Pain Management
Program in a Skilled
Nursing Facility
Nancy Flinn, PhD OTR/L
Tom Kelley MA
1
Courage Center
• A community–based resource and rehabilitation facility
• 81 years old, provides
• Direct traditional rehabilitation services
(OT/PT/SP/Psych)
• Advocacy (grass-roots organizing, lobbyists
representing issues for persons with disabilities,
works with Minnesota Consortium for Citizens with
Disabilities)
• Community based services (Drivers Assessment
and Treatment, Vocational Services, Independent
Living Skills Program, Community Reintegration
Program, Sports and Recreation, Camp)
2
Courage Center Transitional
Rehabilitation Program
• 46 bed unit, licensed as a skilled nursing facility
• Holistic, individualized, goal-focused program to
increase independence, address adjustment to
new life changes, and discharge to more
independent setting.
• Average length of stay is 2.9 months.
• 93% of clients discharged to community setting during
this project
• Project ran from October of 2007 to January 2010
3
Minnesota Department of
Human Services Pay for
Performance Grant
• Project focused on measuring and addressing pain in
our inpatient program
• Our MDS Pain ratings were higher than other SNFs
• Our objectives:
• Measure pain in a systematic way
• Measure interference of pain with activity
• Decrease pain
• Decrease interference of pain with activity.
4
Admitting Diagnosis
Other
10%
SCI
28%
Brain
Injury
20%
Stroke
42%
5
So, based on the literature
for our diagnosis:
• We expected pain rates for individuals
with SCI between 48% and 79%.
• We expected pain rates for individuals
with brain injury to be in the 52% to 73%.
• We did not know what to expect about
pain interference with activity.
• We needed a better way to measure and
manage pain.
6
Pain at Courage Center
• Our pain ratings on the MDS were high
• This was a concern for Courage Center and
Minnesota Department of Human Services
• We received a Pay for Performance Grant
through Minnesota Department of Human
Services to cover this project (5% increase in our
Medicaid rate)
• Project team included the Director and Director
of Nursing of the Transitional Rehabilitation
Program, Director of Outcomes and Research,
and Data Analyst.
7
Choosing a measurement
tool
The Modified Brief Pain Inventory was
developed for use with individuals with SCI
• 4 questions regarding severity of pain
• 2 questions about relief of pain
• 10 questions about the degree to which
pain interferes with activity
8
The MBPI has been modified
for use with individuals with
disabilities
• “Walking” changed to “Ability to Get Around”
• Some additional activities added to “Pain
Interference” scale
• Self Care
• Recreational activities
• Social activities
9
Implementing the
measurement tool
• The MBPI was completed with each
client monthly while they were in the
Transitional Rehabilitation Program
• The data was analyzed once a month
and the grant team met to review the data
• Reviewed charts for groups of clients, or
tried to make meaning of the data.
10
Data collected on our
clients
• There were 431 clients admitted during
this period
• 379 (88%) had at least 1 data point
• Missing data
• Not able to answer the questions, either because of
language or cognitive difficulties
• Incomplete data for other reasons (very early discharge,
rehospitalization)
• 341 (79%) had more than 1 data point
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Pain Severity
Maximum Score = 40
Minimum Score = 0
Clients
12
Pain severity scores
• 48% admitted with no pain, at the lower
range of the data in the literature
• Some clients were admitted with no pain,
but discharged with pain
• Some clients were admitted with pain,
had increased pain during stay.
13
Pain severity and pain
interference scores
Patients Reporting Pain at Admission: % Reporting Decreased Pain
Rating & Interference by Quarter of Discharge
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
70%
58%
76%
64%
63%
54%
Q123 n=59
Q456 n=80
Pain Rating Decreases at Discharge
Q789 n=51
Pain Interference Decreases at Discharge
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Changes in pain severity
and pain interference
effect sizes
Effect Sizes of Decreases in Pain and Pain Interference
1
0.8
0.6
0.4
0.38
0.23
0.2
0
0.44
0.06
Q123
PAIN RATING
0.30
0.33
Q456
Q789
PAIN INTERFERENCE
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Pain Severity
Maximum Score = 40
Minimum Score = 0
Clients
16
Some clients came in
with no pain,
discharged with pain.
