**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**Pain Management and PACT**

**Presenter: Amy Helstrom, Ph.D.**

**March 19, 2014**

Moderator:We are at the top of the hour now, so I would like to introduce our presenter. We have Dr. Amy Helstrom presenting for us today. She’s a Staff Psychologist and MIRECC Researcher at the Philadelphia VA Medical Center, and a Clinical Associate in Psychiatry at the University of Pennsylvania. So I’d like to turn it over to you now Amy.

Dr. Amy Helstrom:Thank you Molly. Thank you for having me on the call today. Molly mentioned that she’s not a pain specialist, and to be honest neither am I. I’m a Researcher here at the Philadelphia VA and I do work for the Primary Care Mental Health Program, but I’m not a pain specialist. The point of the talk today is, “How do we deliver interventions for patients with pain through primary care for all of us who aren’t specialists in managing pain?” I want to talk about today is the problem of chronic pain in primary care and how we can integrate pain management with our Primary Care Mental Health Integration Program, because we know that pain is multifactorial and interventions from various disciplines are often the best way to go in managing chronic pain. Specifically I wanted to talk about a Research Project that we just finished up here at the Philadelphia VA and I’ll get more into the information about that later. We tried out interventions to help a wide population of patients who are in Primary Care with their chronic pain through a randomized controlled trial that I’ll tell you about. We’re going to start off with a poll question. I know Molly knows how to collate those votes. The question is, “What is your primary role in the VA?” For someone like me I guess I would be Clinician and Researcher. A lot of people wear multiple hats. 

Moderator:Thank you Amy, it looks like the responses are streaming in. We’ve got about a forty-five percent response rate right now, so we’ll give people just a little bit more time to submit their responses. As Amy mentioned, I know a lot of people wear multiple hats and at the end of the presentation we will have a survey pop up where you can specify your role. So it looks like most of the responses have come in. Half of our audience is clinicians, about a quarter is managers or policy-makers, about twelve percent each for other and for researchers, and about one and a half percent are student, trainee, or fellow. Thank you to our audience. 

Dr. Amy Helstrom:Thank you. I’m glad that there are so many clinicians on the line today, because I think managing chronic pain affects all of us clinicians in a very profound way on a day-to-day basis. Having those tools available to us to be able to help these patients is something that I think a lot of us want. I think we have another poll question.

Moderator:Yep, we have another poll question that is up now, “Which best describes your research experience? The answer options are: have done research, have collaborated on research, have conducted research myself, have applied for research funding, or have led a funded research grant. It looks like people are a little bit more apprehensive to answer this one, so we’ll give you some time to think about it. Okay, I think we have a general idea of the trend. About thirty-five percent of our audience has not done research themselves. Thirty percent have collaborated, and about twenty-five percent have conducted research themselves. No one has applied for research funding, and about nine percent have led a funded research grant themselves. 

Dr. Amy Helstrom:Okay. That’s perfect actually, because I didn’t want the talk to be overly focused on something specific for our researchers. I wanted it to be grounded. And in what all of us who are working in primary care are seeing everyday was our patients. Thanks for sharing that. As I said, half my time here at the VA is Research, but it’s not all in pain. It’s in the Behavioral Health area, just to give you an idea about what I do. There are so many common experiences with different types of chronic conditions that this seems like a natural thing for me to add on to what I was already doing from a research standpoint. One of the reasons is that chronic pain is so pervasive. When we’re thinking about chronic pain we’re thinking about pain that lasts at least three to six months, often after an injury or a disease process. And often it’s much, much longer after the injury is healed. The kind of pain that keeps going on even though the body has already healed itself, it’s associated with a lot of things that we want to avoid like significant health care expenditures, disability, or lost of productivity. It’s a significant problem particularly here at the VA. We have a lot of Veterans with chronic pain and most of them are treated in primary care clinics. In fact, it’s one of the main reasons that patients come into their primary care provider. They want health with their pain. There’s a statistic here that forty percent of all outpatient visits are pain-related. And most pain, ninety-five percent, an overwhelming amount of pain, is managed in primary care. So these patients are going to a pain specialist, at least most of them are not. The vast majority are being managed in primary care. 

