ABSTRACT
Learning Objectives (1) Describe the components of the VHA Whole Health framework in relation to the biopsychosocial model of pain. (2) Identify the contributions of various disciplines/roles to interdisciplinary care for chronic pain (interventional pain, psychology, dietitian, pharmacy, physical therapy). (3) Explain the importance of involving various stakeholders (i.e. patients, administration) when developing and implementing a novel clinical program. Purpose The Joint Commission and Veterans Health Administration (VHA) require VA Medical Centers to offer interdisciplinary (IDT) evaluations of chronic pain, which are associated with improvements in provider and staff satisfaction, decreased ER visits, increased quality of life, lower overutilization of healthcare services, decreased disability related to pain and impact of pain, decrease symptoms mental health difficulties (i.e. anxiety, depression, stress), and increased selfefficacy for patients. However, there is significant variability in models of programming and no evidence-based implementation strategies have been studied. Many VAs, including Salem VAMC, adopted a consultative model of IDT which typically involve one appointment with multiple providers (typically interventional pain, psychology, physical therapy, and pharmacy) who make chart recommendations before the patients return to their PCP. This model does not include follow-up appointments and follow-through with recommendations from the IDT team are not guaranteed once they return to their referring provider. At the other end of the spectrum, each region in VHA is expected to offer a Commission on Accreditation of Rehabilitation Facilities (CARF) accredited Interdisciplinary Pain Rehabilitation Program (IPRP), which typically involves patient participation in programming for approximately forty hours per week for six weeks (i.e. over 100 hours of provider-led service). Given the staffing shortages related to the COVID pandemic and the amount of effort required by patients, implementing the IPRP model can be challenging. To overcome these patient and provider barriers to effective pain management, the PREVAIL Program for Chronic Pain was developed and implemented at the Salem VAMC, which serves primarily rural Veterans. PREVAIL utilizes the VHA's Whole Health framework to develop patient-centered, biopsychosocial treatment plans tailored to Veteran preferences. These plans emphasize active self-management of chronic pain, nonpharmacological strategies, involve low burden for patients and the healthcare system, and allow the Veteran to choose three of the following Whole Health self-care areas to focus on during their 6-month participation in PREVAIL: Power of the Mind, Recharge, Surroundings, Moving the Body, Family, Friends, and Coworkers, Food and Drink, Spirit and Soul, and Personal Development. This work describes the phases of development and implementation of PREVAIL. Methods A multiphase approach was used to iteratively assess and refine the PREVAIL program. Participants were thirty-six Veterans with chronic pain who had completed at least half of six pain education classes offered by the pain department at the Salem VA Medical Center. The a priori aims of the IDT process adaptations were to increase the efficiency of care/ decrease patient burden (number of appointments needed by Veterans to establish a biopsychosocial treatment plan for chronic pain), lower healthcare system burden (number of minutes spent by PCP's placing pain consults, number of scheduling calls needed), and increase access to care (wait time for first pain intervention). Implementation was conducted through 3 phases that included varying lengths of the IDT appointment and inclusion of Complementary and Integrative Health (CIH) modalities. During the preparation phase, a psychologist who was not part of the original IDT program (i.e. third party interview) who was trained in sound qualitative methodologies interviewed 5 providers who had placed referrals to the previous consultative model of IDT at the Salem VAMC. Dur ng phase 1 of the new IDT rollout, 9 Veterans completed a 4-hour appointment which included participation in a 1 hour shared IDT appointment (interventional pain, psychology, dietary, pharmacy, physical therapy) and 3 hours of CIH modalities. Using feedback from stakeholders, Phase 2 of the IDT rollout included 27 Veterans who completed a 90-minute shared appointment with the IDT team (aforementioned five disciplines). Stakeholder feedback led to the third phase of IDT rollout, which included a 60- minute shared appointment with the IDT (5 disciplines aforementioned). Each phase also included Veterans receiving monthly phone calls with a whole health coach who used motivational interviewing (MI) techniques to discuss successes, resolve barriers, and establish new goals. A 6-month follow up appointment with the IDT team assessed progress toward their initial goals and changes over time in selfreported measures. Measures were the number of Veterans appointments, time PCPs spent placing consults, number of scheduling calls, wait time for interventions, the three areas of self-care Veterans elected to focus on their participation in the program, and a program-specific patient satisfaction survey. Results Referring providers were satisfied with the following elements of the previous consultative model that was used prior to PREVAIL: Medication recommendations from Pharmacy and Pain MD, inclusion of a face-to-face physical examination, provision of an individualized treatment plan, good follow through from interventional pain, provision of suboxone prescriptions, and involvement of mental health on IDT team. Referring providers were dissatisfied with the lack of communication and follow through of recommendations resulting from the consultative model of IDT. They also noted confusion about the goals of the consultative