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14 Articles in Volume 21, Issue #5
Analgesics of the Future: Interleukin-17 Inhibitors for Treating Psoriatic Arthritis
Ask the PharmD: What evidence exists for metformin in treating rheumatoid arthritis pain?
Case Chat: Spasms vs. Spasticity and Muscle Relaxant Options
CDC Opioid Prescribing Guideline Updates Are in the Works: Will the Changes be Enough?
Chronic Pain Management in Marginalized Populations: How to Rebalance the Provider-Patient Relationship
Dantrolene: The Forgotten Molecule for Outpatient Spasticity
Forgotten Analgesics: The Drugs Pain Practitioners Need to Reconsider
Machine Learning Predicts Patient Response to Rheumatoid Arthritis Therapy
Perspective: Where Have All the Rheumatologists Gone?
Rheumatoid Arthritis and Bridge Therapy: Primary Care Considerations
Root Cause of Plantar Fasciitis: Three-Step Exercise Protocol
Shoulder Pain and Rotator Cuff Injuries: Emerging Treatments
Special Report: The Evolution of Rheumatoid Arthritis Treatment, from Gold to Gene Therapy
Transfer of Care: Barriers and Solutions in Chronic Pain Management

Transfer of Care: Barriers and Solutions in Chronic Pain Management

After surveying pain specialists, the authors propose solutions for the safe and effective transition of patients from a tertiary specialized pain center to primary care.

A Word from the Authors

By means of a survey, we explored difficulties faced by pain specialists when discharging medically stabilized patients to a primary care provider; barriers to this process pose a challenge to free up access for other patients in need of specialty pain services. In addition, the optimal return care of medically stabilized patients to their primary care provider (PCP) is essential, as the PCP also knows the patient comprehensively. With our survey results, we crafted a set of potential solutions, described herein, that we hope may be implemented at our tertiary-pain center and other Canadian – and possibly US-based – specialized pain centers. Further, we propose the implementation of an intermediate support clinic to offer overlap in care through a discharge process that would be progressive.

Pain specialists face challenges when discharging patients to primary care; the author discuss barriers and solutions. (Image: iStock)

Background

The “Bayesian brain” theoryaims to illustrate the complexity of chronic pain and describes the perception of pain as a subjective bodily state resulting from a nonconscious prediction that we are in pain, ‟based on an integration of sensory inputs, prior experience, and contextual cues.”1 Pain clinicians understand that chronic pain is a multidimensional phenomenon that requires a comprehensive, integrated, and multifaceted model of care.

In an era where opioid use in chronic pain management has gained an endemic international reputation related to fatalities and misuse, access to both primary care providers (PCP) and pain specialists has become a public health priority. The World Health Organization released, in May 2018, a new systematic classification of chronic pain, where chronic pain was entered into the foundation layer of the 11th revision of the International Classification of Diseases (ICD-11).2 Despite this recognition of chronic pain as an important problem in medical care in its own right, access to public multidisciplinary clinics in Canada generally involves unacceptable wait times for patients, varying between 6 months to up to 5 years.3 Poor and/or delayed access to care can directly impact the patient’s psychological well-being and health-related quality of life (QoL), while the PCP can be left facing the difficult and emotionally exhausting task of treating these patients alone.4,5 Further, it is well known that a concerted biopsychosocial approach to chronic pain management, including a package of multidisciplinary services, can lead to a more favorable clinical outcome for patients.6

The chronic pain center at the Centre Hospitalier de l’Université de Montréal (CHUM) receives approximately 10,000 patient visits annually. One of the initiatives at our center to address an increasingly long wait list was to understand why patients remainedin the tertiary center after readiness for discharge, from the perspective of pain specialists.  

