Comprehensive Pain Mangement: Beyond F-Tag 309 Debra Bakerjian PhD, RN, FNP President and CEO, geriHEALTHsolutions Chair, Clinical Advisory Workgroup, Advancing Excellence Postdoctoral Fellow, University of CA, Davis Assistant Adjunct Professor, University of CA, San Francisco

Objectives Recognize specific strategies to improve pain management Identify best-practice resources to improve pain care for nursing home residents Learn how to access resources and set goals on the Advancing Excellence web site and the Geriatric Pain web site to manage pain Understand the regulatory requirements for pain management in NHs –Ftag 309

The Problem Pain is under-recognized and undertreated The prevalence of pain is reported as high as 85% in NHs Some reported improvement in prevalence of pain Over 75,000 long stay residents have mod-severe pain Ove 150,000 short stay residents with mod-severe pain

Solution Develop systemized approach to pain management Consists of “program of care” Requires ongoing evaluation and refinement Program based on “evidence based care” and “best practices” in pain management

Regulatory compliance

The Intent of Quality of Care Regulatory Guidelines “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well- being, in accordance with the comprehensive assessment and plan of care. “

F-tag elements

What is F-tag 309? F-tag 309 focus is overall quality of care – much of the f-tag has not changed Requires that NHs provide for the highest practicable level of function & well being Comprehensive resident assessment Care plans must address mental, physical, & psychosocial needs Ensure residents obtain optimal improvement or do not deteriorate Within resident’s right to refuse Limits of recognized pathophysiology & normal aging

New Aspects of F-tag 309 Revised general investigative protocol Any QOC issue not covered specifically by another F-tag is covered here Added Hospice guidelines Added dialysis guidelines Removed unintended weight loss – now in F tag 325

New Pain Aspects of F-tag 309 Pain management has specifically developed guidelines within this F-tag New definitions of terms New investigative protocol Defining care processes for pain management Defined steps in pain recognition, assessment, management, interventions, care plans Investigative protocol for surveyors specific to pain

Definition of Terms Addiction Adverse consequence, adverse drug reaction Adjuvant analgesics Complimentary and Alternative Medicine (CAM) Non-pharmacological interventions 4 types of pain – acute, breakthrough, incident, persistent or chronic Physical dependence Standards of practice Tolerance

Overview of Pain Recognition & Management Facilities & staff must be committed to effective pain management Pain can be acute or chronic & staff must evaluate resident reports of pain or nonverbal signs of pain Residents with cognitive impairment must also have their pain recognized & managed Facilities must break down myths about pain in older adults Staff, resident & family misperceptions about effective pain management

Care Processes for Pain Management Assess for potential for pain Recognize the onset or presence of pain Address & treat underlying cause for pain Develop & implement pain interventions Identify & use specific strategies for different levels or sources of pain Monitor appropriately Modify pain interventions/strategies as needed

Pain Recognition All staff are responsible for recognizing pain upon admission and throughout the stay Recognition efforts must go beyond asking the question “are you in pain” Verbalizations may be nonsensical Non-verbal indicators Aberrant behaviors Functional decline Loss of appetite Difficulty sleeping Observations should be at rest & with movement

Assessment Observing during care, activities & treatments can detect presence of pain, location, & limitations on residents MDS must be completed as “part” of the comprehensive assessment Facilities must document a more detailed assessment that identifies problem, needs, monitors condition, records treatment & response to treatment

Pain Assessment Standards History of pain & its treatment Characteristics of pain Impact of pain on quality of life Factors that precipitate pain Strategies or factors that reduce pain Associated pain symptoms Physical examination Current medical condition & medications Resident goals for pain management

Management of Pain Based on assessment, facility, attending prescriber, staff collaborate to manage pain Develop appropriate interventions to prevent or manage pain Interventions may be integrated into care plan or included as a specific pain management need or goal IDT & resident develop pertinent, realistic & measurable goals for treatment Pain management approaches must follow clinical standards of practice