model, concern about lack of patient buy-in for nonpharmacological strategies to manage pain, and a strong preference for the pain department to prescribe opioid medication. Stakeholder feedback (i.e. patient, administration, PREVAIL providers) were incorporated between phases of PREVAIL implementation. While patients often stated their favorite aspect of the appointment was time with the IDT team, converting to a 60-minute model based on administration preference for reduced use of resources did not decrease patient satisfaction. PREVAIL led to a number of improvements in outcomes of interest. The implementation of PREVAIL IDT decreased the number of appointments needed by Veterans to establish a biopsychosocial treatment plan for chronic pain decreased from 5 to 1, decreased the number of minutes spent by PCP's placing pain-related consults reduced from 10 to 2, decreased the number of scheduling calls needed reduced from 5 to 1, and wait time for first pain intervention decreased from 55 days to 14 days. Results of satisfaction surveys from both Veterans and caregivers were as follows: 100% reported 'providers treated me with respect and courtesy,' 100% agreed or strongly agreed they understood their role in actively self-managing pain, 100% stated the IDT evaluation was a valuable use of their time, and 100% would recommend the IDT evaluation to a friend. The average overall satisfaction for the IDT evaluation was 9/10. The majority of patients chose to focus on Power of the Mind (thoughts and emotional health;72%) and Moving the Body (exercise and movement;67%) as one of their top 3 areas of Whole Health framework to focus on, while 25% preferred to focus on Food and Drink (dietary changes). Conclusion This study provides preliminary evidence that the implementation of PREVAIL IDT decreased the burden to patients and the healthcare system, as well as access to care. These preliminary results suggest IDT models that offer follow-up appointments to patients may not require the healthcare and patient burden of weeks of programming (i.e. IPRP), as PREVAIL was acceptable to both providers and Veterans. Regarding lessons learned, eliciting feedback from patients, referring providers, treating providers, and adm nistrators was crucial in creating a rich clinical experience that wisely utilized limited resources in the midst of a pandemic. Furthermore, while traditional IDT models do not include a dietitian, this study provides evidence that Veterans with chronic pain at the Salem VAMC have an interest in follow-up nutrition services and report a high level of satisfaction with the service when dietitians are included on the IDT. Future studies should examine the efficacy of PREVAIL on physical functioning and mental health symptoms compared to established models (IPRP's, consultative models), the cost effectiveness of PREVAIL, and longitudinal outcomes associated with participation in PREVAIL.
ABSTRACT
Background: The United States is increasingly diverse, but representation of minorities (specifically Black/African-American) in medicine has not followed this trend. Lack of mentorship is identified as a barrier at multiple levels. We developed and piloted a mentorship program between pediatric emergency medicine (PEM) physicians and underrepresented minority (URM) undergraduate students in the Porter Scholars program (the largest African American student organization at the University of Louisville), known as the Porter Scholars in Medicine Program (PSMP). By providing robust mentorship and educational activities, our goal is to encourage students in this program to matriculate to medical school. Methods: The pilot program included clinical experiences (simulation and ultrasound), direct mentorship, connections with medical school admissions agents, and personal development programming including a book club. Students selected for the PSMP completed a survey upon entry into the program including demographic questions, as well as 5-point Likert scale questions regarding familiarity with the medical school application process, comfort with being a physician, and barriers to becoming a physician. Additionally, they received a survey after specific experiences and at the end of the year. A final survey will be sent following graduation. Data were analyzed using descriptive statistics, and Wilcoxon-Signed Rank tests were used to compare entry to end of year results. Results: Twenty-three PEM faculty, fellows and clinicians volunteered as mentors or led clinical programs in the PSMP program. Twenty-five undergraduate students were accepted into the program in fall of 2020;22(88%) completed the initial survey. Mean age was 18.6 (+/- 0.8) years, 19 (86.4%) were female. On initial surveys, the median Likert scores were: awareness of available resources to assist with medical school application 2, understanding of the medical school application process 2.5, confidence in acceptance to medical school 3, and mentor support 4. Eight (36.3%) students completed the end of year survey. For these 8 students, significant increases in median Likert scores were noted for the following categories: awareness of available resources to assist with medical school application median 3.5 (p = 0.03) and understanding of the medical school application process median 4 (p = 0.03). While not statistically significant, increases were also noted in confidence in acceptance to medical school median 4 (p = 0.10), and mentor support median 5 (p = 0.06). Student comments were generally positive though experiences were limited by the COVID 19 pandemic, see table 2. Conclusion: This pilot program demonstrates feasibility of a longitudinal mentorship program for URM premedical students which was generally well-received by students and physicians. The pandemic was a limitation, with few opportunities for in-person activities, but we look forward to more robust programing this year.