 

Pain Specialist Survey on Transfer of Care

In 2020, we issued a 10-item Likert-type scale questionnaire in paper format to treating physicians at the tertiary level pain center of the CHUM. This quality improvement activity was initiated by one of the authors (Eghtesadi), who leads a committee aimed at improving patient access to care, in the context of an increasing wait list. The statements proposed in the questionnaire were based on discharge challenges that had been communicated to this author by other pain physicians at this specific center. We hoped to gain a group perspective on the importance of each one of these barriers.

All nine pain physicians, including the authors of this manuscript, participated in the study by answering the survey and rating on a 5-point scale their level of agreement or disagreement with difficulties proposed by the authors. Although the survey included one open-ended question allowing respondents to identify other barriers, no additional comment was provided. The following includes a presentation of the survey results and the expert opinion of the authors on how to move forward.

Clinician-Reported Barriers to Transfer of Care

As shown in Figure 1, the top difficulties perceived by the physicians surveyed, in order of importance, were as follows:

  1. lack of interest by the PCP in following patients with chronic pain and discomfort in prescribing opioid analgesics
  2. lack of community resources for patients with chronic pain
  3. burdensome administrative or form-filling aspect specific to this population
  4. concern by the PCP that patients would have to go through the wait list all over again, in case of need for reassessment

 

Solutions: How to Improve Transfer of Care in Pain Management

Integrated Training in Chronic Pain Management

The reason perceived as being most important by expert pain physicians at our center included the PCPs’ alleged lack of interest in following this patient population and discomfort in ensuring long-term prescription of analgesics, a consequence that likely results from insufficient post-graduate training in chronic pain. Both in the United States and Canada, patchy undergraduate and postgraduate training for health professionals has previously been identified as a contributing factor to these attitudes toward the management of chronic pain, whereas mandatory training in pain medicine as a core competency at the undergraduate level and as part of continuing medical education have been proposed as solutions.7

We, therefore, encourage expert pain centers to incorporate within their medical team physicians who are general practitioners with an academic background, who will not only bring a valuable perspective of patient care that is comprehensive, but also will act as mentors who can inspire interest in chronic pain for family medicine trainees.8 Moreover, general practitioners within the team could work to break the stigma that chronic pain management is solely focused on proficiency in procedural skills and make trainees from family medicine programs feel welcomed for a clinical rotation at a specialized pain center.

The team at our tertiary-level pain center includes general practitioners with pain-related interests (eg, headache medicine, cancer pain, fibromyalgia, comorbid pain-substance use disorder). Often family medicine trainees will not only pair up with these clinicians but also keep in touch after graduating, especially when they are faced with challenges in the community caring for a patient with chronic pain.

Tackle Preventive Health

Next, as health promotion and disease prevention are core values to the practice of family medicine, PCPs may feel hesitant about taking back charge of their patients and ensuring adequate preventive health management, in part due to the lack of comprehensive guidelines on how to effectively screen patients for iatrogenic complications of pain management, such as multisystem and endocrine disorders secondary to long-term exposure to opioids, anti-inflammatories, and corticosteroids.9-11

To provide PCPs with a patient-tailored comprehensive transfer of care plan, pain specialists are encouraged seek expert knowledge in preventive health that takes into consideration the dynamics of risk factors that are specific to the patient with chronic pain. Pain specialists at academic institutions often have easy access to myriad specialists; our experience has always been favorable when solicitating a lecture relevant to the chronic pain population, for instance from an internist on the topic of osteoporosis or obesity, a psychiatrist on the management of refractory depression, or a urologist on treatment of male hypogonadism.

Pain specialists should not only guide the needs of peer health professionals in terms of CME opportunities for chronic pain management but also ensure that learning opportunities specific to the practice of primary care are available for practitioners in the community.

