them or something that the physical therapist is doing to them.

Heidi:  Great.  Thank you.  And that wraps up all of our questions.  Dr.  Bank, Dr. Toombs, I want to thank both of you so much for taking the time to present in this session.  We had a huge attendee response, which is fantastic.  A lot of people are obviously very excited and interested in what you’re doing here, so we very much appreciate your sharing your information with all of us.  I also want to thank you for bearing with us and being able to stay late to answer all of our questions.  We really appreciate being able to get all of it on the recording even if some people did have to leave.  I also want to thank our attendees for bearing with us and so many of you stayed on to listen to the questions.  We really appreciate that you were willing to put that time into it.  Do either of you have any final remarks that you want to make before we close things out today?

James Toombs:  No.  We’re happy to answer any follow-up questions that folks have.  Please feel free to e-mail us—or give us a call.  We have a lot of information that we’re happy to share and we really don’t want people to have to reinvent the wheel when they can just steal it.  Just e-mail us or give us a call if you have any questions or need additional information.  We’re here to try to help.

Heidi:  Perfect.  I’m sure you’ll have several people who will take you up on that.  Thank you everyone for joining us for today’s Spotlight on Pain Management cyberseminar and we hope to see you at a session in the future.  Thank you so much.

**[End of Recording]**