The Medical Director

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The Medical Directors Role in Pain Management
and Quality Improvement in the Nursing Home

• Leonard M. Gelman MD CMD
• Ballston Spa, New York

PRESIDENT NEW YORK MEDICAL DIRECTORS ASSOCIATION
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PAIN MANAGEMENT IN THE NURSING HOME

• PREVALENCE / SOURCES / CONSEQUENCES
• BARRIERS
• ASSESSMENT
• TREATMENT

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PREVALENCE

• ESTIMATES OF 45 - 80 OF ALL NH RESIDENTS WITH
  CHRONIC PAIN
• FERRELL et al, 1995 311 bed LTC
• FERRELL, FERRELL, OSTERWEIL 1990
• OF THOSE IN PAIN
• PHYSICIAN ORDERS FOR PAIN 84
• RECEIVED PAIN MEDS IN PREVIOUS 24 HOURS 15

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SOURCES OF PAIN

• LOW BACK PAIN 40
• PREVIOUS FRACTURES 14
• NEUROPATHIES 11
• LEG CRAMPS 9
• KNEE OA 9
• CLAUDICATION 8
• SHOULDER OA 8
• FOOT 8
• HIP OA 6

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CONSEQUENCES OF UNRELIEVED PAIN IN THE ELDERLY

• IMPAIRED AMBULATION
• FALLS
• DEPRESSION

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CONSEQUENCES OF UNRELIEVED PAIN IN THE ELDERLY

• SLEEP DISTURBANCE

• DECREASED SOCIALIZATION
• COGNITIVE DYSFUNCTION

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CONSEQUENCES OF UNRELIEVED PAIN IN THE ELDERLY

• SLOWED PROGRESS IN REHABILITATION

• POLYPHARMACY
• MALNUTRITION
• DECONDITIONING

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CONSEQUENCES OF UNRELIEVED PAIN IN THE ELDERLY

• INCREASED HEALTH CARE UTILIZATION
• INCREASED HEALTH CARE COSTS

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BARRIERS TO PAIN MANAGEMENT IN ELDERLY AND IN
LONG TERM CARE
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BARRIERS TO PAIN MANAGEMENT IN LONG TERM CARE

• SCIENTIFIC BARRIERS
• MISCONCEPTIONS
• SYSTEM BARRIERS

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BARRIERS TO PAIN MANAGEMENT IN LONG TERM CARE

• SCIENTIFIC BARRIERS
• MISCONCEPTIONS
• SYSTEM BARRIERS

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BARRIERS TO PAIN MANAGEMENT IN LONG TERM CARE

• SCIENTIFIC BARRIERS
• Very little data on this patient population
• Pain scales
• Empiric treatment
• Practitioner limitations

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SCIENTIFIC BARRIERSPractitioner limitations

• may not be familiar with approaches to pain
  management
• may not adequately evaluate the patient for pain
• may not receive or use relevant information
  provided by the patient or by other staff
• Practitioners may hesitate to prescribe opioids
• exaggerated fears of adverse regulatory
  oversight
• adverse medication effects
• diversion of controlled substances

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SCIENTIFIC BARRIERSPatient

• HIGHER LIKELIHOOD OF COGNITIVE AND SENSORY
  IMPAIRMENT AND DEPRESSION
• CONCOMITANT MEDICAL CONDITIONS
• RACIAL, ETHNIC, GENDER BIASES

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BARRIERS TO PAIN MANAGEMENT IN LONG TERM CARE

• SCIENTIFIC BARRIERS
• MISCONCEPTIONS
• SYSTEM BARRIERS

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BARRIERS TO PAIN MANAGEMENT IN LONG TERM CARE

• SCIENTIFIC BARRIERS
• MISCONCEPTIONS
• SYSTEM BARRIERS

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MISCONCEPTIONS OF OLDER PERSONS ABOUT PAIN

• PAIN IS AN EXPECTED PART OF AGING
• SIGN OF PERSONAL WEAKNESS
• TO BEAR PAIN W/O COMPLAINT SHOWS STRENGTH OF
  CHARACTER
• PUNISHMENT FOR PAST ACTIONS

