1. Stepped Care Model for Pain Management Nabiha Gill, MD Staff Physician PM&R Chair, Indianapolis VA Pain Committee Chair, VISN 11 Pain Committee Assistant Professor, PM&R, IUPUI, Indianapolis, IN

2. Objectives Progress as facility pain committee Progress as VISN pain committee Successes Struggles Next steps

4. Indianapolis VA Pain Committee

5. Updated pain committee member list Added more pain disciplines rep E-mail group for communication More structured More enthusiasm, motivation, energy among members Updated/reviewed committee objectives Developed “Multidisciplinary Virtual Pain Team Consultation”

6. “Multidisciplinary Virtual Pain Team Consultation” Developed “Multidisciplinary Virtual Pain Team Consultation” Subgroup of facility pain committee Primary and secondary (back up) key people from each discipline Support from departmental chiefs and EMT More than 10 disciplines on the team Regular communication among team members Pilot program done in primary care

7. “Multidisciplinary Virtual Pain Team Consultation” Key members from following disciplines; 1.Physical Medicine & Rehab Physician 2.Pain Psychologist 3.Physical therapist 4.Rec therapist 5.Interventional pain specialist 6.Ortho spine surgeon 7.Neurosurgery 8.Primary care physician 9.Pharmacist 10.Patient advocate 11.Social worker

8. “Multidisciplinary Virtual Pain Team Consultation” Developed CPRS consult order, virtual/historical visit/note title/note/alerts Chart review by all disciplines prior to case discussion Primary care provider gets invited to meeting, short case presentation by PCP….then consultation from all disciplines Opportunity for provider education about services from different pain disciplines and pain management Support for PCP Case example

10. Proposed “Stepped care model for pain management for Indianapolis VA”

11. TERTIARY LEVEL SECONDARY LEVEL PRIMARY LEVEL

12. Proposed Stepped care model for pain for Indianapolis VA Provider education Pain Medication Management Pain Policy Pain School Primary Care Clinics/Teams Bupe Clinic/ SATS Secondary Consults Int Pain Clinic Chronic Pain Rehab Program Multi-dis pain TertiaryTertiary Sec Primary CBT

13. CRIPP Comprehensive Rehab Integrative Pain Program (Proposed)

14. CRIPP (Comprehensive Rehab Integrative Pain Program) Chronic Pain Consult Screening Clinic Bupe clinic/SATS Chronic Pain rehab program PMMP Sec.consults/int/SATS/Biofeedba/ PT/accupuncture CBT Pain School Multi -dis Pain PCPPCP Team meetings with OEF clinic, pain clinic, CRIPP staffing, PCP staffing (q6mon)

15. Tampa VA “Chronic Pain Rehab Program” training Excellent training

16. VISN 11 Pain committee progress

17. VISN 11 Pain Committee progress V-Tel Communication Face to face meeting HSB Stepped care model/policy/education plans VISN Ambulatory care council

18. “Too many clinical reminders” “Not enough support for PCP’s decisions” “Lack of access to comprehensive pain services” “Lack of pain care standards and policies” On-site workshops on chronic pain management for providers Pain schools ORC CBT groups Multidisciplinary virtual pain team consultations Aquatic therapy Interdisciplinary pain rehab programs Opioid detox programs CAM

19. Successes!!!

20. Struggles!!!

21. Next Steps!!

22. Questions!!