Non-Pharmacological Interventions Alterations in environment for comfort Physical modalities – cold/heat, positioning Exercises to reduce stiffness, prevent contractures Cognitive/behavioral interventions CAM – herbal supplements if ordered

Pharmacological Interventions IDT is responsible for developing individualized pain management regimen A systematic approach for meds and doses is important Addressing underlying cause of pain Administration timing – PRN vs routinely Combining short & long acting All medications including opioids or other potent analgesics must be dosed according to standards Clinical record should reflect ongoing communication with prescriber

Monitoring, Reassessment, Care Plan Revision Monitoring response over time helps to determine effectiveness of treatments Adverse consequences to medications can be anticipated & reduced Identification of target signs of pain Inadequate control of pain requires a revision of intervention Resolution of pain should be documented and treatment tapered or discontinued

Investigative Protocol QOC related to recognition & management of pain Determine whether facility has provided & resident has received care & services to address & manage pain Applies to residents who state they have pain, who display indicators of pain, are assessed with pain, receives pain treatment, has elected hospice benefit for pain management

Survey Procedures Observe residents Interview residents or family Interview nurse aides Review records Assessment Care plan, including revisions Interview health care practitioners & other health professionals

Determining Compliance Facility is in compliance if EACH resident has their pain managed in alignment with their goals to attain the highest practicable physical, mental, & psychosocial well-being Recognize, evaluate pain to determine cause Developed & implemented comprehensive care plan Provided measures to minimize, prevent, or treat pain Monitor effects of interventions Communicate with health care practitioner when appropriate to obtain new orders or revise current orders

Noncompliance Determination Failure to show adequate proof that ALL of the previous steps are followed is non- compliance Non-compliance can be at any one step along the way Recognize & evaluate Intervene & treat Prevent or minimize Monitor Communicate & coordinate

Relationship with other f-tags

Related or Associated F-tags F155 – Right to refuse treatment Facility must assess reason, clarify & educate resident of consequences, offered alternatives & documented these steps F157 – Notification of changes Health care practitioner notified if pain persisted or there were adverse consequences Notified responsible party of changes F242 – Self-determination & participation Facility provided resident with relevant options to manage pain

Related or Associated F-tags F246 – Accommodation of needs Adopted resident’s physical environment to reasonably accommodate resident’s pain F272 – Comprehensive assessments Was a comprehensive assessment done F278 – Accuracy of assessments Does the assessment reflect the resident’s condition

Related or Associated F-tags F279 – Comprehensive care plan Did care plan include measureable objectives, time frames, & specific interventions/services Was it consistent with resident’s risks, needs, goals, preferences, & current standards of practice F280 – Comprehensive care plan revision Ensure periodic review of plan & revision as needed by qualified TEAM with input from resident or responsible party

Related or Associated F-tags F281 – Services meet professional standards of quality F282 – Care provided by qualified person in accordance with plan of care F329 – Unececessary drugs Are medications monitored for effectiveness & adverse consequences Are symptoms resident has related to meds

Related or Associated F-tags F385 – Physician supervision Is pain management supervised by physician, including participation in comprehensive assessment process, development of treatment regimen, monitoring & response to notification of changes in resident status F425 – Pharmacy services Were medications available & administered as indicated, ordered at admission & throughout stay

Related or Associated F-tags F501 – Medical Director Did Medical Director help develop & implement appropriate policies c/w standards of practice Did Med Director interact with resident’s physician supervising the care if requested by facility F514 – Clinical records Did clinical records accurately & completely document resident status, care/services provided, in accordance with standards & resident goals Did records provide a basis for determining & managing resident progress & responses to care

Pain management standards of quality care

Knowledge of Pain Know principles of pain management Types of pain & pain terminology How to perform a comprehensive assessment Correct documentation of findings Understand both pharmacological & non- pharmacological interventions How to monitor & revise plans Effective communication