What does that mean for us? It means that we need to help primary care providers and provide methods and tools for helping to manage patients that they’re seeing every single day. To give you an idea of the prevalence in the VA, fifty percent of the Veterans in primary care settings have disabling pain symptoms. So it’s interfering with their lives in a significant way, in their relationships, and in their work. A lot of them stop working if they were doing something that was exacerbating their experience of pain. We know that pain is highly comorbid with psychiatric conditions like depression and anxiety. We know that primary care providers do have medications that help to manage pain, but it doesn’t always do the trick for a lot of patients. And it doesn’t always get rid of pain for patients. It often leaves them with continuing to experience some pain-related disability. For primary care providers, it really is a challenge to try to help these patients. In addition, it takes up a lot of time and resources. I can’t speak to outside of the VA, but I know at the VA primary care providers have very, very limited time with each patient. If you think about ninety-five percent of all of those patients are coming to primary care, that’s a lot of time that’s competing with other demands that primary care providers have such as addressing other chronic diseases like diabetes, heart disease, and other things that do need their time and attention. But we do know that intervening with chronic pain can help reduce some long term disability and other problems. So it makes sense to think about ways that we can help with this before time passes and patients coping skills wear thin and their social support wears thin, which does happen after years of experiencing chronic pain.

What are the challenges for Primary Care Providers in helping patients with their pain? There have been a couple of studies in addition to lots of anecdotal reports. This obviously depends on the provider, but on the whole providers can feel some discomfort in managing chronic pain. They don’t necessarily have a way to help patients get rid of all of their pain, and sometimes patient expectations are unrealistic in that any kind of intervention will get rid of a hundred percent of their pain. They may be concerned about prescribing medications that need to be monitored more closely like opioids, but opioids medication can be really effectively used for a lot of patients. For other patients there are concerns of misuse and some patients may need to be monitored more closely, making sure that they’re taking them as prescribed and not taking too many of them. And that type of monitoring takes time and adds to the primary care provider’s concerns about making those prescriptions. From research and from talking to primary care providers there really is this internal pressure to do something to help their patients, which comes from a very good place of course. So if someone comes to me and they’re hurting, most people in the health care profession of course want to do something to help them to stop hurting. There was a study about ten years ago with primary care providers and general practitioners in the United Kingdom where researchers identified that PCT’s perceptions of the patient’s pressure to do something to help them led to increased prescriptions or medications above and beyond the patient’s medical need, and also increased referrals for imaging. So when a primary care provider felt that the patient was pressuring to do something, they’re more likely to prescribe a medication and more likely to order imaging above and beyond the medical need. That just comes from being a care provider and wanting to help someone. So it’s basically a general feeling overall where primary care providers feel somewhat uncomfortable in managing pain for a lot of their patients.

As to the patients that we see and possibly the patients across the board, a lot of patients with chronic pain are experiencing some depression. And that adds additional burden for patients when they have both onboard. A 2006 study noted that for those patients in primary care with depression, two-thirds of them also have chronic pain, but didn’t have depression. Only about forty-three percent had chronic pain. So there’s a symbiotic relationship between depression and chronic pain. The two combined really are associated with poor outcomes, the quality of life, anxiety, disability, and stress-related problems. Here’s a picture of someone with depression and with chronic pain. In outpatient medical settings, depressive disorders tend to be the most frequent and the most common ones that we would see. In addition you have the pain as well. Anyone seeing patients in a primary care setting likely is going to be seeing patients with chronic pain and depression at some point. With that constellation that particular combination can exacerbate the experience of chronic pain and interfere with the response to treatment. So treatment for chronic pain can be inhibited when the depression or anxiety is onboard, and it’s a challenge. 

The next slide will tell you more about that, Depression and Chronic Pain. I think people are probably familiar with the IMPACT Study. That was a randomized controlled trial with eighteen hundred patients. They tested treatments for depression, which included anti-depressant medication and six to eight sessions of psychotherapy. The patients with the psychotherapy did much, much better with their depressive symptoms overall than with the controlled condition. These are the patients in primary care clinics. There was a subgroup that was examined for patients with chronic pain. They looked at the affect of the depression intervention on pain outcomes only. It’s separate from the depressive outcomes. They show that just addressing their depression improved the patient’s pain symptoms. It also improved their functional status and improved their quality of life. It stands to reason that these two things are meshed with one another, depression and chronic pain, so we can make some improvements on either one or the other domain or both that could lead to improved quality of life for our patients. 

