LESSONS LEARNED IN DEVELOPING EVELOPING 

CARF-ACCREDITED INTERDISCIPLINAR

REHABILITATION (IPR) P (IPR) PROGRAM

St. Louis VA Medical CenterJefferson Barracks DivisionMarch 6, 2012

James TooJames TooMedical DirAdam Bank

Clinical Dire
CARF (COMMISSION ON ACCREDITAT

OF REHABILITATION FACILITIES) 

STANDARDS

Section 3K – an IPR program “provides 

outcomes-focused, coordinated, goaloriented interdisciplinary team services.

Must address the following domains: 

Behavioral, , ,y 

 Functional, Medical, Physica

Psychological, Social, Vocational.
INTERDISCIPLINARY TEAM

|The person served / family |Pain Team Physician Pain Team Physician|Pain Team Psychologist|At l t th h lth At least one other healthcare 

professional
UNDERSTAND THAT CARF IS COO

1) No cookie cutters2) Outcomes help massage your I

Outcomes help massage your I

program format 

3) D i d ti Dynamic over dogmatic
WHAT DOES A CARF-ACCREDITED IPR 

PROGRAM LOOK LIKE?

1) Two Ears2) Four Legs Four Legs3) One Tail

Build what your facility n

GETTING STARTED: STEAL THE W

1) Tampa VA (inpatient and outpat

Formal on-site training available

2) San Juan VA (outpatient)

T l e e-confi t erencing support

3) St. Louis VA (outpatient)

Policies, procedures via CD
A LITTLE HISTORY. . .

Prior to 2006, the St. Louis VAMC’s chronic pain management services were spread across a numof independent specialty clinics (Medicine Psycof independent specialty clinics (Medicine, Psyc

Anesthesiology, Chiropractic, Physical Therapy, Neurology). 

In mid-2006 Dr. Florian Thomas (Associate ChieS ff f S C / f S Staff of the Spinal Cord Injury/Dysfunction Servi

approached Dr. Fred Metzger (Psychology) with 

proposal to establish a multidisciplinary pain proposal to establish a multidisciplinary pain

management service.
A LITTLE MORE HISTORY. . .

St. Louis VAMC Executive Council approved the proposal in 2007.From mid-2007 to mid-2008 the Pain Clinic worksecure space and staff.The Pain Rehabilitation Center began offering comprehensive pain management in March 200

Planning for the Interdisciplinary Pain Rehabilita

program began immediately program began immediately.
STRIKE ONE. . .

In August 2009, the IPR program admitted the fipatients to the nascent program, initially set up apatients to the nascent program, initially set up a

8-week program with visits twice per week.

Of the two patients admitted to the program at inception, one dropped out within the first week, the second patient attended four appointments the second patient attended four appointments, 

then no-showed or cancelled the next six. . . and 

dropped out as well. dropped out as well.Back to the drawing board . . .
STRIKE TWO. . .

The second iteration was an every-other-week 

program lasting 6 months. It reduced commitme

maintained our current drop maintained our current drop-out and no out and no-show ra

show ra

Strike Two.

Back to the drawing board . . .again.
CURRENT STRUCTURE OF

STL VAMC IPR PROGRAM

The current IPR program meets once per week 3 months, with each visit involving 3 3 months, with each visit involving 3-4 hours of 4 hours of

treatment.

For our population and location, this seems to wOther programs have adopted continuous prograwith success with success.
STL VAMC IPR PROGRAM

The Interdisciplinary Pain Rehabilitation Program outpatient program offered to veterans with chrooutpatient program offered to veterans with chro

non-cancer pain who are not candidates for opeor interventional services. 

Patients are taught a variety of self-managemento help improve their ability to cope with chronic to help improve their ability to cope with chronic 

improve day-to-day functioning and mood, decre

reliance on pain medication and the healthcare reliance on pain medication and the healthcare

system, and decrease pain intensity.
IPR SERVICES

o Physical therapy

o Chiropractic treatments

o Group psychotherapy (family and individual therapy as o Gym-based physical exercise /Aqua-therapyo Nutrition educationo Education about pain medications from a pharmacisto F ll o ow-up vi it ith th P i Ph i i isits with the Pain Physician

o Extensive homework with documentation
TREATMENT GOALS

| Develop a broad range of chronic pain selfmanagement skills| M ii d ax mize day-to-d f ti d ti it l l day function and activity level| Decrease emotional distress and negative thin| D i ecrease pain-rel t df d i t lated fear and anxiety| Minimize reliance on medications, particularly 

opioids

| Reduce reliance on the healthcare system| D i i t it Decrease pain intensity| Improve quality of life / reduce suffering
FOR CLARITY. . .