Pain Principles Pain is under-recognized & undertreated Older adults have the right to have pain assessed & treated in accordance with their goals for pain management Pain is subjective- self-report of pain is most reliable indicator Physiological & behavioral signs are neither sensitive nor specific & can’t replace self-report Assessment tools & treatments need to be appropriate & individualized each resident Pain tolerance varies & is individual Prevent &/or manage medication side effects Worry about addiction to opioids is not a credible reason for withholding opioid pain medication

Pain Terminology Pain characteristics are used to describe pain Duration – how long pain has been present Frequency – number of occurrences in a given time period Intensity – descriptive rating based on scale Location – anatomic site Onset – how does pain start Pattern – how does pain vary throughout the day, what affects pain – makes it worse or better Quality – use the resident’s description; provide examples such as aching, cramping, sharp, throbbing, dull, sharp, burning, radiating, shooting

Pain Recognition Staff must recognize pain or potential pain All staff are responsible for helping with pain management Therapy Activities Social services Pharmacy consultants Staff must act on their observations All staff must be educated to recognize pain Once staff know individual resident triggers – all staff must be told about what to observe

Indicators of Pain Verbal indicators – words & vocalizations Written indicators – written interpretations in native languages, written notes from residents Non-verbal indicators – facial expressions, behavioral abnormalities, fidgeting, withdrawal, non-movement

Comprehensive Assessment All residents must have comprehensive pain assessment upon admission Residents who trigger for pain (through MDS/RAI) or have diagnosis of chronic pain or exhibit frequent pain must have comprehensive pain assessment Most pain experts recommend weekly assessments

Comprehensive Assessment Should be appropriate based on cognitive status If resident cognitively intact – use verbal descriptors in their words to describe the pain If cognitively impaired – use a screening tools PACSLAC – screens for behaviors that may be pain related PAINAD – monitor directly observable behaviors in adults with chronic pain Comprehensive includes history descriptions, functional status & physical exam Evaluate of impact on pain on ADLs, sleep, other functional activities

Major Categories of Pain Nociceptive Sources: organs, bone, joint, muscle, skin, connective tissue Examples: arthritis, tumors, gall stones, muscle strain Character: dull, aching, pressure, tender Responds to traditional pain medicines & therapies Neuropathic Source: peripheral nerve or CNS pathology Examples: postherpetic neuralgia, diabetic neuropathy, spinal stenosis Character: shooting, burning, electric shock, tingling Requires different types of medications than nociceptive pain Slide Content: Pain also is categorized depending on its source. [Review slide content] One reason it’s important to distinguish between these two types of pain is because neuropathic pain often requires different types of medications than nociceptive pain. Careful assessment assists in determining whether pain is nociceptive or neuropathic. NOTE: PHN = postherpetic neuralgia

Documentation & Reporting Forms should include resident goal, pain characteristics, history, & physical exam related to location & causes of pain Ex. If pain in abd – check for bowel sounds, pain with palpation If pain in leg – observe the site & look for s/sx trauma Report to MD, NP or PA & other nurses should be complete but concise Be sure to include CNAs in reporting & care planning

Principles of Pain Management Should be individualized & match the need Chronic pain should be treated with long- acting medications routinely Breakthrough pain should be treated with short acting meds with rapid onset Treat with lowest strength med to achieve pain control based on resident goals Minimize side effects & adverse effects

Managing Pain Frequent reassessment of resident & review of care plan Determine what works & what doesn’t work Discontinue what doesn’t work Revise care plan to try new interventions Collaborate with IDT & resident/family Try new things or new ways such as changing the timing or dosing of medications

Non-pharmacologic Interventions Traditional Positioning Massage Environmental – lighting, room temperature, noise Heat and/or cold applications Diversion – social interaction CAM Now recognized as a part of therapy May involve herbals & that must be communicated

Medication Management Non-opioid Opioids – mild to moderate Opioids – moderate to severe Repositioning Heat and Cold Breathing & Guided Imagery Distraction Massage Music Relaxation Pharmacological Non-Pharmacological