I’m sure that most people are familiar with the Biopsychosocial Model of Pain. This is referred to in the Practice Guidelines as the optimal way to manage pain. We know that pain is maintained, worsens, and is composed of a number of factors. The factors are biological factors, psychological factors, social factors, and behavioral factors. All of those things impact one another. As a cause and behavioral therapist myself, we’re always looking at these different areas to see how one is impacting one another. For example, a belief about pain is going to affect your experience with pain. It may be generated from past experiences, but they also might impact future experiences. Those might impact your decision to engage in certain behaviors or your attitude toward pain. All are combined with things like biological factors and the actual injury itself to produce the chronic pain symptoms that the patients are experiencing. 

This slide is just another way to think about the model, the Biopsychosocial Model of Chronic Pain. You can see that this is broken down into a Psychological Vicious Circle and a Physical Vicious Circle. The expression of pain may trigger things like anger, anxiety, fear, and distress. And that mood might be related to depression, which may in turn increase the perception of pain. So there’s a cyclical event going on. And then the same thing happens with the physical activity. Pain may lead to a decrease in activity. If my back hurts when I move, I may be prone to move less. Unfortunately that will lead to deconditioning, which will lead to increased pain. To a point where someone does engage in activity, it may lead to further avoidance of activity and then further deconditioning. You can see how that would work. The idea would be to interrupt both these cycles as much as we can, and through a multi-modal approach. That’s what we tried to do with the project that I’ll be talking about in a little bit. 

This slide shows it broken down into what happens with these cycles. It depends on so many different things. If you’re presented with the two patients side by side with those two circles, mine would look exactly the same. But there is a biological pain specialist that everybody has that is different for each person. It depends on the site of the injury and the stimulus at the site of the pain. Psychological status varies for each individual person. They might have different emotional status, different beliefs and expectations, a self-efficacy, how much they can overcome this pain and how much they believe that they have the ability to do that varies from person to person. Their past experiences with pain and then their overall health to begin with before the chronic pain onset all factors into a patient’s experience with pain and also areas that we can intervene as clinicians to help them with their pain. 

We used the Biopsychosocial Model in our Guidelines. Ideally we’d like to be approaching ever person with chronic pain. They’re behavioral, emotional, cognitive areas, as well as their physical and using that to help interrupt those circles. For example, I’m encouraging patients to exercise more and to resume normal activities as much as possible. Even in their minds understandably they think that an activity is going to be the opposite thing that they should do, because they fear re-injury. There’s a lot of literature about the fear-avoidance process where patients get so engaged in the idea that any kind of activity will lead to further damage to tissue or further re-injury above and beyond the actual physical ramifications that are likely to occur that they recondition themselves to the point where they’re actually going to more likely to reinjure themselves. It’s counterintuitive to a lot of patients, but that activity level is really important. All of these things sound like it takes a lot of people. It takes a lot of conception and individual attention to all of these different domains. As I said before, primary care providers don’t necessarily have the time and the resources to do this with every patient. Thinking back to how many patients they have in their practice or on their panel, it’s quite a lot. We can’t send everybody to specialty care. At least we can’t in our VA system. Patients may not need that type of care. We might be able to do something for them at the primary care level helping primary care providers. 

What we physically do if a patient was going to be going to specialty care, they might receive something called Cognitive Behavioral Therapy for chronic pain. I’m sure that a lot of people have heard about CBT intervention. Eight to ten sessions examining patterns of thoughts and behaviors and emotions, and ideally having that be a part of the interdisciplinary pain management team has really been effective. There are a number of treatment outcome studies showing that CBT can be very effective in helping to manage pain. Even educational interventions have been shown to be helpful. Unfortunately the resources required for that and an engagement in that by patients can be limited and not everybody has access to Cognitive Behavioral Therapy. If you think about those eight to ten, one-hour sessions, or eight to twelve, not everybody is ready to commit to that level of intervention. And it may not be available to them or easily available to them. This leads into some of those barriers for patients getting access to Cognitive Behavioral Therapy interventions. They may be living a distance from a hospital that would allow them to do that. Or they may be working with schedules that preclude appointments. And their pain itself might be related to their inability to get treatment. Unfortunately I have plenty of patients who said that they can’t come to the hospital because of their pain, which makes it sometimes hard to help them with their pain. And also we want to be using our resources appropriately. There are patients who absolutely need specialty pain care. They would greatly benefit from a Cognitive Behavioral Therapy intervention or with a specialty mental pain management with a multidisciplinary team. Not everybody does though. And there are different levels of chronic pain. Since so many patients are going to primary care, that seems like the place to start with improving pain.

