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15 Articles in Volume 20, Issue #6
20/20 with Mark Wallace: Where Cannabis Fits into Pain Practice
A Commentary on Opioid Stewardship: Fentanyl, Sufentanil, and Perioperative Pain
Adherence and Relapse – How to Maintain Long-Term Gains in Patients with Chronic Conditions
Advanced Practice Matters with Theresa & Jeremy: COVID, Pain, and Power
Analgesics of the Future: Inside the Potential of Janus Kinase Inhibitors
Application Note: Using Photobiomodulation to Treat Trigeminal Neuralgia
Case Report: Quadratus Lumborum Block for Managing Pathologic Pain to the Hip
Chronic Pain and the Short-term Effects of Medical Cannabis
Differential Diagnosis: Polymyalgia Rheumatica or Rheumatoid Arthritis
Genicular Nerve Blocks: Field Tips on Prognostic Value and Technical Considerations
Guideline Update: ACR Promotes Pharmacologic Treatment for Osteoarthritis
Navigating New York's Medical Marijuana Program: A Patient Handout
Person-Centered Care: Lessons from the VA’s Whole Health Model
Psychedelics for Chronic Pain: Is It Time?
Resident’s Corner: What Pain Medicine Education is Missing in the COVID Era

Person-Centered Care: Lessons from the VA’s Whole Health Model

The former lead examiner of the VA's COVER Commission talks about self-care as a focus on people − not pills and procedures − and how the agency's reduced-cost model can extend to private practice.

A Provider Perspective

Chronic pain is a major health problem in the United States and its prevalence has certainly not diminished during the COVID-19 pandemic. The Veterans Administration’s ambitious and largely successful innovations in alleviating pain for countless men and women who have served in our country’s military have remained a relatively well-kept secret to the public. Civilian clinicians and their patients could benefit greatly by incorporating some of the key lessons learned in recent years from the launch of the VA’s new and expanding Whole Health model.

Having spent much of my 40-year medical career in the military, I have studied and written about how to get healing back into the heart of medicine. I believe the Department of Defense and VA efforts point the way toward reinventing our medical practices. American healthcare must shift to a person-centered model stressing self-care, rather than its traditional medical-centered focus that relies heavily on pills and procedures.

 

VA Report

Earlier this year − before COVID hit America − a 10-member Congressionally mandated commission, on which I had the honor to serve, released a 150-page report that strongly supported the VA’s approach stressing patient engagement and the promotion of non-drug and integrative approaches, alongside standard medical treatment.

The report is the product of the Commission, Creating Options for Veterans’ Expedited Recovery (COVER), which for more than a year exhaustively examined VA’s performance, particularly in treating veterans suffering chronic pain, PTSD, traumatic brain injuries, depression, opioid use, and suicides, which claim the lives of more than 20 men and women per day. The Commission’s recommendations, released in February, ultimately called on Congress to expand this whole person-centered, integrative model throughout the VA’s sprawling $120-billion system.

If these recommendations are fully implemented, every one of the 9 million veterans served by the VA would create their own personal health plan and be assigned a designated “health partner” as part of a team of professionals including physicians, nurses, nurse practitioners, social workers, health coaches, navigators, and mental health providers to both provide care and, significantly, encourage and support self-care.

 

The Model Works for Veterans and Employees

We know this works. For two years, the VA has partially implemented this model at 18 “Whole Health Centers of Excellence” across the country. Early indications are that these pilot sites have improved care while significantly reducing costs by nearly $5,000 per veteran in 18 months. If the government, payers, and the public fully embraced such a model, this could ultimately have far greater impact on America’s health than any incremental refinements or expansions in Medicare or the Affordable Care Act.

Employees also liked it and were more engaged in their work. In a large evaluation of Whole Health by the VA’s Center for Evaluation of Patient-Centered Care (EPCC), employees who used or delivered Whole Health services rated their sites more often as one of the Best Places to Work, had decreased turnover, and less burnout.

In addition, Veterans at Whole Health sites also reported higher patient-centered care ratings and patients more often discussed care goals and care difficulties with their provider. Finally, sites with greater Whole Health involvement did better on global measures of quality performance. Notably for pain patients, there was a 38% drop in opioid use in patients using Whole Health services.

The Rationale

This approach is based on a solid rationale. Healthcare, as currently delivered, is not producing health. Studies show that only 15% to 20% of health, for individuals or entire populations, comes from medical care. Nearly 80% arises from other factors rarely addressed in doctors’ offices; factors such as the behavioral and lifestyle choices that people make every day about nutrition, exercise and movement, sleep, stress management, substance use, and coping with the social and economic environments in which they live. 

We know that many of the most common chronic conditions, such as hypertension, diabetes, obesity, chronic pain, anxiety, and depression, can be mitigated and treated effectively with behavioral and integrative health approaches that are evidence-based. These approaches include diet, movement, stress management, therapeutic yoga, acupuncture, and massage therapy. All are safe, effective, and far less expensive than drugs and surgery − if employed in a timely manner.

The VA model provides Veterans with access to a suite of these proven, non-drug approaches. All patients still receive conventional medical treatments − but only when necessary.

 

The VA Model in Civilian Practice

For civilian practitioners and private practices, a massive reinvention such as the VA’s may be beyond imagination in a smaller clinical setting. But the fundamentals of this model can be implemented at a relatively low cost by embracing the all-important culture change that lies at the root of VA’s innovations.

Ask the Right Questions

I have done this in my own practice and would like to share some of the key methods for putting it into action. I begin by having every patient fill out a brief Patient Health Inventory (PHI) that is adapted from the VA’s Whole Health model and is the starting point for treating my client as a whole person, not just as a patient. The two-page PHI questionnaire, available in English and Spanish, addresses key aspects of a person’s life, asking him or her to consider not just what ailments they might have, but to assess themselves in terms of their body, behavior, lifestyle, social, financial, emotional, and even spiritual life.