Pharmacologic Interventions Non-opioids Tylenol NSAIDs such as Ibuprofen Side effects in older adults (damage to kidneys, GI bleed) Opioids Types of opioids, routes of administration Length of action Side effects – constipation, confusion Adjuvant therapy Muscle relaxants Seizure meds for neuropathic pain

Managing Side Effects Most pain meds have potential side effects, particularly opioids Side effects need to be anticipated and managed Common opioid side effects include Drowsiness Respiratory depression Constipation Nausea Delirium – particularly in residents > 85 yrs Itching

Managing Side Effects Side effect management should be part of the care plan Side effect treatments need to be individualized Reduced dosages Alternate opioid Bowel regimens Medications to treat side effect if necessary Obtain appropriate orders from prescribers Care plan effective management techniques

Resident Centered Care Plan Includes residents goal for pain management I want my pain relieved so I can sleep I want pain treatment before my therapy I would like my pain reduced to level 4-5 Care plan should include both drug and non- drug interventions Care plan should include managing side- effects, decreased respirations,

Effective Communication Nurses need to be able to understand resident pain issues and to use the right language in describing Pain related problems need to be effectively communicated to prescribers Pain related issues need to be documented accurately using appropriate language

Communication with Health Care Provider Communicating with the health care provider is not a “one time” deal Most health care providers do not mind multiple communications IF nurse is prepared with the right information Before calling, gather the information together; then even if provider has to call back later, information will be in one place

Best practices in pain management

Elements of Pain Best Practice Recognition/Assessment Cause identification/Diagnosis Management/Treatment Monitoring Sustainment

Recognition/Assessment Initiate appropriate pain assessment on admission Identify pain related risk factors Identify & document pain characteristics- include behaviors Report signs & symptoms Ensure that assessment forms available for cognitively intact & impaired Ensure training on risk factors, pain characteristics & behaviors Create policies & procedures to support the correct processes PATIENT LEVEL ORGANIZATION LEVEL

Cause Identification/Diagnosis Interview resident and/or family to understand characteristics of pain Perform a physical exam Palpate sites Check ROM Determine what makes pain worse, what makes it better Create policies & procedures requiring resident interviews (required by MDS 3.0) Provide training on physical exam for pain PATIENT LEVEL ORGANIZATION LEVEL

Management/Treatment Identify resident/family goals of care Incorporate resident goals into the pain care plan Consider both drug & non-drug treatments Document results of treatment Create a culture of resident centered care Adopt care plans that focus on resident perspective Develop policies, procedures & training related to drug & non-drug treatments Require rechecks after all pain treatments PATIENT LEVEL ORGANIZATION LEVEL

Monitoring Assess and reassess for pain every shift Perform comprehensive pain assessment regularly – weekly is advised If pain response inadequate revise treatment Monitor for side effects or complications Provide training on pain reassessment & require documentation Ensure forms, policies & procedures require ongoing monitoring PATIENT LEVEL ORGANIZATION LEVEL

Sustainment Reassessments should be ongoing Review & revise care plans regularly Meet with resident & family regarding pain management Communicate changes to prescriber Systemize processes so there is no variance in procedures Consider a pain related quality improvement project Audit documentation Report audit results to DON & NHA Revise program if needed PATIENT LEVEL ORGANIZATION LEVEL

RESOURCES

geriatricpain.org Website specifically designed for NH staff Resources are evidence based Resources are free Go to www.geriatricpain.org Registration is required but takes about 2 minutes

Assessment Cognitively Intact

Assessment Cognitively Impaired

Advancing Excellence National volunteer initiative to help NHs improve quality 30 organizations Gov’t – CMS Survey & Certification, Quality Consumer – Pioneer Network, NCCNHR, Alzheimer’s Association Professional – AMDA, GAPNA, NADONA, AANAC Provider – AHCA, AAHSA

Purpose of Campaign To provide resources and guidance to NHs to improve the quality of care To assist in quality improvement efforts

Campaign Data Campaign publishes quarterly data on pain Data available to individual NHs and consumers Data can be used for quality improvement Data are graphed by quarter over time

Campaign Resources Implementation Guide – offers guidance in how to implement a quality improvement process Webinar Fast Facts for Staff Consumer guide for families and residents New resources are coming

Campaign Website www.nhqualitycampaign.org

The Case of hazel p

Case Study – Hazel P 72 yr old female admitted to facility late Friday afternoon from acute hospital after fall at home. In hospital she had ORIF of Rt hip 2 days ago. Other pertinent diagnoses include diabetes mellitus, COPD, CAD, CHF, HTN, anemia, osteoporosis, depression, peripheral vascular disease, osteoarthritis, dementia & morbid obesity.