That’s where the effective care approach came out and it was developed. I think that this makes a lot of sense. This is the work of Bob Kerns and Steven Dobscha and Don Otis has written about this as well. It’s an Integrated Model of Pain Care where there are levels of intervention. The first level would be primary responsibility with pain would be with a primary care provider. Level two would be patient education and maybe a rehabilitation model with an exercise plan, and a discussion of the pain management model. The third level is comprehensive pain management. In our case here at the VA, that would be a specialty pain management clinic. What we want them to do is to focus on level one where the primary care provider is responsible for helping patients better manage pain. The idea of the Stepped-Care Approach is where the interventions are sequenced. So if a patient came to primary care with pain, we would try to triage and identify which level would be the best for that patient. If they needed to go to specialty care for the second or third step we would do that, or if they could be managed with step one we would do that. So the idea with step one is incorporating collaborative care with the primary care provider and its population-based. This means that we want to try to reach as many patients as we possibly can. Remember that’s a lot of patients with pain. We’re not providing specialist care for individual patients. We’re trying to reach as many patients out there as we can.

Here’s a little bit of a diversion. I wanted to talk about the Pennsylvania VA’s primary care health integration program, which is the BHL, Behavioral Health Lab. I’ll tell you why we’re talking about this in a little bit, but this is our primary care mental health program. It’s been in existence for quite some time. What we do in that program is to provide behavioral health assessment and triage to patients in primary care, as well as treatments for patients in primary care. Those patients that don’t need to go to specialized care, research has shown through the BHL that depression, anxiety, and alcohol misuse can all be effectively managed at the primary care level. They don’t need to go and see a psychiatrist or specialty mental health care. We can provide brief, targeted interventions using a measurement-based care that can be really helpful for those patients. Some may need to go to specialty mental health care, but most can be effectively managed and that’s all that they need. So again, thinking about helping as many patients as possible with a targeted type of intervention is what the VA is about. There have been some treatment outcomes for depression care management. It was a BHL and an alcohol-based treatment in something that we call Referral Management for patients who need to go to specialty care. We track them and make sure that they actually get to that care and engage. 

This slide shows a few quotes about the PC-MHI Program. We really think about the BHL as a part of PACT, so combining behavioral health with primary care and behavioral supporting primary care. If you think about the joint principles of PACT of the medical home, providing those two things you really focus on the whole person orientation and coordinated or integrated care. The BHL is providing treatment to patients, but in the service of supporting primary care providers; to do that we really need a behavioral health component. 

I want to take you quickly through how the BHL works. We have an assessment that occurs after our patient is referred to us. And then depending on the outcome of that assessment, which is done by a software program administered by our health technicians, patients may have one of four dispositions. It might be very clear that they need specialty care and we’ll schedule them for an appointment. It might be more appropriate for brief treatments to manage them in primary care. So we will go ahead and engage them in that care and if they need something above and beyond that, we usually have very brief, four to eight sessions, and we’ll have them to go specialty care. We have some prevention or health promotion programs. We have one called Watchful Waiting where we’re trying to promote health and prevent disease. Or they might not need treatment at all or say that they’re not interested. That’s how our BHL process works. It’s staffed by psychiatrists. Psychiatrists consult with clinicians. Clinicians are nurses, psychologists, and a social worker. I think the way that it’s distributed is that we have one health tech and one clinician for every eight thousand unique patients at the VA. So we’re really able to reach a wide range of patients through this model, rather than referring all patients directly from primary care to specialty mental health care when maybe only a fraction of those patients might actually need that. We do have software that helps with that process. 

We noticed s lot of our patients being referred to our service, to the BHL, spontaneously endorse pain, and after noticing that we added in some questions to our standard assessment packets to patients. For a brief period of time we wanted to find out, “Okay. It seems like a lot of these patients are having pain. How many?” When we did this we found out that over eighty percent of those patients that we sampled reported that they’re having pain that interfered with their daily activities. So we thought that we’re providing a PACT service. We’re providing behavioral health within PACT; we may be able to help with this problem of chronic pain at the step one level. How do we do this? We started out with a Pilot Study. Becky Helms and Johanna Klaus came up with this. Johanna Klaus is our Director of the BHL.  I should say that it started up by Dave Oslin. We wanted to come up with an offering for those patients, some kind of intervention that would help their patients with chronic pain who are coming to us anyway for behavioral health. 

