Pain Medicine 2015; 16: 1844–1848 Wiley Periodicals, Inc.
LETTERS TO THE EDITOR An Integrated Pain Clinic Model Dear Editor, We were interested to read the paper by Sletten et al. [1] reporting the economic benefits of a multidisciplinary outpatient pain rehabilitation program. Here, we describe an integrated pain clinic model which shares a similar treatment paradigm and which has functioned successfully for almost 30 years.
Today, the unit has more than 20 full-time positions, divided between 30 specialist staff and has been renamed the Center for Pain Management and Palliative Care. Trainee anesthesiologists have a 12-week rotation in the unit and there is a 16-week residency for final year psychology students. The unit has three clinical teams (Figure 1): 1. Outpatient Clinic for Chronic Noncancer Pain The outpatient clinic receives 600 referrals per year from primary care physicians in Western Norway. All referrals are reviewed by the team comprising pain physicians, clinical psychologists, and physiotherapists. On referral, the patient is usually assigned to a brief interview to determine whether the clinic can offer an appropriate course of action. Prior to this the patient completes a comprehensive pain questionnaire. This, in addition to hospital records and the referral documents, ensure that the therapist has sufficient information to conduct the interview. On the basis of the interview, the patient is offered a specific pathway within the clinic, for example, a multidisciplinary evaluation, or evaluation followed by outpatient group therapy. Multidisciplinary evaluation comprises four consultations, each lasting 60–90 minutes. All therapists (physician, physiotherapist, and psychologist) are 1844
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Haukeland University Hospital in Bergen has 880 somatic ward beds and is the regional hospital for Western Norway which has a population of 1,080,000 people. In 2014, there were 406,292 outpatient visits, and a total of 27,403 surgeries were performed. The multidisciplinary Pain Clinic was established as Norway’s first in 1985, having five full-time positions (anesthesiologist, psychologist, physiotherapist, nurse and secretary). The clinic was funded by the Norwegian Cancer Society, and from 1987 was organized within the Department of Anesthesiology. Initial focus was on cancer patients having pain and/or other distressing symptoms such as nausea, dyspnea, and insomnia. Services were soon expanded to include an outpatient clinic for chronic noncancer pain, and from the beginning of the 1990s, a service for patients with refractory acute pain.
present at the fourth and final consultation, where the patient receives results of the evaluation and treatment options are discussed. A detailed treatment plan is subsequently sent to the patient’s primary care physician. The majority of treatments are available in primary care. Patients unlikely to benefit from attending the clinic are provided with an alternative. Those least likely to benefit have problems of alcohol addiction/drug abuse and/or serious psychiatric illness, or are sceptical to the biopsychosocial pain model and lack motivation. As an alternative to direct evaluation, the primary care physician is invited to discuss the patient’s pain problem in a specialist meeting (Pain Group). The Pain Group comprises a neurologist, a psychiatrist, members of the pain clinic team, and if necessary, an addiction specialist. Other relevant medical specialists or therapists involved in regular treatment of the patient may also participate. If the primary care physician has difficulty attending, the meeting is conducted by telephone. The objective of the meeting is to decide whether the patient’s pain condition is adequately assessed, and to discuss an appropriate treatment plan and follow-up. 2. Acute Pain Team The acute pain team comprises anesthesiologists and acute pain nurses, but has assistance from a psychologist and/or physiotherapist from the outpatient clinic as needed. The team has a close collaboration with the Department for Addiction Medicine. The team works within the hospital and receives approximately 500 referrals per year, usually postsurgical patients with refractory pain, for example chronic pain patients with acute postoperative pain, or surgical patients with problems of addiction. The team also receives referrals from other departments such as Neurology, Orthopedic Rehabilitation, and Pediatrics. If the referral concerns a chronic pain problem the acute pain team offers advice to the ward physician, but does not directly evaluate the patient. Instead, the primary care physician is advised in the discharge document to refer the patient to the outpatient clinic. In our experience chronic pain is best handled in an outpatient setting, rather than a hospital ward. The acute pain team and the chronic pain team meet regularly to discuss current patients and to coordinate treatment plans. 3. Palliative Care Team The palliative care team is the largest in Norway and comprises specialist physicians (anesthesiology/ intensive care, oncology, internal medicine and pulmonary medicine), psychologists, physiotherapist, specialist nurses, social worker, and hospital priest.
