1. Pain Clinic – One Solution for a Multi-faceted problem Pam Webber MD Fort Collins Family Medicine Residency Program Fort Collins, Colorado

2. Goals and Objectives  Explore the challenges of managing patients with chronic pain in the residency setting  Gain understanding of the FCFMR “Pain Management Clinic”  Discuss the multiple ways that residents can be engaged in a “Pain Management Clinic” and/or the care of patients with chronic pain

3. Fort Collins Family Medicine Residency  6/6/6 community based program in catchment area of 200,000  29,000 annual visits, 15% Medicare, 38% Medicaid, 28% uninsured  approximately 400 identified pain patients in clinic  125 currently in pain clinic, wait list 150 patients, 12 dismissed

4.  Clinic challenges Concerns about inconsistency of care Appointment availability Provider frustration Provider education Patient education Patient satisfaction Why we developed the pain clinic model

5. How did it happen  Prior pain clinic model, limited by availability: trial in 2005-2006  Faculty champion  Buy in from faculty December 2010  Development of team Desire for consistent providers Identified need for registry of patients Identified LPN familiar with group visits and specialty clinics

6. Multidisciplinary team  David Marchant, MD – faculty, clinic medical director  Tasha Ballard PhD – faculty, lifestyle medicine coordinator  Donna Goldstrom – LPC, CAC II  Michelle Hillaire – PharD  Kathy Randall – LPN, clinical coordinator for project

7.  Blocked time for clinics  Recruited patients Requested referrals from providers/nurses Contacted by LPN  Held initial group visits –Jan 2011  Introduction to pain clinic Focus group about patient needs Have been discontinued – but reintroduced (new patients, resident involvement)

8.  Initial individual visit Seen by each member of team  LPN – brief introduction, vitals  Physician – physical assessment  Lifestyle coach – MI, functional goals  Behaviorist – SBIRT, other screenings and referrals as indicated  Referral for group visits discussed with the patient

9.  Group visits – started March 2011 Educational topics  Bowel care  Biofeedback  Relaxation  Massage  Mental Health  Pain Contracts (see handout)

10. Individual Goal Setting 1) Last Month’s Goal__________________ 2) Was this goal Met or Not Completely Met? Please Circle one. 3) This Month’s Goal__________________ Are you currently experiencing any mental health symptoms that are not being managed? If yes, please explain___________________

11. Confidentiality Agreement Pain Medication Follow-up (handout) Publicity Consent Release (handout) Active medication list to review Evaluation of session Appointment card for next visit Given monthly prescriptions One on one time with physician and other providers as needed.

12. Project in process  September visits Those with individual visits – group to go over pain contract Group members  Individual visit with all team members at same time Long term goals Able to discuss strengths patient brings to group Feedback from patient

13. Excel spread sheet  Patient identifiers  PCP  Pain source  Other diagnoses  Last pain clinic visit, color coded for number of visits  Issues  PDMP review (every three months)  Brief provider notes, referrals, phone calls

14. Nuts and Bolts Team huddles for about 1 hour for each ½ day session to discuss issues and new patients  Each ½ day clinic Seeing 9 individuals (2-3 new patients) 15-20 patients in group  Brief huddle after each clinic  Charting in EHR by each team member  Given direct number to LPN for medication questions

15. Evaluation  Comment cards after each visit Individual visits  The services provided by FMC meet my healthcare needs  There was good teamwork a month the staff that cared for me during my visits  I consistently received respect and compassion from the staff at the FMC Pain Management Clinic  My wait time to be seen by the nursing staff was satisfactory  My overall experience at FMC Pain Management Clinic was positive

16.  Group Visits How would you rate the presentation of this topic? How would you rate the content of this presentation? Was the content of this presentation helpful to you? Are there topics you would like to have discussed in the future? If you have any comments, please share them with us:

17. Successes  Viewed favorably by residents less chronic pain in their clinics  Most patients enjoy extra education  Some development of group dynamic and support  Decreased phone calls for pain medication refills  Change in dynamic  Entry into other services facilitated  Concentration on each patient’s function  Movement to long acting pain medications  125 patient appointments opened in resident schedules monthly  8 patients indicated that they were interested in volunteer work at the September visit

18. Challenges  Effect on flow of whole clinic – reception  How to involve residents  How to continue to teach pain management for non pain management clinic patients  Clinic overwhelming Need for more clinics to met needs, keep group sizes at reasonable size