By Ms. Suzanne Ovel (Army Medicine)April 17, 2015
Pain management experts at Madigan Army Medical Center at Joint Base Lewis-McChord, Wash., are now creating pain champions throughout the Western Regional Medical Command with the help of experts at the Department of Veterans Affairs and the University of Washington.
In early March, the Interdisciplinary Pain Management Clinic here became the WRMC hub for the Department of Defense's Extension for Community Healthcare Outcomes initiative, making them the lead for training subject matter experts in pain management at most of the Army Medical Homes west of the Mississippi River.
Using a telemedicine model created at the University of New Mexico, the ECHO hub here hosts weekly video teleconferences for primary care managers at more than 30 AMHs to develop them into local pain management experts, or pain champions.
"The only way we can improve pain management in our nation, in the world, or in the Military Health System, is to improve the skills at the primary care level, because there's just not enough pain physicians to take care of everybody with complicated pain," said Dr. Diane Flynn, Madigan's primary care pain management advisor.
Using virtual means to create these pain champions creates subject matter experts at the clinic level who can then educate and consult with their clinic colleagues, as well as bring their colleagues' complicated pain patient questions to the ECHO conferences for consults. The ECHO VTCs are force multipliers, said Flynn, because the one provider who dials in can have such a large effect with their own patients, their colleagues, and their colleagues' patients.
The weekly VTCs combine an educational portion as well as time for PCMs to present complicated pain patients' cases to an interdisciplinary panel. The education portion can cover everything from addiction assessments to how to make pain management more efficient and safer, or from how to treat nerve pain to information on common pain conditions seen in primary care, such as fibromyalgia.
According to Flynn, the most common consult question is how to have a conversation with patients about bringing them down from high levels of opioids when the patients don't want to or are afraid to lower their dosages.
In addition to coaching PCMs on lowering opioid use to increase patient safety, consults also focus on increasing effectiveness of other pain management practices.
"If you're not using opioids, what can you use to help reduce pain and its impact? Some of that's medication management; some of that's psychological management," said Flynn. "We talk a lot about cognitive-behavioral therapy and how we can help patients identify their goals and make progress towards their goals and overcome obstacles through their goals."
Another advantage of engaging in the ECHO VTCs is that there is no waiting list to consult about patients. Waiting for traditional consults could take a month, Flynn said; while consulting about patients through the ECHO initiative won't replace needed referrals to specialty care, these consults between providers can sometimes answer simple questions which then allow providers to move forward with their patients' care.
The effectiveness of the ECHO model has already been proven at the University of New Mexico, where it was launched in 2003 as a means to increase the ability of community providers to treat hepatitis C by making specialized medical knowledge available to these providers. Before then, the state only had two clinics that treated the disease, according to the University of New Mexico web site. Since then, the ECHO model expanded to include dozens of other hubs for nearly 30 diseases, to include chronic pain.
The military contracted with the University of New Mexico two years ago to adopt the ECHO model; Flynn found herself on the ground floor of that and has been sitting in on the University of New Mexico's pain management VTCs for two years as the clinic here prepared to lead its own ECHO initiative.
"I can speak from experience that it is a very effective way to learn not only the concepts of pain management … but (also) the application," said Flynn.
She's followed the success of the university's initial ECHO hub for hepatitis to measure how successful the pain management hub here might be.
"What they were able to show over the course of years … with that program is that they elevated the level of care for hepatitis in those communities to the same level as if they had traveled to the university," she said.
Despite its recent start, the ECHO pain management hub here has already shown some successes since some of the local AMH pain champions have been listening in on other pain management VTCs for the past year. Now, they're asking if they can present their colleagues' patients' cases for consults.
The hope is that by creating pain champions throughout WRMC, and really throughout the DoD, that more patients living with chronic pain can successfully manage that pain to lead satisfying lives.
"The most important outcome in pain management is helping people lead functional lives, lives that they're satisfied with. It may not mean elimination of pain, because usually we can't eliminate chronic pain; it's how do we help them lead a life that's satisfying to them despite pain," Flynn said.