The interventions were drawn from previous studies from the people that we read about who were providing interventions through the larger, more expensive clinical trials with behavior interventions. We focused on the behavioral versus the cognitive interventions because we wanted them to be delivered by anybody in PACT mental or behavioral health. So a nurse, a psychologist, a social worker, we really wanted them to be specific interventions for those patients who could be managed in that first step. I should have mentioned this before, but the BHL does a lot of work by telephone to provide greater access to all of our patients. So again, there are plenty of patients who are not able to come into the hospital for whatever reason. Our parking is notoriously awful. Or they may have other things to do. They may be a caretaker of someone in their family. They may be working. So a lot of scheduling as well as physical problems may get in the way of patients actually coming in and attending an appointment. When the BHL was started it was designed specifically to provide access by telephone for those patients who want it. But anybody who would like to come into the hospital, we do provide in-person appointments. We wanted our pain intervention to be similarly able to be delivered by phone. We wanted the chronic pain intervention to be similar to the other interventions that we’re doing in the VA itself. So identifying those patients who need the care and figuring out the level of care that they need. Maybe they need something more expansive than we provide in the BHL. We wanted to know which domain of our program they should be in and then making good use of our specialty care when needed. Then we facilitate engagement with that and track those patients. We wanted this pain intervention to be identical in practice to the other modules that we were already delivering.

The way that this works for everybody that comes to the BHL is that they complete a standard battery, either by phone or in person depending on what the patient want. The battery includes measures on psychiatric functioning and behavioral health symptoms and substance use, as well as overall functioning. Most people probably complete the assessment by phone. And because of a lot of inpatient in person care, we do a lot of mailings of information for the purpose of psychoeducation or self-monitoring. Communication can be enhanced with our telephone-based interventions by using the mail. This is a list of our assessments. This is the package of assessments for measurement that we use. And for all of our modules in the BHL we track symptom improvement over time. So for example for patients who come in with depression, we administer the full battery and if they are elevated on the PHQ-9 we would enroll them in our depression care management program. It tracks their progress in treatments. We administer the PHQ-9 and we provide feedback to the patient about their success and improvements. 

We use that information to give to their primary care providers to let them know how they’re doing. If they’re getting worse we want to know that and we will also communicate that to their primary care provider and say, “We need to do something different.” Maybe we need to change their antidepressant medication. It’s data driven and measurement-based interventions. We use a stepped care approach. The contacts are longitudinal but they are brief. The goal is to help patients manage their own care. We want to collaborate with the primary care providers. And when necessary we use recommendations from our psychiatrists about psychiatric medications like most antidepressants. This is a little bit more information about our measures, but I’m going to skip over it in the interest of time. You can see here that we really think of us as a BHL provider as being the center of helping the patient get the best care they can from the primary care clinician and the mental health supervisor. I briefly wanted to show what our software looks like and how we track patients. You can see how we can track their values on different things. 

I wanted to talk about the next step after our Pilot Project. We successfully enrolled Veterans in our pilot project to manage pain. We drew from elements that were helpful from existing literature for behavioral interventions for pain, which included things like relaxation, guided imagery for relaxation, pain self-monitoring. And patients really responded to this. Twenty-nine patients completed it and so we thought that the next step would be to do a randomized controlled trial. We were luckily funded by the Center for Evaluation of PACT to do a randomized controlled trial that had intervention as a step one level to manage chronic pain in primary care. But will this work? Will we be able to effectively treat pain for Veterans in primary care above and beyond what their usual care is? To what extend does the intervention lead to improvement on quality of life, and to what extend does the intervention improve depression and anxiety outcomes?  For our Study Design we randomized a hundred and sixty patients to either Pain Care Management, the intervention program, or to a control. The control was our usual care, which is depression or anxiety care management. All of these patients were patients that came to the BHL already with symptoms of anxiety or depression as well. So everybody involved in this study had depression or anxiety. And all of them received depression or anxiety care management. Half of them received additional pain care management intervention. 

