Multidisciplinary Transitional Pain Service for the Veteran Population
Background: For patients with existing chronic opioid use or a history of substance use disorder, often little presurgical planning or postsurgical coordination of care among surgeons, primary care providers, or addiction care providers occurs.
Methods: In 2018, we developed the Transitional Pain Service (TPS) to identify at-risk patients as soon as they were indicated for surgery, to allow time for evaluation, education, and developing an individualized pain plan, and opioid taper prior to surgery if indicated. An electronic dashboard registry of surgical episodes provided data to TPS providers and included baseline history, morphine equivalent daily dose, and patient-reported pain outcomes, using measures from the Patient-Reported Outcome Measurement System for pain intensity, pain interference, and physical function, and a pain-catastrophizing scale score.
Results: Two-hundred thirteen patients were enrolled between January and December 2018. Nearly all (99%) patients had ≥ 1 successful follow-up within 14 days after discharge; 96% had ≥ 1 follow-up between 14 and 30 days after surgery; and 72% had completed personal follow-up 90 days after discharge.
Conclusions: In 2018 the overall use of opioids after orthopedic surgery decreased by > 40% from the previous year. Despite this more restricted use of opioids, pain interference and physical function scores indicated that surgical patients do not seem to experience increased pain or reduced physical function.
Discussion
With any new clinical service, there are obstacles and challenges. TPS requires a considerable investment in personnel, and currently no mechanism is in place for obtaining payment for many of the provided services. We were fortunate the VA Whole Health Initiative, the VA Office of Rural Health, and the VA Centers of Innovation provided support for the development, implementation, and pilot evaluation of TPS. After we presented our initial results to hospital leadership, we also received hospital support to expand TPS service to include a total of 4 nurse care coordinators and 2 psychologists. We are currently performing a cost analysis of the service but recognize that this model may be difficult to reproduce at other institutions without a change in reimbursement standards.
Developing a working relationship with the surgical and primary care services required a concerted effort from the TPS team and a number of months to become effective. As most veterans receive primary care, mental health care, and surgical care within the VA system, this model lends itself to close care coordination. Initially there was skepticism about TPS recommendations to reduce opioid use, especially from PCPs who had cared for complex patients over many years. But this uncertainty went away as we showed evidence of close patient follow-up and detailed communication. TPS soon became the designated service for both primary care and surgical providers who were otherwise uncomfortable with how to approach opioid tapers and nonopioid pain strategies. In fact, a substantial portion of our referrals now come directly from the PCP who is referring a high-risk patient for evaluation for surgery rather than from the surgeons, and joint visits with TPS and primary care have become commonplace.
Challenges abound when working with patients with substance abuse history, opioid use history, high anxiety, significant pain catastrophizing, and those who have had previous negative experiences with surgery. We have found that the most important facet of our service comes from the amount of time and effort team members, especially the nurses, spend helping patients. Much of the nurses' work focuses on nonpain-related issues, such as assisting patients with finding transportation, housing issues, questions about medications, help scheduling appointments, etc. Through this concerted effort, patients gain trust in TPS providers and are willing to listen to and experiment with our recommendations. Many patients who were initially extremely unreceptive to the presurgery education asked for our support weeks after surgery to help with postsurgery pain.
Another challenge we continue to experience comes from the success of the program.
Conclusions
The multidisciplinary TPS supports greater preoperative to postoperative longitudinal care for surgical patients. This endeavor has resulted in better patient preparation before surgery and improved care coordination after surgery, with specific improvements in appropriate use of opioid medications and smooth transitions of care for patients with ongoing and complex needs. Development of sophisticated note templates and customized health information technology allows for accurate follow-through and data gathering for quality improvement, facilitating data-driven improvements and proving value to the facility.