The focus is not on pain elimination. Reduction in pain intensity is de-emphasiz

Focus is on improving patients Focus is on improving patients’ ability to ability to

cope with pain, increasing overall activit

levels and decreasing use of healthcare levels, and decreasing use of healthcare

resources.

Family involvement strongly encouraged.
IPR INTERDISCIPLINARY TEAM

| J T b MD James Toombs, MD D id J Ph 

Pain Physician

| David Jansen, Pharm

Pharmacist

| Carey Keys, DPT

Physical Therapist

| Jacqueline Henderso

RD, LDDietician

| Pamela Wakefield, DC

Chiropractic Physician

Dietician

p y | Takisha Lovelace, BB

| Adam Bank, PhD

Staff Psychologist

Program Manager

Staff Psychologist | Jackie Caskanett RN Jackie Caskanett, RN

BSNCoordinator
REFERRAL CRITERIA

| Experiencing chronic pain despite operative or 

interventional therapies

| Abl t ti i t f ll d f ll l Able to participate fully and follow program rule| Free of active substance abuse, including alco

and marijuana for at least 30 consecutive days and marijuana, for at least 30 consecutive days

shown on UDS

| Psychiatrically stable such that they can active

Psychiatrically stable, such that they can active

and safely participate in an outpatient program
OUTCOME MEASURES

|What are the Targets of Treatment?| Pain Intensity (QVAS)| Depressive symptoms (PHQ-9)| Catastrophic Thinking (PCS) Catastrophic Thinking (PCS)| Pain-Related Fear and Anxiety (PASS-2| F ti l St t d P h i l Functional Status and Psychosocial

Functioning (PDQ)
PROGRAM PATH

SCREENING TO DISCHARGE| Initial Consult Review| Initial visit for group screening and Methadone 

Ui D S r ne Drug Screen

| Interdisciplinary Evaluation and Recommendat| S h d l f IPR d i i Schedule for IPR admission| 3-Month Outpatient Program (14 weekly visits)| Interdisciplinary Pain Team meetings (both form

and informal)

| P t os -Di h A t d F ll Discharge Assessment and Follow-up 

(Booster Sessions, Support Group, 3-month an

12-month assessments) month assessments)
PSYCHOLOGY - CONTENT OF SESSIONS

| Based on Managing Chronic Pain: A Cognitive

Behavioral Therapy Approach, by Dr. Otis (200

| 1) O i t ti t IPR R l 1) Orientation to IPR program, Rules| 2) Basic Pain Education, Hurt vs. Harm| 3) A ti it P i 3) Activity Pacing| 4) Relaxation and Tension Reduction| 5) Sleep Hygiene| 6) Distraction vs. Mindfulness Meditation, 

mid-tt t t reatment assessment

| 7) Depression Management, Pleasant Events
PSYCHOLOGY - MORE SESSION CONTEN

| 8) Cognitive Reframing| 9) Impact of Chronic Pain on Self| 10) Impact of Chronic Pain on Others| 11) Substance Abuse, Opioids, outcome 

assessment

| 12) Discharge Planning, Relapse Preparation, 

Coping with Flare Coping with Flare-ups

| Dietician and Pharmacy sessions usually occu

during the first third of the IPR program during the first third of the IPR program
SAMPLE DAY

| 8:00 am – 9:00 am – Pool therapy or gym exer

(45 to 60 minutes); emphasize graded exercise 

cardio slow but sure approach cardio, slow but sure approach

| 9:15 am – 11:00 am – Chiropractic and Physica

Therapy and Pain Physician (two visits) Therapy and Pain Physician (two visits)

| 11:00 am – 12:00 pm – Group Psychotherapy*Daily walking, stretching, TENS unit use, Physic