Anticipating Pain Issues Review of current diagnoses is one way to anticipate potential pain Some residents come in with diagnoses that are recognized as pain producing Hospital discharge planners should communicate pain related issues to admitting home

What do we know already? Pain is likely to be an issue Different types of pain are likely Acute post operative pain (rt hip fx) Chronic muscle & joint pain from (osteoarthritis) Potential cardiac pain (CAD, CHF, HTN) Potential neuropathic pain (DM, Morbid Obesity, CAD) Potential psychogenic pain (Depression) Communication may be an issue (Dementia)

What is the Approach Screening for immediate pain & treat if needed Perform comprehensive pain assessment Communicate with health care provider, resident, family, IDT Develop comprehensive care plan to include intervention Implement the plan Monitor & revise plan as needed

Hazel’s Assessment Upon admission Hazel is found to be suffering from rt hip pain rated 9/10 – transfer orders include an opioid pain medication Before continuing with admission interview: Nurse checks Hazel’s allergies (none) Checks the order with Hazel’s PCP & gets approval Gives Hazel the medication.

Hazel’s Assessment The nurse comes back to continue the interview about 45 minutes later – asks if pain med effect & asks about any side effects Nurse reviewed Hazel’s diagnoses ahead Anticipated that Hazel might have several types of pain issues Included all questions to include potential sources of pain Used comprehensive pain assessment form

Individualized Care Plans Involve residents and help them set goal (s) Families may also need to be involved Ex: I don’t want to be too sleepy but I want my pain to be relieved so it is mild to moderate Individualize care plan around that goal Collaborate with other members of the IDT Prescribers & pharmacy consultant Therapy, activities, social services Other nurses

Hazel’s Care Plan Hazel had several types of pain, so the care plan addressed those issues Acute post op pain – opioid pain med, particularly prior to therapy Osteoarthritis- a non-steroidal was contraindicated, so a plan to assist with frequent repositioning was initiated Potential cardiac pain – nitroglycerine was available, Hazel was assessed & determined not to be safe for self- administration, Oxygen was also ordered as treatment Neuropathic pain – daily medications were ordered for neuropathic pain and to promote improved circulation Depression – Hazel was on an age appropriate anti- depressant

Care Plan continued Care plan included anticipation of pain at specific times of increased movement such as therapy, so coordination with rehab dept was done Monitoring of pain was ongoing – charge nurse was careful to review how many times she requested pain meds & how well they were working, documented that in the record & communicated with her health care provider & family, & other staff as necessary

Hazel’s Management Hazel responded well to opioids for her acute pain management She had a worsening of her neuropathic pain that required increasing the dosages of medication (Neurontin) Hazel did not progress well with therapy and could not regain her pre-fall function and so was admitted to custodial care Her charge nurse reassessed her upon the change in status – therapy was replaced with RNA

Revising Care Hazel’s Plan Hazel’s entire care plan was reviewed and revised with her change of status Her family was notified of her change of condition & participated in care plan revision Recommendations were communicated to her health care practitioner

In Summary Facilities & staffs are responsible for ensuring that residents obtain their highest practicable level Residents must be involved in their pain management & their individual needs & goals should be basis of care plan Care provided must be individualized based on a comprehensive assessment and MUST meet clinical standards of quality Staff must monitor continuously, revise processes and plans when necessary and in a timely manner Staff must communicate resident status or change of condition with health care practitioners, resident, & family Staff must document accurately and descriptively

QUESTIONS?