Our main outcomes were pain interference, depression, quality of life. We will be looking at a bunch of predictors as well. We’re in the preliminary stages. Our usual care is consultation with psychiatry about medication, support, behavioral activation. These are all things that we do for patients in our depression care management program, along with of course, psychoeducation. With our intervention of pain care management we did the usual care plus of psychoeducation about pain, helping patients self-monitor their own pain levels so they don’t feel like they’re always at a ten in their pain levels, but that it fluctuates. We help them to set SMART goals and encourage relaxation with deep breathing. Guided imagery is helping patients learn how to pace themselves, and then we help them to learn how to manage when they have a flare-up of pain. In terms of the psychoeducation we use the Gate Control Theory as a way to explain how the pain model works. I’m sure that most of everyone on the call are familiar with that. We also sent a workbook home to patients with information about pain. We present them with a CD with relaxation strategies. We’re really borrowing things that have already worked in the past from the folks in the field who have already done this in behavioral interventions. Of course we use the BHL software. If patients needed it we refer them to specialty care. They can consult with a psychiatrist and they collaborate with a primary care provider. 

Eligibility included patients who are either a five out of ten, ten being the highest of pain severity or pain interference. We did not include patients who needed to go to specialty mental health care or specialty pain care or had other cognitive problems and they weren’t able to understand what they were enrolling in. Here is a diagram of the PCM Study Procedures just to get an idea about the flow and the referral process and how they got to us. Out of three hundred and seventy-six patients we ended up with a hundred and sixty patients enrolled in the study, and then they were assigned to those two conditions that I mentioned. In describing sample characteristics, a lot of patients were in a lot of pain. Eighty-four percent of patients were endorsing a pain rating of a six or more out of ten in the last twenty-four hours. Almost a hundred percent of them said that their pain was at greater or equal to a five in the last twenty-four hours. And almost all of them, ninety percent, said that they had interference due to chronic pain on a five or more level on a scale of zero to ten. So they really were endorsing a lot of pain. There is nowhere on the body that someone didn’t identify as the place where they’re experiencing pain. There is one little “x” there that doesn’t belong on the face, but almost every patient who enrolled had at least one site of pain. Most of them had two or three. We ended up with a pretty heterogeneous sample in terms of pain origin. 

We asked patients whether they are already doing to manage their pain and you can see there that they did a lot of these common sense things. They were doing a lot of things that were helpful for them. None of them really management their pain, however, we asked them also to tell us what made their pain worse and this is pretty heterogeneous too with activity or not enough activity. It really depended on the patient. So there were no trends there. Most patients completed the number of sessions that we administered. And that was nine overall sessions for the patient care management program. That included six in our active phase and three follow-up sessions, and about four to eight sessions for our controlled conditions. Most people completed most of them. Only forty percent completed fewer than that. You can see a little about describing our population. They were mainly African-American and the majority was male, but forty-six percent are married or partnered. A lot of them were having some financial problems in the sense that they only had enough to get along. You can tell from our description here of Psychological Variables that a lot of the patients were severely depressed in this sample. About fifty percent were in the moderately to severe range in our PHQ-9 scale. Alcohol use did not seem to be a significant problem for the majority of the samples. Thirty-three percent of patients were in the severe range for anxiety. That’s a lot. And then with the depression/anxiety scale, if you look at the moderate to severe range there are quite a few. We’re working with a sample of patients that were pretty depressed and anxious.

This is the unfortunate conclusion to our outcomes so far. These are the preliminary results, but not looking at moderators, we did not find any difference between the groups on either the pain variables or the psychological variables. We had the two conditions and our pain care management conditions didn’t do any better. The good news is that both groups did improve over time. You can see from my graph here that the pain interference scores got better over time, but with both groups. They weren’t any better in our pain care management group. It’s the same for pain severity. Both groups got better, but our pain group didn’t do it any better than our usual care condition, even when we controlled for baseline differences on all of these. Again with the depression scores both groups got better. Pain care management didn’t do any better than usual care unfortunately. With the quality of life patients are doing better. I wish I could say it was due to our pain care management treatment intervention, but I can’t because controlled conditions are also doing very well and the trend continues.

What do we make of this? We can intervene with pain in PACT. It’s feasible. The patient found it acceptable. We can do it by phone and patients get better when we enroll patients with pain, depression, or anxiety. We don’t yet know what elements were helpful. Was it because both groups were getting their depression treated? I’m not sure. Unfortunately a study came out that had similar results that just came out not too long before we were done wrapping up our study. But they provided CBT’s for patients by phone, compared to pain education and twelve sessions of CBT over twenty weeks. They also found no differences between the groups. So I guess we could say we’re in good company. There is something there in that patients are getting better. We need to figure out what elements are really helping them. One thing that we’ll be looking at with our data are moderators. Does age, gender, personality, coping style, or cognitive set play a role in their response to our treatments? We’ll be finding out soon. I think if I were to go back in time and do this again, things that we would do differently and maybe something that we want to do in the future is to really emphasize the chronic pain rationale in Biopsychosocial model that was only one component of our intervention and went for only six sessions. Only half of that session was focused on that. So reiterating that model so that you get patient buy-in will be important for the future. I don’t know that patients were able to wrap their heads around it, especially if that pain-related behavior is very entrenched. 