Get to Know the Patient Community

Following transfer of patient care, PCPs are invited through the patient discharge summary to join our team during various initiatives aimed at supporting their learning needs on chronic pain management in general or for a specific patient. For group learning opportunities, our center has integrated the innovative telementoring Extension for Community Healthcare Outcomes (ECHO) model from the team of Sanjeev Arora, MD, at the University of New Mexico.12,13 Based on this model and its goal of “amplifying the capacity for providers to deliver best-in-practice care to the underserved in their own communities,” our team leads weekly virtual clinics with PCPs province-wide and not just limited to underserved communities.14

Take a Patient-Partnership Approach

As our institution has also embraced a transition from a patient-centered to a patient-partnership approach model of care, our ECHO sessions also invite a patient-partner, who not only advocates for patients, but also provides valuable insight on community resources available in different regions of our province and that is pertinent to each clinical case discussed during the virtual sessions.15

Our center also offers one-on-one support modalities, such as a biweekly telemedicine service and tele-advice phone line to all PCPs as well as other health professionals within the province (dedicated one-hour time slots with an expert physician). Several other Canadian centers have similar individualized support opportunities for PCPs: eastern Ontario offers a web-based ‟Champlain Building Access to Specialists” through eConsultation, with a median response time of 1.9 days to speaking to a pain specialist, while Alberta Health Services offers a physician-only tele-advice phone line where community health professionals can exchange with a chronic pain specialized nurse practitioner, with a call return window of 1 hour.

Cultivate an Intermediate Support Clinic

Another solution we propose to the challenge of transfer of care would be the creation of what we are calling a Transfer of Pain Management Intermediate Support Clinic (TOPMISC), between an outpatient tertiary pain center and the community PCP, for patients with chronic non-cancer pain (CNCP). A TOPMISC should not be confused with a transitional pain clinic, which has been implemented at centers such as the Toronto General Hospital and is a service specific to hospitalized patients with post-surgical pain, who have been identified as high risk for substance abuse.16 It is thus atransitional service from hospital admission to the PCP, whereas the TOPMISC would be for all patients with CNCP seen at an outpatient pain clinic, once the painmanagement plan approaches stabilization.

A TOPMISC would enable frequent bi-directional communication between the tertiary and primary care level health professionals, in order to progressively transfer care back to the PCP. Such collaboration would involve a temporary overlap of care for pain management between the support clinic and the PCP, as opposed to the traditional discharge summary that is sent to the PCP that can be perceived as abrupt cessation of care and abandonment for the PCP. The TOPMISC would ideally be managed by a highly skilled nurse practitioner (NP) in pain management, while supervised by a daily on-call pain physician, who would make recommendations as needed to facilitate the process.

The NP could be in direct contact with the PCP or a designated NP at the primary family medicine clinic, in working collaboratively with the patient to support transfer of care. The TOPMISC could also provide the PCP with an expert pain physician tele-advice phone line to offer support throughout the process of a patient who is awaiting complete discharge.

Figure 2 illustrates this scheme as well as an optimal referral pathway for new patients to tertiary pain centers, while offering support to PCPs when fully taking back charge of their patients. The proposal of a TOPMISC within our pain center was viewed favourably by our team members and we are conducting further research to implement it as a pilot project, determining its outcomes, including patient satisfaction, as well as healthcare resource utilization both at the institutional and the community level.

 

Strategize Practice Management Tasks

Next, the pain physicians at our center perceivedformulary-filling tasks related to patient follow-up as burdensome for the PCP. Investing time to fill in forms for drug or paramedical coverage, work and disability status, is undeniably a part of caring for this vulnerable population. However, as part of CME opportunities, pain experts can teach skillsets in managing efficiently a medical appointment with these patients, from better understanding guidelines on chronic pain management, to setting an adequate therapeutic framework with the patient that allows thorough history taking, especially at the first appointment.17

Plan for Missed Appointments

Our pain experts were mostly undecided if missed medical appointments by chronic pain patients were a dissuasive or irritant factor for PCPs in managing patients. This question was asked because of known high rates of patient “no-shows” at speciality pain clinics in the United States, which can be as high as 24.6%, with reasons identified such as oversleeping (irrespective of time of appointment), mistakenly double-booking another appointment, lack of transportation, longer wait time, low back pain or headache condition and snow precipitation.18

Most PCPs can likely implement simple measures to palliate this factor if their practice is negatively affected, by using strategies such as electronic, telephone, or text messaging reminders within 72 hours of the appointment, which are also the modalities currently applied at our center.

