Pain Management Clinical Support Service and the MHS Stepped Care Model Sharon L. Rosser, DSc PA-C LTC, SP, USA Chair, Pain Management Clinical Support Service Director, Army Comprehensive Pain Management Program 24 September 2018

Disclosures Presenter has no interest to disclose. AMSUS and ACE/PESG staff have no interest to disclose. This continuing education activity is managed and accredited by Affinity CE/Professional Education Services Group (ACE/PESG) in cooperation with AMSUS. ACE/PESG, AMSUS, planning committee members and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

Learning Objectives At the conclusion of this activity, the participant will be able to: Provide an overview of the MHS Stepped Care Model for Pain. List the related legislation that continues to impact pain management and opioid safety. Discuss key considerations for planning implementation of the Stepped Care Model for Pain.

The Military Health System (MHS) This slide is a high-level overview of the Military Health System Our system supports 9.4 million military beneficiaries through a combination of military hospitals and clinics as well as a very extensive TRICARE network of civilian providers. As you can see in the upper left-hand corner, we have very active pharmaceutical services with more than 128 million scripts filled annually. Opiates make up about 4.5% of that total – roughly 5 million opioid scripts per year Across the United States, there are over 191 million opioid prescriptions written annually.

Requirements Relating to MHS Stepped Care Model DHA-PI 6025.04: Establishes the MHS SCM as the comprehensive model for pain management for quality, safety and consistency of care Requires PM CSS to develop the MHS SCM training Requires PM CSS to support Clinical Communities in implementation of MHS SCM Requires DVPRS as the standard pain scale for the MHS Requires MTFs to appoint Primary Care Pain Champions (PCPC) Additional Authority Documents: NDAA FY10, Section 711 NDAA FY17, Section 746 NDAA FY18, Section 735 Presidential Memorandum, “Combatting the National Drug Demand and Opioid Crisis,” 26 Oct 17 Presidential Memorandum, “Addressing Prescription Drug Abuse and Heroin Use,” 21 Oct 15 HA Policy 11-003, “Policy for Comprehensive Pain Management,” 30 Mar 11 R3 Report (The Joint Commission), “Pain assessment and management standards for hospitals,” 29 Aug 17 Pre- decisional - For Official Use Only - Not for Release under FOIA

MHS Stepped Care Model Purpose The MHS Stepped Care Model seeks to enable Clinical Communities to provide evidence-based pain management guided by clinical practice guidelines (CPGs): effectively treat acute and chronic pain; promote non-pharmacologic treatment; prevent acute pain from becoming chronic; and minimize use of opioids with appropriate prescribing only when indicated. The MHS Stepped Care Model is the comprehensive standardized pain management model for the MHS to provide consistent, quality, and safe care for patients with pain with an emphasis on non-pharmacologic treatments. The DoD and our partners are on the forefront of national efforts to accelerate the evolution of pain management through a comprehensive pain management strategy We are working to affect a culture of change in pain management that focuses on a biopsychosocial approach to the measurement and treatment of pain As I’ll discuss shortly, we are committed to implementing a stepped-care model of pain care

MHS Stepped Care Model Although this is a very busy slide, it captures the MHS comprehensive approach to pain management. On the horizontal scale we have patient complexity and the vertical scale indicates care complexity Down in the lower left you see self-management And at the upper right is tertiary level care – often pain management clinics offering a wide spectrum of treatment options. We have rapidly evolved our approach to pain management over the last decade Pain clinics used to be primarily staffed by anesthesiologists Today they are multispecialty clinics that can address the biopsychosocial needs of our patients. The stepped care model allows us to follow a structured approach to pain management through the continuum of care from self-care, to PCM and when necessary, to secondary and tertiary levels Our goal is to help patients manage their pain at the lowest care level necessary…and to teach them the skills necessary to move back down the continuum of care represented here The MHS Stepped Care Model is a team-based, interdisciplinary model for pain management that aligns across the Services. “Stepped care” delivers and monitors pain treatment utilizing the Patient-Centered Medical Home (PCMH) first, moving patients forward on the continuum of care only as clinically required. Patients with longer-lasting pain or higher medical complexity advance to the interdisciplinary Medical Neighborhood, where they benefit from additional services such as physical therapy, pharmacy review, care coordination, and behavioral health. Only the most chronic and/or complex patients who do not improve in the Medical Neighborhood will require referral to a Pain Management Clinic. The MHS Stepped Care Model seeks to enable Clinical Communities to provide evidence-based pain management guided by clinical practice guidelines (CPGs): effectively treat acute and chronic pain; promote non-pharmacologic treatment; prevent acute pain from becoming chronic; and minimize use of opioids with appropriate prescribing only when indicated.

Establishment of Primary Care Pain Champions (PCPCs) PCPCs within MTFs fulfill a critical role in ensuring the successful execution of the Stepped Care Model and better equipping primary care teams to manage care for patients with complex and chronic pain. High-level PCPC roles may include: 1 Ensuring all members of the treatment team understand their roles and responsibilities 2 Answering clinical care questions from PCMs and team members 3 Augmenting education and tele-mentoring initiatives 4 Establishing local pain education initiatives Serving as the main point of contact for Comprehensive Pain Management Program (CPMP) leadership 5

Implementation Planning Collaborative effort Strategic Communications Key Education Concepts / Products Biopsychosocial Model of Pain Defense and Veterans Pain Rating Scale (DVPRS) Providing Pain Education & Collaboratively Setting Treatment Goals Self-Management / Behavior Change Interdisciplinary Team Training Workflow Outcome Metrics Methods of Training

Summary Comprehensive pain management is necessary to address MHS challenges with opioids Comprehensive pain management strategy includes the biopsychosocial approach to the measurement and treatment of pain nested within the stepped care model We continue to pursue collaborative efforts to share and develop best practices for pain management and opioid safety

MHS Pain Management Point of Contact MHS Pain Management Clinical Support Service Lieutenant Colonel Sharon L. Rosser Sharon.l.rosser.mil@mail.mil