Duke’s PARTNER Chronic Pain Program Celebrates Milestone

PARTNER Program Team

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.

Chris KeithDuke’s PARTNER Chronic Pain Program Celebrates Milestone
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Vice President Joe Biden Brings Cancer Moonshot to Duke

Biden urges groups to work together to find cure for cancer

February 10, 2016
By Sarah Avery, Duke Medicine News and Communications

VP Biden at DukeInvoking the aspirational spirit that put U.S. astronauts on the moon, Vice President Joe Biden visited Duke Health today as part of the national “Moonshot” initiative he is leading to advance cancer research.

With the Duke Cancer Institute and the Duke University School of Medicine as a backdrop, the vice president cited the unique history of the Research Triangle area, where major universities, biotechnology companies and federal research agencies have long combined forces, demonstrating the sort of collaborative efforts that the cancer cure moonshot aims to foster nationwide.

“I’m not naïve that we are going to cure every cancer,” Biden said during a round table discussion, noting that more government funding is just one element necessary to achieve the moonshot’s goal of condensing a decade worth of research advances into just five years. Biden urged all groups to work together across academic disciplines, joining business and industry, philanthropic organizations, advocacy groups and others.

A. Eugene Washington, M.D., chancellor for health affairs at Duke University and president and chief executive officer of the Duke University Health System, said the vice president’s visit highlights the leadership role Duke is prepared to play in bringing together those disparate communities in a united front against cancer, which has proven to be a formidable foe.

“Vice President Biden’s visit with our Duke Health community was a great honor,” Washington said. “We very much appreciated the opportunity to discuss how we are conducting cutting-edge research and to have him lead a productive dialogue with our world-class faculty and community leaders.

“Today’s events are also a tremendous validation of the efforts of people at all levels of our health enterprise,” Washington said. “Because of their work, we at Duke Health are uniquely positioned to accelerate discovery in cancer research and its translation into public benefit.”

As part of his visit to Duke on Wednesday, Vice President Biden met with Dr. Paul Modrich, who shared the 2015 Nobel Prize in Chemistry with UNC’s Dr. Aziz Sancar. Both scientists have been pioneers in the study of DNA repair, which has been crucial to understanding how cell repair mechanisms can go awry and lead to cancer, and Biden cited the “groundbreaking work” as the kind of science that should be further fostered.

The vice president also met with Dr. Matthias Gromeier, of the Preston Robert Tisch Brain Tumor Center at Duke, whose work has focused on a modified form of the poliovirus as an innovative brain cancer therapy. The work is showing promising results in an early clinical trial, and was featured in a two-part segment on 60 Minutes last March.

During the round table discussion, Biden singled out the first patient treated with the poliovirus therapy, Stephanie Lipscomb, whom he met in a private gathering. Noting that she looked “as healthy as can be,” Biden praised the innovation involved in the research endeavor.

“In my view, the science is ready, the science is ready.” Biden said. “I believe we can make much faster progress –- as an outsider looking in from a different  perspective —  if we see greater collaboration, greater sharing of information, breaking down some of the research that is trapped inside of silos.”

Dr. Michael B. Kastan, executive director of the Duke Cancer Institute, said the two Duke researchers were ideal ambassadors to meet the vice president – chosen among dozens of worthy researchers and clinicians doing breakthrough work – because they represent how discoveries in the laboratory lead to new treatments or clinical approaches that ultimately benefit patients.

“Outstanding basic science in the laboratory can impact our understanding of cancer development and lead to new therapies for cancer – it’s the perfect example of what we call translational impact,” Kastan said.

After Biden wrapped up the laboratory tour, which was led by Dr. John Sampson, chair of the Department of Neurosurgery, the vice president held a round table discussion with key leaders in the cancer community who were convened to share their aspirations for the moonshot.

Kastan said he was honored that Duke was chosen by the vice president as a he is gathering information and putting together the various pieces that will enable his cancer moonshot to lead to the goal that everyone seeks – a cure for cancer.

“it’s a very exciting time in cancer right now, and it’s a very challenging time,” Kastan said. “When the National Cancer Act was passed in 1971 by Congress, people expected that discoveries were going to be made very quickly. But we were in no position to quickly advance our diagnosis and treatment of cancer at that time.”

After 40 years of research and development, however, the field is at a pivotal point, Kastan said. The vice president’s advocacy for the moonshot initiative could be that final push that enables science to reach its goal.

“In many ways, Vice President Biden is asking the same questions we are,” Washington said. “How do we accomplish 10 years of advancement in five years? How do we really pick up the pace? In research, education, patient care, and our communities locally and globally, that is exactly what we aspire to do and what we will do.”