Accompany the Patient on Their Journey

Another reason that was elicited included the PCPs’ fear of patient abandonment by tertiary specialists after discharge, in case of need for reassessment. As chronic pain can indeed demonstrate a fluctuating nature, patients may experience episodes of exacerbations, often influenced by stressful psychosocial factors.19 One of the many challenges in chronic pain management is to accompany the patient through their journey of acceptance of the chronicity of their condition and subsequently of learning how to adapt their lifestyle. Considering that the majority of patients at our center are financially restricted, we tool them with self-management skills through mandatory attendance of therapeutic workshops, during the course of their management at our center.20 Such educational resources are unfortunately not easily available for patients in the community, especially the ones that are free of cost.

Continue Collaborating and Consider Mental Health Care Adjuncts

We strongly believe that pain specialists have a responsibility to remain available for PCPs even after patient discharge from specialized centers, and a fast-track access back must be available for the PCP who requires it for a previously known patient. Such a fast-track access can provide PCPs with more reassurance that they will benefit from continued support, even after patient discharge. Patients previously known to the center will also have realistic expectations of what the center has to offer and, in our experience, recidivist patients will generally require only a short-term intervention.

Expert opinions were divided in our survey results in regard to PCPs having difficulty accepting back charge of poorly improved patients. We believe these results can be explained by the appropriate general sensitization of PCPs to the distinction between chronic pain from acute pain: whereas the latter focuses on identifying pathology and finding a cure, the management of chronic pain aims to improve the patient’s quality of life, autonomy, and/or functioning.21 On the other hand, resistance in taking back a patient’s pain management plan, especially in the case of therapeutic stagnation, could arise if a PCP feels a strong negative countertransference reaction, in particular when facing a patient with a personality disorder, severe anxiety, or pain catastrophizing behaviour.22-24

Although psychological resources are also insufficient at our center for the volume of patients seen, we have adopted the strategy of pairing a psychologist with a physician as early as the first patient encounter for those patients detected to have a higher psychological burden during triage of consultation requisitions. We have found this strategy to be most effective in not only addressing jointly the physiological and psychological aspects of chronic pain, but also in putting the patient in contact early on with community resources for mental health and bridging these with care provided by the PCP.     

 

Practical Takeaways and Next Steps

Several barriers were identified by pain specialists when trying to discharge a patient with chronic pain from a tertiary pain center back to the primary care level, creating another challenge in wait delays to access specialized multidisciplinary pain centers for new patients. Based on the model of care at our tertiary institution to increase interest and contact with both practicing and in-training PCPs, we proposed initiatives such as embracing pain-expert general practitioners to be part of the team and serve as mentors, as well as encouraging pain specialists to seek expert knowledge in preventative health, which is a core value to the practice of family medicine.

We highlighted various Canadian models of learning opportunities to support PCPs after transfer of patient care, including ECHO, eConsultation, telemedicine, and tele-advice phone line, and we hope to see such modalities become the mainstay of practice at the national level. We propose integrating in group mentoring opportunities a patient-partner who could not only sensitize the medical community on the needs of patients with chronic pain, but also educate on available community resources.

Finally, we propose the implementation of a TOPMISC to offer support to PCPs and care overlap, through a discharge process that would be progressive from the tertiary to the primary level of care. Feedback is welcome; email the authors at marzieh.eghtesadi@mail.mcgill.ca

 

Disclosures: All respondents gave their individual informed consent in writing prior to inclusion in the study. According to the policy activities that constitute research at the CHUM, this work met criteria for operational improvement activities that are exempt from ethics review. The authors of this manuscript declare that they are among the surveyed clinicians to have participated in this study.

 

Last updated on: September 8, 2021
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Tips from the Field: Treating Pain in an Under-Resourced State
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