Integrated Nurse Mgmt Lowers Pain Interference, Rural PC (Pilot)

Preliminary pilot data from pilot rural and urban practices in three states suggest that the combination of pharmacologic and behavioral interventions, delivered through nurse-led care management, can result in reductions in interference of chronic pain on activities of daily living, work, sleep and physical activities. Patients do not view reducing pain as the major goal of successful management of chronic pain. Instead, they would be able to walk a mile, sleep 8 hours/night, work 5 days a week, take care of spouse and children. Many rural practices struggle with the lack of specialty services for pain management, behavioral health and physical therapy yet are expected to maintain long-term management of chronic pain. One promising model for primary care is the embedding of nurses as care managers within practices themselves. This model enables safe weaning of patients off high doses of opioids, education on a variety of self-management techniques, and coordination of effective, non-medication interventions to improve function.

Why It Matters

While chronic pain is challenging for patients, it is not the whole story. Pain interference, or the consequences of pain, is what really hinders quality of life. Does pain interfere with work, sleep, activities, independent living, or relationships? Over time, patients and providers work hard to manage pain through a combination of clinic visits, urgent care, imaging, and medications. However, the majority of these efforts provide minimal long-term pain relief. A function-first approach to pain helps both patients and providers understand the impact of pain and focuses on what matters most to each individual. It then identifies the small steps that can be taken to meet those goals.

Pain interference can become a public health issue at the community level in rural settings where few local resources are available to manage pain and where primary care teams address the most complex pain cases with less than optimal resources. Many patients face significant barriers in accessing physical therapy, behavioral therapy and specialty evaluations including cost, distance, time and transportation. Clinics often have too few staff members, too little time to spend with each patient and no access to other disciplines and teams. Chronic pain can become “stuck” and managed with more medication, more misery and less gain. A team-based approach using nurse care management is one strategy to reduce this disparity using a workforce and configuration of services commonly found in rural primary care practices.

Integrated nurse management is essential in transforming the way chronic pain, catastrophic thoughts and their symptoms are managed from a reactive, problem-focused approach to a proactive, organized and ongoing approach to chronic pain management. The care manager assists patients and families to make lifestyle changes such as engaging in regular, gentle activity and practicing relaxation techniques on a daily basis. In addition, the nurse care manager can assist patients and families in troubleshooting and problem solving throughout the duration of care. For example, the nurse can work with a patient to adjust their walking plan in order to decrease pain or to develop a sleep routine to improve insomnia. The care manager supports the patient and family in reinforcing the simple pain management plan that is developed with the patient and their physician and documents changes in the patient’s status as needed.

Chronic pain management is not just about having a multitude of medications, devices, and surgical procedures from which to choose. Most current professional guidelines emphasize the importance of nonpharmacologic pain management strategies, safe pain medication prescribing practices, and patient-centered pain outcomes. A variety of interventions and tools should be used to provide a comprehensive approach to pain management. Patients and their families also need to be educated, coached, and reassured as they learn to use these tools to incorporate them into their daily lives. The nurse plays a vital role in helping patients and clinicians translate the professional guidelines and research findings into meaningful patient-centered goals of care for both short-term and long-term pain management. Nurses use individualized stepwise approaches to enhance patients’ physical and emotional function and promote safe, long-term pain management with minimal risk for harm.

The reduction in pain interference also has costs to the health system and payers through decreased use of healthcare services following treatment. Patients regaining function and stability to prevent a trip to the emergency room, duplicative testing, and the risk of prolonged disability is a powerful benefit. Improved function and stability also leads to improved mental health and increased participation in life activities. For rural health systems with limited budgets, small staffs, and lack of access to many specialist services, an improvement of only a modest amount can have a huge impact.

Pain Interference refers to the degree that pain affects a patient’s life and is a topic of great research interest when it comes to studying chronic pain and its effects.

Pain interference is an important and practical outcome for primary care to track and target. Two patients with similar levels of pain may have very different levels of interference in their lives including their function, coping, sleep, and work status. Monitoring for these outcomes will help teams and patients determine if the current treatment plan is effective even when pain levels have not decreased substantially. Interference outcomes reflect what patients say matters most to them, and they report being willing to live with substantial levels of pain if they can also get good sleep, adequate function, and be able to do usual activities and roles. Function-based targets are viewed as being more attainable and less overwhelming for patients than pain-focused targets.