Chris KeithVice President Joe Biden Brings Cancer Moonshot to Duke
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Advancing Health Together: Duke Health’s 2016-2020 Strategic Planning Framework

DukeHealth_Strategy_Website_ImageOn Friday, January 29, 2016, Duke Health distributed Advancing Health Together: 2016-2020 Strategic Planning Framework to all personnel. The framework is the product of a strategic planning initiative that started in June of 2015 and collaboratively engaged the entire Duke Health community including faculty, staff, trainees, board members, alumni and others. After much deliberation among these groups, the framework also marks the adoption of “Advancing Health Together” as the Duke Health mission statement.

“In the world of health, potential life-altering breakthroughs in biomedical science, education, technology, and health care are occurring at a dizzying pace. This is a time when unimaginable possibilities beckon from beyond recognizable opportunities. Duke Health stands enviably positioned to take advantage of these opportunities and pursue these possibilities. With Advancing Health Together: 2016-2020 Strategic Planning Framework, we at Duke Health share our vision of how we will seize this moment,” said A. Eugene Washington, MD, Chancellor for Health Affairs, Duke University, and President and CEO, Duke University Health System.

Advancing Health Together is a comprehensive, integrated strategic planning framework based on academic, clinical and population health priorities. It outlines goals and strategies across five core mission areas (Patient Care, Research, Education, Community Health Improvement, Global Health), and in a sixth area (People & Environment) critical to Duke Health’s success in each mission area. Going forward, the framework will serve as a guide, a reminder of our possibilities and priorities, and a point of focus as Duke Health adapts to changing circumstances and capitalizes on unexpected opportunities.

The framework represents the combined contributions of over 10,000 Duke Health personnel who responded to surveys, joined focus groups or served on mission area working groups.

“You vigorously deliberated without losing your way, earnestly criticizing, probing and stretching while remaining collegial.  I thank everyone for their energy, collaborative spirit and insight. I am deeply grateful to all who participated,” Washington said.

Town hall meetings will be held in the coming weeks to share Advancing Health Together with the Duke Health community and offer all the opportunity to ask questions. The dates for these meeting will be announced soon.

Click here to learn more about the Advancing Health Together: 2016-2020 Strategic Planning Framework


Chris KeithAdvancing Health Together: Duke Health’s 2016-2020 Strategic Planning Framework
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Duke’s PARTNER Program Adds Chronic Headache Collaboration

Members of the PARTNER team.

On Friday, January 15, 2016, Duke’s PARTNER Program (Pain Assessment Risk Treatments for Novel Effective Recovery) kicked-off a new initiative focused on adult patients who frequently visit the emergency department (ED) with a chief complaint of chronic headache or migraine. The PARTNER program is a collaboration between the Department of Neurology – Duke Headache Practice, 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 “home rescue plans” for better headache pain management.

The PARTNER Chronic Headache program’s goal is to identify ED high utilizer patients with chronic headache and introduce them to novel, more effective management care pathways for their chronic headache condition, ultimately reducing the frequency of ED visits due to headache. “There’s a culture of going to the ED for problems that may not be necessary,” said Executive Vice Chairman, Solomon Aronson, MD. “We are trying to recondition behaviors.”

In early 2015, Duke Anesthesiology’s Perioperative Enhancement Team (POET) conducted a retrospective analysis of patients that had at least one visit to the ED in a six-month period for a chief complaint of pain. Based on this data, the DUH hospitalists were able to create a list to identify patients with more than five visits in a six-month period and design treatment plans for them. This was the beginning of the PARTNER program. After POET team members also noticed that many patients went to the ED with a chief complaint of migraine and/or headache, the PARTNER Chronic Headache program soon followed.

Headaches are widely prevalent, affecting between 16% and 22.7% of adults and are the fifth leading cause of emergency department visits in the United States, according to a May 2011 statistical brief by the Agency for Healthcare Research and Quality (AHRQ) titled “Headaches in U.S. Hospitals and Emergency Departments, 2008.”

The POET multidisciplinary team concluded that improving the care of headache patients through outpatient management, including routine use of headache preventative agents, may significantly decrease ED visits.

At the launch of PARTNER Chronic Headache, the stakeholders discussed the protocol for identifying possible patient candidates of this new initiative. By utilizing screening tools and a targeted DISCERN patient list, ED social workers will refer these patients to Timothy A. Collins, MD, chief of the Duke Department of Neurology Headache Division and a neurologist at the Duke Headache Practice (932 Morreene Road, Durham). Dr. Collins will create a treatment plan for each patient, which he emphasized will not include the use of opioids for chronic headaches or migraines. Instead, he will craft a “home rescue plan” for the patient to follow, ultimately preventing another ED visit.

At the conclusion of Friday’s meeting, Dr. Aronson thanked the entire PARTNER team for their help in growing the program. He revealed that there are other POET pilot programs currently in development. In the meantime, PARTNER will continue to find solutions to prevent overcrowding in the ED.

For more information about Duke’s PARTNER Program or Duke Anesthesiology’s Perioperative Enhancement Team (POET), please contact (919) 684-2918.

Chris KeithDuke’s PARTNER Program Adds Chronic Headache Collaboration
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