• These clients were often were admitted on
narcotic pain medications
• Some clients had increased pain with
increased activity in rehabilitation
17
Pain Severity
Maximum Score = 40
Minimum Score = 0
Clients
18
Came in with some pain,
got better or got worse
• About 1/3 of those whose pain increased
during our stay had chronic pain issues
prior to the injury that brought them to us.
• Again, some of these clients were on
strong pain medication at admission
• Some clients with SCI developed
neuropathic pain during their stay
19
Neuropathic pain
• A type of chronic pain resulting from
changes in the central or peripheral
nervous system
• It occurs in individuals with spinal cord
injury
• For individuals with SCI, time of onset is
“weeks to months” post injury.
20
Case Study Group 2
• Mike 56 year old, Spinal cord injury and
history cardiovascular problems.
• Admit pain range 3 least, 10 worst and
average 5
• Increased to 8 and interference with all
activities
• Discharged with no pain and no
interference
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Pain Severity
Maximum Score = 40
Minimum Score = 0
Clients
22
Case Study Group 3
• Julie 35 year old spinal cord injury
• Admit pain 0 least, 3 average, 10 worst
with minimal interference
• Mid-way pain 2 least, 4 average, 9 worst
with interference in all areas
• Discharge pain 3 least, 6 average, 8 worst
with interference in sleep and enjoyment
of life
23
Six Month Follow-up
67% of Discharges
Incidence of Joint and Muscle Pain 6 Months after
Discharge
40
35
Percentage of Clients
35
30
25
26
28
30 31
22
Clients Discharged in
2008
22
20
Clients Discharged in
2009
15
10
6
5
0
Not a
Problem
Mild
Problem
Moderate
Problem
Significant
Problem
24
Interventions:
Medication management
• Manage medications
•Reduce/eliminate dependency on narcotics
•Add as appropriate: antidepressants,
anti-inflammatory, anti-epileptics, muscle relaxants,
sleeping medications, anti-anxiety agents, and nonnarcotic analgesics
• Injections:
phenol, botox, joint and
localized injections, etc.
• Incorporate pain scores into rehabilitation
rounds, address pain in therapy
25
Interventions
• Incorporate mind-body techniques into
therapy and nursing care
• Yoga
• Biofeedback
• Relaxation/imagery
• Breath work
• Spiritual approaches
• Acupuncture
• Massage
• Self-hypnosis
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Interventions
• Sleep hygiene and control
• Nutrition and dietary measure
• Focus on activities of daily living
• Education
• Being with others with similar problems
and strengths
• Individual counseling and adjustment
• Making and taking steps to solve
problems
27
Interventions
• Planning for meaningful life activities
• Vocational/avocational planning: return to
work
• Recreational activities
• Distraction
• Family involvement and counseling
• Stress management
• Addressing other psychosocial concerns
28
Effects of those
interventions
• The effects of these interventions have
increased the number of clients
discharged with decreased pain
significantly.
• However, we still have slightly more than
24% of our clients who are discharged
with pain
29
Pain Management
• For many of our clients, pain is likely to be
a lifelong problem
• Teaching clients how to deal with it
requires an intensive model
30
Adjustment
• Our clients also struggle with adjustment
issues
– Clients are discharged to the community early
after injury
– In 2001, the average length of stay at
Courage Center was almost a year, often
following several months of inpatient
rehabilitation
– Now clients are discharged from the TRP to
the community before they would have left
31
inpatient rehab 10 years ago
Adjustment
• The clinical question that has come up in
our discussions is “to what degree is the
pain we observe in our clients really a
reaction to disability?”
• We have started a Coping with Disability
Program, modeled after the Pain Program
• These two programs may end up
interweaving or merging, as we move
forward
32
What’s next?
• Continue to measure pain regularly
• Continue to educate staff, clients, and
families about pain issues
• Refine the Coping with Disability Program
• Examine outcomes, continue to redesign
the management program
33