Letters to the Editor
This team works primarily within the hospital but in addition provides support to ward staff by facilitating patient transfer from hospital to homecare or nursing home. The team receives more than 600 referrals per year from all hospital wards having patients in need of advanced palliative care, including the Department of Pediatrics. The Importance of an Integrated Model Pain clinic organization differs widely. Typically, there are separate services for chronic pain, acute pain, and palliative care. This organizational model integrating the three teams enables the staff to become proficient in all areas of difficult pain whether it be acute, palliative care-related or chronic, noncancer pain. It also provides a unique continuity of service for the patient who may be cared for by the same staff, despite different treatment settings. A palliative care patient requiring surgery can receive tailor-made perioperative pain treatment, as can a chronic pain patient requiring surgery, or a palliative-care patient with a history of chronic pain and/or addiction. The model encourages flexibility, with staff having the competency and ability to move between teams should
there be a temporary staff reduction, and enables more effective use of personnel resources. We believe this pain clinic model to be robust and costeffective, providing high-quality coordinated service to the patient with problematic pain. We would be interested to hear whether colleagues in other countries have similar models and experience. RAE FRANCES BELL, MD, PhD Centre for Pain Management and Palliative Care/ Regional Centre of Excellence in Palliative Care, Haukeland University Hospital, Bergen, Norway email: [email protected] Reference 1 Sletten CD, Kurklinsky S, Chinburapa V, Ghazi S Economic analysis of a comprehensive pain rehabilitation program: a collaboration between florida blue and mayo clinic Florida. Pain Med 2015 Feb 3. doi: 10.1111/pme.12679. (Epub ahead of print)
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Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Figure 1 Organization and patient flow. GP: General Practitioner (primary care physician); phys: physician. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
LETTERS TO THE EDITOR An Integrated Pain Clinic Model Dear Editor, We were interested to read the paper by Sletten et al. [1] reporting the economic benefits of a multidisciplinary outpatient pain rehabilitation program. Here, we describe an integrated pain clinic model which shares a similar treatment paradigm and which has functioned successfully for almost 30 years.
Today, the unit has more than 20 full-time positions, divided between 30 specialist staff and has been renamed the Center for Pain Management and Palliative Care. Trainee anesthesiologists have a 12-week rotation in the unit and there is a 16-week residency for final year psychology students. The unit has three clinical teams (Figure 1): 1. Outpatient Clinic for Chronic Noncancer Pain The outpatient clinic receives 600 referrals per year from primary care physicians in Western Norway. All referrals are reviewed by the team comprising pain physicians, clinical psychologists, and physiotherapists. On referral, the patient is usually assigned to a brief interview to determine whether the clinic can offer an appropriate course of action. Prior to this the patient completes a comprehensive pain questionnaire. This, in addition to hospital records and the referral documents, ensure that the therapist has sufficient information to conduct the interview. On the basis of the interview, the patient is offered a specific pathway within the clinic, for example, a multidisciplinary evaluation, or evaluation followed by outpatient group therapy. Multidisciplinary evaluation comprises four consultations, each lasting 60–90 minutes. All therapists (physician, physiotherapist, and psychologist) are 1844
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Haukeland University Hospital in Bergen has 880 somatic ward beds and is the regional hospital for Western Norway which has a population of 1,080,000 people. In 2014, there were 406,292 outpatient visits, and a total of 27,403 surgeries were performed. The multidisciplinary Pain Clinic was established as Norway’s first in 1985, having five full-time positions (anesthesiologist, psychologist, physiotherapist, nurse and secretary). The clinic was funded by the Norwegian Cancer Society, and from 1987 was organized within the Department of Anesthesiology. Initial focus was on cancer patients having pain and/or other distressing symptoms such as nausea, dyspnea, and insomnia. Services were soon expanded to include an outpatient clinic for chronic noncancer pain, and from the beginning of the 1990s, a service for patients with refractory acute pain.