It is important to monitor for interfering pain to ensure that optimal communication and pain management plans are in place. Monitoring function over time will alert clinicians to early decline in function such as decrease in walking distance, decrease in workdays, and poor sleep. It will also alert clinicians to which types of interventions such as physical activity, cognitive training, improvement in mood, and medication are most effective for individual patients. We find that even brief, easy to complete patient reported measures can be easily incorporated into busy practices. A nurse care manager can collect the measures on a consistent basis and present the results at team meetings.

Safety and Medication Stewardship in Rural Pain Care

When healthcare is provided in a team model within a nurse managed centre, medication safety can be optimised. Chronic pain management is a prime area of focus given the high iatrogenic risk associated with polypharmacy and long term therapy. In rural primary care patients take multiple medications for long term analgesia, as well as sedation, depression, diabetes and heart disease management. Nurses can focus on organised medication review, screening for adverse effects, appropriate use of medication and adherence to prescribed regimens. In addition, planning a taper of medications is one of the hardest steps to take in management of chronic pain and the nurse can play a vital role in this process and be seen by patients as supportive rather than abandoning them.

This model helps to avoid overuse of opioids and instead fosters use of alternative approaches and self management strategies. Many patients and families are looking for alternative options to opioids, but are not sure where to start or how to incorporate new strategies. The nurse educates patients and families on activity pacing, flare planning, gentle strengthening, sleep and stress management techniques. The nurse connects patients and families to community based walking groups/exercise programs as well as telehealth-based behavioral health interventions when available. The resulting treatment plan will emphasize function and quality of life.

Who It Affects

Efforts are focused primarily on the approximately 36 million patients with chronic pain who are most in need of access to specialty pain services because many of the underlying conditions contributing to their pain remain untreated. In addition to needing access to pain specialists, many rural patients with persistent pain also engage in physically demanding jobs or have difficulty accessing transportation to travel to healthcare providers. Rural populations also have a higher prevalence of many conditions that can cause persistent pain such as arthritis, back pain, and diabetic neuropathy. To enhance pain care on rural medical campuses, CMSA established the Model for Nurse Management of Chronic Pain and the Business Case for Embedded Nurse Management. The embedded nurse management model is particularly effective because patients receive the same high quality care between physician office visits as they receive during scheduled visits. An emphasis on function helps patients establish realistic goals for themselves, such as increasing their physical activity, improving their sleep or reducing the number of “bad days” they spend at home.

Patients with complex psychosocial needs may benefit from intervention given that pain interference is often influenced by stress, mood, trauma history, and social isolation. Many rural communities are lacking in access to behavioral health services, however, anxiety and depression are very common and worsen pain and disability. Education and support by nurses using motivational interviewing and basic behavioral pain strategies can empower patients to use coping strategies, to engage in healthy pacing, and to reduce avoidant behaviors based on pain-related fear. Tele-behavioral health services can be coordinated with local providers who offer these services. Patients need to understand that practices like meditation, yoga, mindfulness, and breathing are normal and helpful parts of pain management to achieve greater disability reduction.

As primary care clinicians become increasingly over stretched, having a nurse care manager on their team could be very helpful in extending their reach and increasing their capacity to continue to provide quality care within the confines of very short appointments. A nurse can prepare for a chronic pain visit by gathering the latest patient information, reviewing and posting recent patient reported measures of function, reinforcing the key elements of the treatment plan to the patient and physician, and bringing to the physician’s attention any concerns or issues that need to be addressed at that visit. By having the nurse assist with these tasks, the clinician can better avoid burnout by not having to start from scratch at every visit with a patient.

Nurses in care management roles are also key stakeholders as this new care delivery model presents opportunities, challenges, training needs and ways of service that nurses can fulfill. Care managers might be a direct service RN, a RN with experience managing chronic illness, or an Advanced Practice RN. They coach and care coordinate, do safety checks on patients’ medications, and discuss treatment goals with patients and families. Care Managers need protocols, clinical supervision, time to make outreach calls, and tools to document and track progress throughout the care management process. From a provider perspective, pain management is a natural fit for nurse-led clinical practice.