What I would have liked to do also is to access their motivation for change before we started the intervention. So there may be differential responses for patients who are very motivated to work on their pain compared to patients who weren’t. We were asking patients to engage in behavioral activation for example, and that can be very hard. We wanted to know who was really interested in making those behavior changes. And then really considering what types of behaviors are built up around their pain on a day-to-day basis. So again those entrenched behaviors that maybe have been in existence for twenty years, the response for that person may be different than the response for someone who’s had chronic pain for six months. One thing also that I think we can consider in the future is also looking at ways to help patients with behavior change. Particularly since behavioral activation is such a key component to pain management, when we look back at our data and we found that the average patient in our study was obese with a BMI of thirty-one. So in a sense we’re asking patients who are obese to engage in behavioral activation without focusing on the barriers that may be in place for them having both pain and obesity onboard. So we have programs here at the VA like MOVE and other lifestyle programs. We might be able to borrow from or collaborate with to help those patients who have maybe more hurdles than we were thinking about before we started this. I’ll conclude there, and hopefully we have some time for questions.

Moderator:Thank you so much. Yeah, we do have some great questions pending so I’ll go ahead and get into those now. Can you please give some examples of “measurement-based care?” Is this like using a score of PHQ-9 for others?

Dr. Amy Helstrom:Yes that’s exactly what we’re talking about. There is a good reference if anybody wants it about the BHL and how that works. We’ve repeated a measure of an assessment is what we’re talking about with measurement-based care. So if a patient comes to us with a PHQ-9 of twenty, the treatment algorithm would be to talk to the patient and find out more about their symptoms, and possibly consult with a psychiatrist who may recommend a medication. We would go to the primary care provider and say, “This is the recommendation from our psychiatrist. Are you interested in prescribing that medication?” We don’t want to leave things there, which is what I think can happen sometimes. What we do is to follow-up with our patient over time in addition to providing support and helping with problem-solving and things like that. We want to re-administer that PHQ-9 to make sure that the symptoms are decreasing in the right direction. So that’s what we talk about with the measurement-based care that we have through our Behavioral Health Lab. For a typical patient we probably re-administer that PHQ-9 if the person has depression at every contact. It’s easy. There are only nine questions. We have a software package for it and we can even graph it really easily and generate some information to provide to both the patient and the primary care provider about their response to that treatment. 

Moderator:Thank you for that reply. The next question is, “How concurrently do starting PC-MHI psychologists take advantage of your work to bring CBT light to their own PACT sites?

Dr. Amy Helstrom:That’s a really good question. I like that you called it CBT light, because we’ve been talking about it like that. Within our group too because I think what we’re trying to do is to borrow pieces of CBT and to incorporate them into PACT in a way that’s manageable for those patients who aren’t going to get a full course of CBT. Fortunately for us the BHL and our PC-MHI program has been in existence for a while. And I think with seeing it grow one of the things that really helps us with growing is making a lot of contacts and even doing some marketing with our primary care providers. I’ve been at this facility for six years and psychology wasn’t a presence really maybe ten years ago. So when we were building up our PC-MHI program one thing that we did, which was very helpful I think, was just going to a lot of meetings and promoting things and letting primary care providers know what we can do to help their patients by showing them responses to our PC-MHI interventions. That’s one piece I think that’s really important to get a program off and running. And then doing a lot of education with the primary care providers, which will help with their collaborations with them and working with the patient.

Moderator:Thank you. Was the RCT conducted as research or quality improvement?

Dr. Amy Helstrom:It was a research project. We had IRB approval to conduct the project. As a part of PACT I think it was envisioned by PACT as a QI project. But because we were collecting assessments and we were required by IRB to have approval and have informed consents. So I guess it’s a little bit of both in a sense, but it was a research project.

Moderator:Thank you. This came in a little bit earlier before you did the results. How many that improved were forwarded to psych or specialty care?

