1. A Whole Person Model of Care for Persistent Pain in Hunter New England Health
Fiona Hodson and Dr Chris Hayes
Hunter Integrated Pain Service HNE Health
Figure 5: HIPS Waiting times and targets
Marked reduction in medical reviews and procedures in the context of delivering a broader model of care & best available evidence (Figure 6)
Figure 6: HIPS Activity
Over sevenfold increase in group attendance from (Figure 7)
68% of group participants bring a support person
Fewer patients use regular opioids (71 to 58%)
77% patients satisfied/highly satisfied with groups
Patients using less caffeine (66 to 82% low-mod level), less alcohol (84 to 94% within normal limits) and less nicotine (26 to 23% non smokers)
HIPS overall clinical outcomes remain statistically significant with improvements in self efficacy and reduced psychological distress
Figure 7: HIPS Group Programs
Background
The Hunter Integrated Pain Service (HIPS) is a multidisciplinary team based at John Hunter Hospital. HIPS manages acute, persistent and cancer pain with an emphasis on health promotion and active self management
In 2004, HIPS began a process of service redesign to improve access for patients from a wide geographical area, where referral rates consistently exceeded service capacity and waiting lists were excessive.
The model (Figure 1) that has evolved is consistent with the HNE 2008 Health strategic plan (1), 2004 & 2007 NSW State Health Plans (2,3) and 2008 World Health Organisation health priorities (4). The model balances community, primary and tertiary interventions and also biomedical treatment with active self management. Progress was achieved without increasing resources, by divesting in obsolete practices and reinvesting in new evidenced based approaches.
The inaugural National Pain Summit March 2010 Canberra, acknowledged the HIPS model as one of Australia’s 5 best practice models (5). It was also rated as a leading model against those from United States, Canada and United Kingdom.
Figure: 2 HIPS Filter Strategy
The whole person model shown in Figure 3, emphasised a balanced approach to therapy and has enhanced patient experience and clinical outcomes.
Figure: 1 HIPS Integrated Model of Care
Figure 3: HIPS Whole Person Model of Care
Key strategies in the redesign process:
New referral/triage criteria & waiting time targets
Modifications to clinical services, referral questionnaire, outcome measures and individualised care planning
Website for pain management resources, links for healthcare professionals & community
Discharge policy liaising with general practitioner
Telephone support for patients & health providers
Personalised Pain Management Action Plans (PMAPs)
80 hour group program replaced by shorter groups tailored to individual needs: Moving with Pain, Living with Pain, Story Group, Neuropathic Pain Group
Pre-assessment: Understanding Pain education
Research activities eg) benchmarking of outcomes with other specialty pain units around Australia
Conclusion
HIPS has reduced waiting times and improved equity of access for rural and disadvantaged communities in HNE. Key focus areas have included primary health care, disease prevention, health promotion and strengthening partnerships with local communities and government and non-government organisations.
Future Scope
The model has proven to be successful in the Hunter New England region. Currently the Agency for Clinical Innovation (ACI) is investigating transferability of this and other models across NSW consistent with the National Pain Strategy. Future directions will involve delivery of key public health messages; continued partnerships with primary care including education; development of resource kits, complexity/referral criteria; delivery of short group interventions in the community.
Aim
8 year evaluation of service improvement and patient access following implementation of a new model of care for persistent pain in HNE Health.
Method
Evaluation of HIPS model included qualitative data such as staff, patient and referrer feedback and quantitative analysis of waitlists and clinical outcomes.
A series of key changes were initiated from late At a systems level, this encompassed a stratified and integrated model which aimed to improve access and patient flow. The approach (Figure 2) included a greater focus on community and primary resources, group interventions and more selective and efficient use of specialist services at tertiary level.
At the level of the individual patient, therapeutic balance shifted away from more traditional biomedical treatments and high intensity cognitive behavioural (CBT) programs towards a more person centred approach. Early exposure to more optimistic messages around neuroplasticity, mindbody (6,7,8) and lifestyle interventions (9) has encouraged uptake of active self management for a much larger cohort of patients
Results
Prior to 2004 waiting list was far in excess of system capacity and access was restricted through inefficient organisational processes. System redesign produced the following outcomes:
Figure 4: HIPS Referral Activity
Overall reduction in waiting time for clinical
assessment across all triage categories A,B,C
(Figure 5) despite a 26% reduction in medical FTE over last 4 years.
Understanding Pain < one month from referral
Reduced impact of non attendance
References
Hunter New England Health ,(2008) Strategic Plan – A New Direction for Hunter New England Health Service Strategic Plan Towards 2010, viewed 4th May,2010,
NSW Department of Health, (2004) NSW Health and Equity Statement – In All Fairness,Increasing equity in health across NSW, viewed 4th May, 2010 <
NSW Department of Health (2007), Future Directions for Health in NSW – Towards 2025, viewed 4th May ,2010 ,<
World Health Organisation , (2008), Closing the gap in a generation, health equity through action on the social determinants of health, viewed 10th May ,2010, < >
Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine, Australian Pain Society,Chronic Pain Australia (2010), National Pain Summit Strategy,,. viewed 10th May ,2010 ,
Flor H. Cortical reorganisation and chronic pain: implications for rehabilitation. J Rehabil Med. 2003;(41 Suppl):66-72
Broom B. Meaning-full Disease. Karnac Books. London 2007
Sarno JE. The divided mind: The epidemic of mindbody disorders. Harper Collins. New York 2006
Egger G, Binns AF, Rossner SR. The emergence of ‘lifestyle medicine” as a structured approach for management of chronic disease. Med J Aust 2009;190(3):
Acknowledgements: Hunter Integrated Pain Service Team