Providers, payers and health systems are actively exploring reimbursement strategies for nurse-integrated models of care for the management of chronic pain through care management, virtual follow up and outcomes measurement and tracking. Many of the most valuable things that can be done for patients with chronic pain occur between in-person visits (e.g. a brief phone call with the patient or another team member such as a physical therapist, to check on the patient, to encourage the patient to complete their activity plan, etc.). Many of these activities are not currently reimbursed by the structure of the pay for service payment models and, therefore, unsustainable. Long-term, those organizations that design payment systems that reward quality and functional outcomes for patients with chronic pain will realize reduced avoidable utilization and better patient reported outcomes.

Scaling this model to other sites will require planning for the training and sustainable staffing of administration and clinical staff. Partnership with workforce and education partners will be needed to plan for and provide training, as well as ensure sustainable staffing. This may involve planning for education on pain assessment (using function-based assessment), effective patient communication, behavioral pain management approaches, and appropriate medication use. Partnerships with larger health systems or academic centers can be particularly useful in gaining access to mentorship and consultation for difficult cases. Staff at rural sites will receive telehealth supervision by specialists who may be located off-site but are available by video link, phone, or other electronic means. The quality of the link, clinic workflow, and organizational policies will all impact the quality of this supervision.

Equity Considerations in Rural Pain Management

Improving Equity. Integrated nurse management brings evidence-based treatment of pain to patients who would otherwise have difficulty accessing specialist medical and surgical services. Rural patients and families receive care coordination and coaching in the community clinic and by phone to develop skills to manage chronic pain, access safe and effective medication, and receive ongoing support. Rural patients and families benefit from having chronic pain viewed and discussed in the community clinic, reducing the stigma of this common condition.

What Changes

• Practical care delivery: Embedding nurse care management within rural primary care shifts the focus from episodic visits to ongoing, function-centered management — meaning patients get regular check-ins, goal-setting, and care coordination that target pain interference rather than only pain scores.
• Medication safety and stewardship: A team-based model supports safer prescribing through medication reviews, close monitoring for side effects, and coordinated tapering when appropriate, while also emphasizing nonpharmacologic options as first-line strategies for reducing functional disruption.
• Access and equity: Integrated nurse management makes evidence-based pain care more accessible in areas without specialty services by using nurses and telehealth to deliver behavioral therapies, link patients to local resources, and guide simple exercise and rehabilitation plans.
• System readiness: For this approach to scale, systems need payment reforms that reimburse care management and virtual services, training programs for nurses in pain-focused behavioral strategies, and data systems that track functional outcomes rather than only pain intensity.

While there is still much to be done to ensure that pain management is integrated into primary care, there are several steps that can be taken in the next few years to support greater adoption. Health systems could test and learn from integrating a nurse into pain care practices, monitoring both function and patient experience. Payers could test bundles for procedures such as spine surgery or osteoporosis medications, or create codes for care management to pay for care coordination and disability reduction efforts. Training programs for nurses in pain management could be established to build the pain care workforce. Pain specialists could be hired and trained as mentors. Telehealth and remote supervision technologies can be used in conjunction with efforts to improve broadband access and streamline clinical workflows to ensure that these innovations do not widen disparities in access to treatment.

Although there are limitations and trade-offs (not all patients will succeed with nurse-led treatment and will require more specialty pain procedures, interventional pain management or multidisciplinary pain rehabilitation programs), there are effective pathways of care that can be organized and monitored by the healthcare team and referral pathways for these more complex patients must also be considered. In addition to these challenges, there are limitations to sustaining effective nonpharmacologic services including physical therapy, behavioral and other treatments and community-based programs. Many of these services are severely under-funded and lack necessary resources despite strong evidence that these services can help patients with chronic pain to attain improvement in function.

For clinicians and health policy makers the main message is that in order to impact positively on pain and reduce its interference with normal life painful physical and psychological symptoms need to be well managed by health professionals, most efficiently within primary care, particularly in rural settings. A nurse-led pain management service is a safe, functional and accessible patient-centred approach to pain management, which is efficient clinical health care when well supported by allocation of resources, training and resources. As more models move from pilots to main stream practice it is critical that monitoring of both functional outcomes and patient experience continues in order to ensure benefits and avoid harm.

It has become common to define success in pain care as reducing pain intensity. However, success might also be described by the ability of individuals to sleep, work and live full and meaningful lives despite pain and to engage in life’s pleasures. Attaining these outcomes in primary care, particularly in rural settings, will require intentional strategies and considerable effort on the part of clinicians, payers and policymakers to optimally implement and nurse-integrated pain management models.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC10030130/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6519560/