Dr. Amy Helstrom:That’s a good question. I could get the data for you because it’s something that I also had a question about. This is something that I probably should have tracked at the beginning going forward, now its data that I have to retrieve. In hindsight we do have the data and it’s something that I can provide later on. But I don’t know the proportion of patients who were referred differs between the two groups. I know that both had plenty of patients that they refer to specialty care. So that’s a non-answer, but it’s something that I want to find out as well.

Moderator:Thank you. We do have some pending questions left. I just want to let our attendees know that I am going to put up the feedback form now. So go ahead and take just a moment to provide us with your responses. The next question is, “How many hours of CBT were given to this important intervention? Also, thank you for your work.”

Dr. Amy Helstrom:Thank you. That’s something that I should have addressed as well. So I’m glad that you brought that up about how long the intervention is. The pain care management intervention was six sessions for our active phase, and that was over the course of three months. Each session varies. Some patients you would call on the phone and they would only have ten minutes for you and so we would do the best that we can with those ten minutes. Ideally, they would be twenty to thirty-minute sessions each. So we would do six of those. And then we had three follow-up sessions for one month at a time afterwards to try to encourage patients to use those skills that they found useful and maybe remind them of those things that they had learned before. So if they had been using relaxation and it kind of fell off, maybe practice with them and problem-solve about how they can help manage their pain. I was one of the clinicians, but in addition to better intervention by us clinicians we had a great health technician who was calling to do the assessments separately across the two conditions. She would also call and administer repeated measures of assessments as a part of the research project for both patients and our usual care and in our treatment. In fact our research assistant was so good she could possibly be a confound, because she was providing support. Granted she did it across both conditions, so I think she was equally supportive for both groups. But I think sometimes she was so supportive that the patient didn’t feel as great of a need to get support through the clinicians with the next upcoming appointments. 

Moderator:Thank you for that reply. Do you think your affect is due to the increased attention that the patients are receiving? That is that someone is finally listening.

Dr. Amy Helstrom:That could be it and I think that’s a really important factor with pain. I think that patients often get the impression at least that the pain is all in their head or that it’s not important or that there’s nothing that can be done to address their pain. So I think that’s a valuable thing to consider because of what we’re doing. This is the real thing. We’re actually doing a study to see how we can help with it. We wanted to know how they responded. We were asking them how they felt. So I think there was a great value to just validating that experience with pain. And that could be driving a lot of results that we got. 

Moderator:Thank you. There are just three pending questions. What measures do you use to measure readiness for change?

Dr. Amy Helstrom:This is one of those questions that I wish I had added in the sessions. If I could do this again I would add Eva Prochaska’s measurements readiness for change. The motivation on half the literature is that you have a lot of measures that can be used to see what stage of change the patients are in. I think the one I would recommend is called the *Stages of Change* and getting a sense beforehand, because this is not a passive intervention. To make things better for their pain everybody would have to be ready and willing to engage in some kind of effort to engage in these behaviors. And so it would have been helpful to find out who was at that stage at that point, but I think that I would use a *Stages of Change* ladder is what it’s called. 

Moderator:Thank you. Have you looked at any generational or cohort differences in your participants?

Dr. Amy Helstrom:That’s a really good idea. We had a very wide range of ages. The mean age was in the fifties, but we had at least twenty something and as high as I think the early eighties. So that would be something that we could do. I would need to double check to make sure that we have enough patients to be able to stratify appropriately that there’s enough patients in the youngest group, because I think that twenty-nine year old was an outlier. But that would be really interesting and it might also be a proxy for trying to identify how long patients have been experiencing chronic pain. It’s certainly a moderator I’m really looking forward to examining those analyses.

Moderator:Thank you. The last question, “Has palliative care consultation been considered?”

Dr. Amy Helstrom:In terms of chronic pain in our system what we would do is that the next step after our pain intervention when we started this project would have been going to our specialty pain clinics. And then they would probably talk about palliative care. That wouldn’t be a decision that we would make within our framework for PC-MHI, but in other systems it might vary.  

Moderator:Okay. Thank you for that reply. That does wrap up the Q&A portion of this. I do very much want to thank you Dr. Helstrom for joining us and sharing your expertise with the field. And I’d also like to thank our attendees for joining us today. That does wrap up today’s cyber seminar. Thank you very much.

Dr. Amy Helstrom:Thank you Molly. Thanks everyone for being on today.

Moderator:Have a good one.

Dr. Amy Helstrom:You too.

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