Then I focus on a fundamental shift in my patient engagements. Instead of only asking my patients “What’s the matter?,” I attempt to learn what would actually drive them to seek health and well-being by asking, “What really matters to you?”

In medical school, we were all trained to employ the SOAP note (Subjective, Objective, Assessment, and Plan) and use it to chart a patient’s condition and treatment. This method limits the ability of physicians to make healing their primary mission. So, I supplement the SOAP approach by adding what I call a HOPE note, which stands for Healing-Oriented Practices and Environments.

The HOPE note questions address:

  • Mental and Spiritual Areas: What is your goal for your healing? What’s meaningful for you?
  • Social and Emotional Areas: What are your connections and relationships?
  • Lifestyle and Behavioral Areas: What do you do during the day? What is your lifestyle like?
  • Physical Environment: What is your home like? Your work environment? Do you get out in nature?

This quick, straightforward approach aligns what is most important to the patient and addresses their underlying determinants of health. Understanding what motivates a patient is key to encouraging their ability to change behavior.

The HOPE note has helped me learn to listen more closely to my patients, to better understand the underlying drivers of what may be making them sick, and to help them choose their best personal path to healing, often through a combination of integrative and conventional care.

A whole health recovery model depends on engaging, educating, and empowering patients. (Image: iStock)

Patient-Guided, Evidence-Based Care

Perhaps most importantly, this initial integrative health visit starts a patient-guided process designed to identify the personal values and goals for their life and for healing. The physician’s primary role is to provide evidence and support to help them define and meet their goals.

Nearly 40% of the US population uses a wide variety of alternative approaches to treat their pain and other chronic conditions, usually paying out-of-pocket for pain-relief methods such as chiropractic, massage therapy, therapeutic yoga, acupuncture, Tai Chi, supplements, and many other remedies for their chronic illnesses. Our patients have long known the value of treating pain with these approaches. We, as healthcare practitioners, need to help them find the best ways to manage their own health with these and self-care.

I’ve had patients who have suffered pain for more than 10 years, but they have only begun to get better when they became self-motivated to address the underlying behavioral and social factors that prevent their healing. This recovery model depends on engaging, educating, and empowering your patients, rather than just waiting for them to show up for medicine or treatment. Healing them means giving them hope for a recovery based on their own actions.

From my experiences, I believe that practitioners can become more effective healers if we can learn to ask our patients the right questions, listen more closely to their answers, and guide them more surehandedly on a path to self-care.

 

Practices of Any Size Can Do It

This does not require hiring new staff or investing in expensive new technology. Instead, it means investing in your current team members by training them with new skills, while also investing in your own future by incorporating into your practice new modalities and new attitudes about how best to treat pain.

The VA has the advantage of teams of nurses, nurse practitioners, social workers, health coaches, navigators, and other specialists. But even small clinical practices can greatly expand their capabilities by training medical assistants to become effective health coaches and health navigators who can assist patients in defining their primary personal needs and supporting them in making steady, incremental changes toward their pain-relief goals.

Small practices that organize their clinical practice to promote Whole Health are able to greatly expand their suite of offerings, organizing group visits, and linking up to community resources to provide nutritional counseling, mind-body practices, and use of biofeedback, acupuncture, yoga, and other clinically proven methods.

See also, Dr. Vanila A. Singh's take on integrated care in a special Q&A.

 

Evidence for Incorporating Integrative Medicine

In the past, well-informed and well-intentioned clinicians faced serious roadblocks in attempting to revamp their practices. Primarily, there was little scientific evidence to document the safety and effectiveness of complementary and alternative forms of medicine − and therefore payers usually refused reimbursement for delivering such services.

But that is changing. Some providers still believe the myth that treatments such as acupuncture and therapeutic yoga are unproven. But those treatments have been demonstrated to be safe and effective for chronic pain in good randomized studies and meta-analyses funded by the NIH and published in JAMA, the Annals of Internal Medicineand other highly respected journals.

These studies support the move of government and private payers to acknowledge the cost-effectiveness of evidence-based alternative treatments. Just this year, for example, CMS has approved the use of acupuncture for the treatment of chronic back pain. Progress on the reimbursement front has not been fast enough, but as more and more patients and practitioners are seeking out and benefiting from these treatments, pressure will continue growing to make them reimbursable.

Of course, this doesn’t mean that patients will be cured by going to a yoga studio. But they will likely experience tangible pain-reduction in the hands of a properly trained and certified practitioner of therapeutic yoga. This is where the role of the provider is crucial − to bring evidence-based approaches into their clinic.

On my website, practitioners can find evidentiary summaries for many non-pharmacological approaches for pain: what they are, what we know about the evidence, what specific conditions they help, and how to find qualified practitioners. In addition, the Center for Innovation in Family Medicine enables practitioners to take a self-directed course on pain management and explore new approaches to helping patients with chronic pain, with the goal of finding alternatives or additions to treating with opioid analgesics.

 

Conclusion

Meaningful change in our entrenched system of treating pain will take many years to accomplish, but the VA’s new approach represents a major move in the right direction. We have already learned the dangers of overusing opioids and the limited effectiveness of many forms of surgery. What we need now is for practitioners to open their minds to integrative health as a routine part of clinical care.

 

Disclosure: The Samueli Foundation, of which the author is the executive director, provided the Center for Innovation in Family Medicine with a grant to create the pain management course noted herein.

Continue Reading:
Commentary: VA Shows the Way to Treat Low Back Pain
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