Therapy Chiropractic exercises and relaxation Therapy, Chiropractic exercises, and relaxation

exercises are assigned as routine homework.
PATIENT DEMOGRAPHICS

| In 2009 - 2011, 48 veterans with chronic non-c

pain completed the IPR program:

| A 51 5 ld Average age = 51.5 years old

(Range = 27 years to 76 years)

| 21% f ti i t k d f ll 21% of participants worked full-ti t me or part-tim| Gender: 60% Male, 40% Female| Ethnicity: 68% Caucasian, 30% African-Amer
TYPES OF PAIN PROBLEMS

| Types of chronic pain conditions included:

38% Back Pain

17% Fibromyalgia/Diffuse Pain11% Headache11% Neck Pain4% Extremity Pain

19% Other Pain Problems (Carpal Tunne

Abdominal Pain, Joint Pain, Knee Pain, 

O t th iti ) Osteoarthritis)

| Average length of time since onset of chronic p

was 14 8 years 14.8 years. 
2009 - 2011 IPR OUTCOMES

74 veterans were formall

y pg admitted to the IPR 

pro

gram

5% were involuntarily, prematurely discharged due to illisubstance abuse, and 30% dropped out (multiple no-shocancellations, transportation problems, imprisonment, etcancellations, transportation problems, imprisonment, etAmong the remaining 65% who completed the IPR prog(n=48), overall improvement rates (defined as clinically si ifi t i t f b li t di h ) ignifican

t improvemen

t

from 

baseline 

to disc

harge

) wer

y Pain-related Fear and Anxiety – 65% improvedy Catastrophic Thinking Catastrophic Thinking

– 67% improved 67% improved

y Functional status and psychosocial 

functioning –63% improved

y Depression 

– 58% improved

y Average Pain Intensity (in the past week) – 36% imp
3-MONTH POST-TX OUTCOMES

At 3-month follow-up, results were available fo39 veterans:

y Pain-related Fear and Anxiety – 62% improy Catastrophic Thinking – 74% improvedy Functional status and psychosocial 

functioning – 46% improved

y Depression – 46% improvedy Average Pain Intensity (in the past 

week) – 49% improved
12-MONTH POST-TX OUTCOMES

At 12-month follow-up, results were available for 

24 veterans: 24 veterans:

y Pain-related Fear and Anxiety – 58% improy Catastrophic Thinking Catastrophic Thinking – 63% improved 63% improvedy Functional status and psychosocial 

functioning – 46% improved 46% improved

y Depression – 46% improvedy Average Pain Intensity Average Pain Intensity

(in the past week) – 21% improved
PATIENT SATISFACTION (0-10)

| Based on n = 17| Overall treatment = 8.6| Staff warmth, respect, kindness, 

willingness to listen = 9.3

| Skill d t f th t ff 9 6 Skills and competence of the staff = 9.6| Ease of getting appointments, 

hours of treatment etc 9 2 hours of treatment, etc. = 9.2

| Would you recommend this treatment to someo

you know who has a pain problem? = 9 5 you know who has a pain problem? = 9.5
SUCCESS STORY

| Morbidly obese male (331 lbs.) in his early 60s| Chronic pain in low back, both hips and should

and k t 15 d knees, onset 15 years ago

| 100% SC, chronic depression, DM, DDD| “I k h t t d I j t d ’t d it ” “I know what to do, I just don’t do it.”| On disability and SSD, failed MOVE program| Actively engaged in psychology/psychiatry tx
SUCCESS STORY: DISCHARGE & FOLLOW

| Domain Baseline Post –Tx 4-Mo| PHQ-9 21 4 | PCS 45 24 | PASS-20 66 25 | PDQ 107 67 | QVAS 6 5 | Weight (lbs.) 331 299 | Dramatic improvement during treatment in mos

domains. Continued to practice self-managemstrategies even after L ankle Fx at 2-months pomaintained or improved gains at 4 maintained or improved gains at 4-month follow month follow
FUTURE GOALS

| Lodger Program| In-Patient Program| Treatment Readiness Enhancement Group| ACT for Chronic Pain| Tele-Pain Services to Rural Populations| Export training to VISN facilities
QUESTIONS?

Contact info:James.Toombs@va.govAdam.Bank@va.govTakisha.Lovelace@va.gov