present at the fourth and final consultation, where the patient receives results of the evaluation and treatment options are discussed. A detailed treatment plan is subsequently sent to the patient’s primary care physician. The majority of treatments are available in primary care. Patients unlikely to benefit from attending the clinic are provided with an alternative. Those least likely to benefit have problems of alcohol addiction/drug abuse and/or serious psychiatric illness, or are sceptical to the biopsychosocial pain model and lack motivation. As an alternative to direct evaluation, the primary care physician is invited to discuss the patient’s pain problem in a specialist meeting (Pain Group). The Pain Group comprises a neurologist, a psychiatrist, members of the pain clinic team, and if necessary, an addiction specialist. Other relevant medical specialists or therapists involved in regular treatment of the patient may also participate. If the primary care physician has difficulty attending, the meeting is conducted by telephone. The objective of the meeting is to decide whether the patient’s pain condition is adequately assessed, and to discuss an appropriate treatment plan and follow-up. 2. Acute Pain Team The acute pain team comprises anesthesiologists and acute pain nurses, but has assistance from a psychologist and/or physiotherapist from the outpatient clinic as needed. The team has a close collaboration with the Department for Addiction Medicine. The team works within the hospital and receives approximately 500 referrals per year, usually postsurgical patients with refractory pain, for example chronic pain patients with acute postoperative pain, or surgical patients with problems of addiction. The team also receives referrals from other departments such as Neurology, Orthopedic Rehabilitation, and Pediatrics. If the referral concerns a chronic pain problem the acute pain team offers advice to the ward physician, but does not directly evaluate the patient. Instead, the primary care physician is advised in the discharge document to refer the patient to the outpatient clinic. In our experience chronic pain is best handled in an outpatient setting, rather than a hospital ward. The acute pain team and the chronic pain team meet regularly to discuss current patients and to coordinate treatment plans. 3. Palliative Care Team The palliative care team is the largest in Norway and comprises specialist physicians (anesthesiology/ intensive care, oncology, internal medicine and pulmonary medicine), psychologists, physiotherapist, specialist nurses, social worker, and hospital priest.
Letters to the Editor
This team works primarily within the hospital but in addition provides support to ward staff by facilitating patient transfer from hospital to homecare or nursing home. The team receives more than 600 referrals per year from all hospital wards having patients in need of advanced palliative care, including the Department of Pediatrics. The Importance of an Integrated Model Pain clinic organization differs widely. Typically, there are separate services for chronic pain, acute pain, and palliative care. This organizational model integrating the three teams enables the staff to become proficient in all areas of difficult pain whether it be acute, palliative care-related or chronic, noncancer pain. It also provides a unique continuity of service for the patient who may be cared for by the same staff, despite different treatment settings. A palliative care patient requiring surgery can receive tailor-made perioperative pain treatment, as can a chronic pain patient requiring surgery, or a palliative-care patient with a history of chronic pain and/or addiction. The model encourages flexibility, with staff having the competency and ability to move between teams should
there be a temporary staff reduction, and enables more effective use of personnel resources. We believe this pain clinic model to be robust and costeffective, providing high-quality coordinated service to the patient with problematic pain. We would be interested to hear whether colleagues in other countries have similar models and experience. RAE FRANCES BELL, MD, PhD Centre for Pain Management and Palliative Care/ Regional Centre of Excellence in Palliative Care, Haukeland University Hospital, Bergen, Norway email: [email protected] Reference 1 Sletten CD, Kurklinsky S, Chinburapa V, Ghazi S Economic analysis of a comprehensive pain rehabilitation program: a collaboration between florida blue and mayo clinic Florida. Pain Med 2015 Feb 3. doi: 10.1111/pme.12679. (Epub ahead of print)
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Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Figure 1 Organization and patient flow. GP: General Practitioner (primary care physician); phys: physician. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
