1. 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

2. 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.

3. 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.

4. 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.

5. Requirements Relating to MHS Stepped Care Model
DHA-PI :
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 , “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

6. 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

7. 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.

8. 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

9. 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

12. 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

13. MHS Pain Management Point of Contact
MHS Pain Management Clinical Support Service
Lieutenant Colonel Sharon L. Rosser