More than 100 million Americans suffer from chronic pain, often defined as a persistent pain lasting longer than twelve weeks. The pain is usually not constant but can interfere with daily life at all levels, affecting a person’s physical and mental well-being.
This week marks the six month anniversary of the Duke PARTNER Chronic Pain program, launched on September 11, 2015. According to the PARTNER team, this new initiative is the first of its kind in the country which focuses on adult patients who frequently visit the emergency room (ER) with a chief complaint of chronic pain. The PARTNER program is a collaboration between the Department of Anesthesiology, Department of Surgery, Emergency Medicine Division, Department of Medicine, Hospital Medicine Division, Department of Case Management, and Duke University Medical Center to ultimately provide patients with more effective pain management strategies.
Today, we take a look back at how the PARTNER program came to be and how its development over the past six months has helped those with chronic pain.
The Beginning of the PARTNER Program
In early 2015, research conducted by Duke Anesthesiology’s Perioperative Enhancement Team (POET) revealed that there is a select group of patients who are “high emergency department utilizers” – people who keep coming back over and over without ever seeming to have their problems resolved. During a string of POET meetings to develop a new patient quality-improvement project, the team noted the exceptional success of Dr. Steve Prakken’s interventions with high utilizers sent to him from Dr. Joanna Kipnes and the Sickle Cell Clinic. Using Dr. Prakken’s Medical Pain Management model and Dr. Kipnes’ operational expertise, the group set out to find another population within the Duke system that would benefit from these interventions – ER patients.
A study in PubMed shows that 78 percent of patients seek treatment at emergency rooms with a chief complaint related to pain. “They keep coming to the ER to get their pain managed in ways that are unhelpful to the system and unhelpful to the patient,” says Dr. Prakken, assistant professor in anesthesiology. “This is not good for their long-term care.” Dr. Prakken adds that the typical person who continually visits the ER is shown to have some contact with their primary doctor, feels that their pain is not reasonably controlled and is not having a positive outcome.
“We know there are patients who go to the emergency room every week because they have uncontrolled pain and that can’t be the best option…for patients to sit in an ER and see a provider they may have never seen before, possibly get a couple doses of medication and not have any chronic management…that’s why we wanted to conduct this small pilot,” says Dr. Kipnes, assistant professor of medicine and a clinical hospitalist for Duke University Health System (DUHS). “The goal of this new program is to treat pain like we treat a disease.”
Dr. Kipnes and other POET members conducted a retrospective analysis of patients who visited the emergency room at least five times over a six month period, at least four of which were for a chief complaint of pain. Dr. Kipnes then reviewed those charts and generated a list of patients who would be ideal to approach when they came to the emergency room. “As a pilot program, we need to see whether this program is something patients want; are they going to feel this helps control their pain, helps prevent them from going to the ER and improves their quality of life,” says Dr. Kipnes. When asked about why patients were pre-selected for this program, she responded, “We thought it was better to start with an identified population and move it forward from there. Ideally, if patients think that this program is helping to better control their pain, then a wider roll-out would need to be further explored. This isn’t reinventing standard of care. This is making standard of care come to the pain patients.”
The Key Stakeholders
Alongside Dr. Prakken’s interventions, another key component of the PARTNER program is social workers. They seemed to be the obvious go-to group who could approach these specific patients in the emergency room, finding out what their needs are and talking to them about the program. Due to the popularity of the Duke Pain Clinic, appointments are often booked months in advance. But the PARTNER program ensures that spots are reserved for this particular group of ER patients and they are given an expedited appointment to the Pain Clinic. At that point, social workers can identify whether active alcohol or substance abuse is a factor and try to get the patient additional help if they want it. They can also help troubleshoot transportation barriers which may prevent patients from seeking treatment for their pain.
Lindsay Waters, program coordinator for the Duke Pain Clinic, has remained committed to reaching out to this particular patient population, though it can be challenging. “Many of these patients can be hard to reach with limited transportation options or they simply just don’t show up for their scheduled appointments,” says Waters. However, according to one of her colleagues, the program would not be successful without her continued adherence. “She is a true champion and this should be highlighted,” notes Maria Jimenez, program coordinator for POET and one of the main organizers of the PARTNER program.
Two Platforms of Care
Effective treatment of chronic pain requires addressing physical as well as psychological aspects of the condition. As a double board-certified pain specialist and psychiatrist, Dr. Prakken takes care of both sides of that equation. His treatment and his work with highly trained advanced placement practitioners (APP) is the core of the PARTNER program. Dr. Prakken leads an outpatient Medical Pain Service (MPS) team which provides an in-depth assessment of high-risk chronic pain patients, assists with physician education in pain treatment, and coordinates pain management throughout DUHS. Notably, there is no other MPS group of this size in the nation.
Ultimately, patients in the PARTNER program receive unique treatment with the ability to quickly speak with a pain specialist, such as Dr. Prakken, to address both the physical and mental components of their pain and treatment. When patients arrive to the pain clinic, Dr. Prakken spends about 90 minutes with them for the initial intake and most of them will go on to work with one of his APPs. “By the end of these visits, they feel they have been heard, that their internal experience of pain is understood, leaving us the option to ask for changes they might not have been willing to make in the past,” says Dr. Prakken. “We don’t just talk with them, we don’t do therapy. We do a very detailed assessment of their pain.” That assessment includes functional capacity, psychiatric history, mood, previous treatments, response to medications, genetics, addiction risk and personality qualities, resulting in a very detailed, patient-specific plan of treatment commonly entailing a substantial change in medication.
The PARTNER Progression
The team at Duke began this pilot program with a cohort of 149 patients. Throughout the past six months, social workers have screened 73 of those patients, resulting in 55 patients who are officially part of the PARTNER Chronic Pain program. To date, 22 of them have completed their first appointment. As patients continue to volunteer their time and the PARTNER team continues to provide its services, Dr. Kipnes hopes to collect valuable data about the patient experience. While still in the pilot phase, patients now have a place where they can receive more personalized treatment for their pain conditions. And they have a place to turn to when they have questions about what happens next when it’s not going so well. “There is a relationship that develops with these patients that is primary to the positive outcome,” says Dr. Prakken.
Another valuable piece of the PARTNER program is primary care doctors. “We’re looking forward to having more in-depth relationships with primary care doctors so pain patients can avoid the ER,” explains Dr. Prakken. He currently goes into clinics to teach primary care doctors how to better manage patients’ pain and hopes that as a result of this knowledge, PARTNER members won’t have to approach patients for this program. Dr. Prakken adds that once his pain patients feel they are stable, they are sent back to their primary care doctor.
What the Future Holds for PARTNER
Dr. Prakken’s hope is that this program will generate some incredibly positive research, and as a model, it will show robust shifts in ER utilization. “I look forward to seeing more of these types of collaborations in the future. Over the next five years, I hope we will garner even more support for this program and that more robust treatment options can become available for our patients.” Dr. Kipnes adds, “If this is a successful pilot, this could be groundbreaking and easily reproducible for other health care systems in the nation.”
On January 15, 2016, PARTNER launched another new initiative focused on ER high utilizers with a chief complaint of chronic headache or migraine. Pre-identified patients are currently being referred to Timothy A. Collins, MD, chief of the Duke Department of Neurology Headache Division and a neurologist at the Duke Headache Practice. In the coming months, POET will also add two more pilot programs to its resume; the “Diabetes Clinic” and “Pain Optimization” programs will launch at the Duke Spine Center, where the team expects a big impact in patient outcomes.
For more information about Duke’s PARTNER program or Duke Anesthesiology’s Perioperative Enhancement Team (POET), please contact (919) 684-2918.