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MISCONCEPTIONS OF OLDER PERSONS ABOUT PAIN

• PAIN ALWAYS INDICATES SERIOUS DISEASE
• FEAR OF WORSENING DISEASE
• FEAR OF FURTHER TESTS AND TREATMENTS

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MISCONCEPTIONS OF OLDER PERSONS ABOUT PAIN

• FEAR OF MEANING OF PAIN
• LOSS OF INDEPENDENCE
• DEATH NEAR

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BARRIERS TO PAIN MANAGEMENT IN LONG TERM CARE

• SCIENTIFIC BARRIERS
• MISCONCEPTIONS
• SYSTEM BARRIERS

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BARRIERS TO PAIN MANAGEMENT IN LONG TERM CARE

• SCIENTIFIC BARRIERS
• MISCONCEPTIONS
• SYSTEM BARRIERS - FACILITY

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Systems Theory

• Systems rarely exist in isolation
• Understanding the interdependence of related
  systems is critical in problem solving

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Systems Theory

• Changes made to one system may cause unexpected
  or unintended changes in other systems !!

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Characteristics of a System

• Boundary
• Structure
• Culture

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Characteristics of a System

• Boundary
• Interface where information flows
• between systems
• Who is involved in the process?
• May be
• Permeable information flows freely (open
  system)
• Impermeable- controls or restricts the flow of
  information (closed system)

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Characteristics of a System

• ? Structure
• Interrelationships
• Expectations
• Roles
• Interactions

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Characteristics of a System

• Culture
• ? Beliefs and Values
• ? Mission Statement
• ? What is the organization all
• about?

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Roles, Functions, and Tasks
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Role

• Definition
• The set of behaviors an organizational member is
  expected to perform and that he/she feels
  obligated to perform
• Role of the medical director varies
• situation specific
• dependent on individuals knowledge and skills
  and facility culture and needs

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Function

• Definition
• Major domains of activity within the role
• Functions of the medical director
• statements of responsibilities of the medical
  director

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Tasks

• Definition
• Specific activities used to carry out a function
• Tasks
• specific activities performed by the medical
  director to fulfill functions

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SYSTEM BARRIERS FACILITY

• MISCONCEPTIONS OF STAFF ABOUT PAIN IN OLDER
  PERSONS
• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

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SYSTEM BARRIERS FACILITY

• MISCONCEPTIONS OF STAFF ABOUT PAIN IN OLDER
  PERSONS
• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

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SYSTEM BARRIERS FACILITY

• MISCONCEPTIONS OF STAFF ABOUT PAIN IN OLDER
  PERSONS

• LOWER PAIN INTENSITY
• HIGHER TOLERANCE
• LESS TOLERANCE OF OPIOIDS
• ELDERLY MORE LIKELY TO BECOME ADDICTED

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SYSTEM BARRIERS FACILITY

• MISCONCEPTIONS OF STAFF ABOUT PAIN IN OLDER
  PERSONS

• COGNITIVELY IMPAIRED CANNOT BE ADEQUATELY
  ASSESSED FOR PAIN
• PATIENTS COMPLAIN TO GET ATTENTION
• PATIENTS WITHOUT TYPICAL SIGNS OF INCREASED
  AUTONOMIC DISCHARGE (AS SEEN IN ACUTE PAIN) ARE
  NOT SUFFERING PAIN

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SYSTEM BARRIERS FACILITY

• MISCONCEPTIONS OF STAFF ABOUT PAIN IN OLDER
  PERSONS
• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

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SYSTEM BARRIERS FACILITY

• MISCONCEPTIONS OF STAFF ABOUT PAIN IN OLDER
  PERSONS
• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

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SYSTEM BARRIERS FACILITY

• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT
• DEFINE SYSTEM
• ASSESS CURRENT SYSTEM

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SYSTEM BARRIERS FACILITY

• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT
• DEFINE SYSTEM
• ASSESS CURRENT SYSTEM

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• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

• DEFINE COMPONENTS OF PAIN SYSTEM
• Organizational Commitment
• Initial Screening
• Comprehensive Assessment for Pain
• Development of Care Plan
• Ongoing Screening and Monitoring
• Simplicity

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SYSTEM BARRIERS FACILITY

• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT
• DEFINE SYSTEM
• ASSESS CURRENT SYSTEM

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SYSTEM BARRIERS FACILITY

• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT
• DEFINE SYSTEM
• ASSESS CURRENT SYSTEM

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• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

• ASSESS CURRENT SYSTEM
• ASSESS PAIN POLICIES
• ASSESS STAFF

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• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

• ASSESS CURRENT SYSTEM
• ASSESS PAIN POLICIES
• ASSESS STAFF

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ASSESSING PAIN POLICIES

• Includes statement of commitment?
• Includes screening, assessment and monitoring?
• Includes goals for program?
• FOR EXAMPLE
• Prompt assessment
• Prompt diagnosis
• Improve residents well being
• Optimize ADLs
• Monitor for side effects

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ASSESSING PAIN POLICIES

• Addresses a protocol for ongoing monitoring of
  pain?
• Addresses a protocol for communication of
  reporting to MDS personnel?
• Are the policies too complex to be easily taught
  and performed?

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ASSESSING PAIN POLICIES

• QUALITY IMPROVEMENT
• Addresses who, how and when program
  effectiveness should be monitored and evaluated
• Monitoring of MDS and QMs
• Accuracy, reliability in facility
• Patient level
• Facility level
• Performance indicators

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Performance Measurement Indicators

• Process indicators
• Outcome indicators

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Performance Measurement Indicators

• Process indicators Examples
• Facility has adopted policies and procedures that
  promote a systematic, interdisciplinary,
  individualized approach to pain management
• Facility staff and affiliated professionals
  receive appropriate education that reflects
  current standards and practice in pain management
• Patients are regularly assessed for the presence
  of pain or risk factors for pain
• Staff has selected a pain assessment method
  appropriate for each patients cognitive level
       

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Performance Measurement Indicators

• Process indicators Examples
• Scope of diagnostic workup for pain, or reasons
  for limiting its scope, and pain relief measures
  are documented in the patients record
• An appropriate, individualized, interdisciplinary
  care plan that includes stated care goals is
  implemented for each patient with pain
• Environmental and other nonpharmacologic
  interventions are implemented to optimize
  function and quality of life for patients with
  pain
• Analgesic medications are used and monitored
  appropriately in patients with pain

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Performance Measurement Indicators

• Process indicators Examples
• Patients prescribed NSAIDs are monitored for
  deterioration in cardiac or renal function
• When opioids are prescribed, a bowel regimen is
  implemented to prevent opioid-induced bowel
  dysfunction
• During initiation of opioid therapy a monitoring
  plan to address excessive sedation and
  respiratory depression is prepared and
  implemented
• Patients with pain are assessed for depression

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Performance Measurement Indicators

• Outcome indicators Examples
• Increases in
• Number of patients achieving pain control goals
• Number of patients with pain showing improvements
  in function and quality of life
• Number of patients receiving scheduled pain
  medications

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Performance Measurement Indicators

• Outcome indicators Examples
• Decreases in
• Number of patients receiving PRN pain
  medications
• Number of patients with severe opioid-related
  constipation or fecal impaction
• Number of patients prescribed partial opioid
  agonists or meperidine, or propoxyphene

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• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

• ASSESS CURRENT SYSTEM
• ASSESS PAIN POLICIES
• ASSESS STAFF

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• LACK OF WORKABLE SYSTEM OR PROCESS OF PAIN
  MANAGEMENT

• ASSESS CURRENT SYSTEM
• ASSESS PAIN POLICIES
• ASSESS STAFF

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ASSESSING STAFF

• New staff assessed for need to train?
• Agency staff assessed?
• Current staff provided with ongoing education?
• Discipline specific education?

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ASSESSING STAFF

• Is there a designated clinical expert available
  to answer questions from all staff?
• Does education take into consideration personal ,
  ethnic, cultural and religious beliefs?
• High rate of staff turnover?

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ASSESSING STAFF

• Is education provided at the appropriate level?
• Does education include staff training on
  documentation?

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ADVANTAGES OF LONG TERM CARE SETTING

• RESTORATION AND MAINTENANCE OF FUNCTION
• PRESERVATION OF AUTONOMY
• DELAYING THE PROGRESSION OF CHRONIC MEDICAL
  PROBLEMS
• ENSURING QUALITY OF LIFE

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ADVANTAGES OF LONG TERM CARE SETTING

• INTERDISCIPLINARY TEAM
• REGULAR REVIEW
• MDS
• CARE PLANS
• PAIN MANAGEMENT LENDS ITSELF VERY WELL TO
  INTERDISCIPLINARY INVOLVEMENT

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PAIN ASSESSMENT
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PAIN ASSESSMENT

• DOCUMENTATION - AMDA/AGS
• FLOW SHEET - ASSESSMENT SHEET
• MEDICATIONS
• INTERVENTIONS
• DESCRIPTORS OF PAIN
• OUTCOME AT SPECIFIED INTERVAL
• PHYSICAL EXAM
• REGULAR REASSESSMENT

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MDS 2.0

• J2 a Frequency of pain symptoms
• 0. No pain
• 1. Pain less than daily
• 2. Pain daily
• J2 b Intensity of Pain
• 1. Mild pain
• 2. Moderate Pain
• 3. Times when pain is horrible or excruciating

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MDS QM

• Number of residents who experience moderate pain
  at least daily or horrible/ excruciating pain at
  any frequency
• Chronic Care / Post-Acute Care
• J2 a 2 and J2 b 2
• OR
• J2 b 3
• Mild pain, less than daily or daily NOT IN
  MEASURE

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Section J Health ConditionsMDS 3.0

• Pain Management
• 2.0
• Under-reporting
• Does not support pain management well
• 3.0
• Direct interview

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Section J Health ConditionsMDS 3.0

• Pain Management
• 1. Chart Review
• Scheduled pain med regimen
• Prn pain med
• Non-medication intervention

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Section J Health ConditionsMDS 3.0

• Pain Management
• 2. Pain interview
• Pain presence
• Pain frequency
• Pain effect on function
• Sleep
• Day-to-day activities
• Pain intensity
• Numeric rating (0-10)
• Verbal descriptor scale
• Staff assessment if resident unable to respond

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Section J Health ConditionsMDS 3.0

• Pain Management
• Two questions considered but rejected
• In your opinion, how important is it for your
  pain treatment to completely eliminate your
  pain?
• extremely important 38
• Very important 41
• Somewhat important 18
• Not at all important 3
• Do you feel that more should be done to keep you
  free from pain?
• No 66
• Yes, a little more 25
• Yes, a lot more 9

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MDS QM

• To avoid
• Confusion

DOCUMENT DOCUMENT DOCUMENT
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PAIN ASSESSMENT

• ACCURACY OF DIAGNOSIS
• ACCURACY OF DESCRIPTION
• ACCURACY OF DOCUMENTATION
• ACCURACY OF COMMUNICATION
• ACCURACY OF REEVALUATION

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TREATMENT
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GOALS OF GERIATRIC MEDICINE

• CONTROL OF CHRONIC DISEASE SYMPTOMS
• MAINTENANCE OF FUNCTION
• INCREASED COMFORT
• PRESERVATION OF DIGNITY

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GENERAL PRINCIPLES - AMDA

• ADOPT INTERDISCILINARY CARE PLAN
• SET GOALS FOR PAIN RELIEF
• CARRY OUT THE CARE PLAN
• RE-EVALUATE PATIENTS PAIN
• ADJUST TREATMENT

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GENERAL PRINCIPLES

• PHARMACOLOGIC
• BENEFITS / BURDEN BALANCE
• START LOW GO SLOW
• DISCUSS GOALS WITH PATIENT / FAMILY
• ADVERSE REACTIONS
• NON-PHARMACOLGIC
• INTEGRAL PART OF CARE PLAN
• PATIENT EDUCATION

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GENERAL PRINCIPLES

• THE PATIENT SHOULD BE GIVEN AN EXPECTATION OF
  PAIN RELIEF, BUT IT IS UNREALISTIC TO SUGGEST AND
  SUSTAIN AN EXPECTATION OF COMPLETE RELIEF FOR
  SOME PATIENTS WITH CHRONIC PAIN.
• AHCPR/AHRQ
• AGS
• CMS

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• FEARS OF DRUG DEPENDENCY AND ADDICTION DO NOT
  JUSTIFY THE FAILURE TO RELIEVE PAIN, ESPECIALLY
  FOR THOSE NEAR THE END OF LIFE.
• AGS