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Ann Longterm Care. Author manuscript; available in PMC 2015 May 04. Published in final edited form as: Ann Longterm Care. 2015 February ; 23(2): 29–35.
Pain Management in Long-Term Care Communities: A Quality Improvement Initiative M C Reid, MD, PhD1,2, Kevin W. O’Neil, MD, FACP3, JaNeen Dancy, PharmD4, Carolyn A. Berry, PhD5, and Stephanie A. Stowell, MPhil4
Author Manuscript
1Joan
and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, NY
2New
York Presbyterian Hospital, New York, NY
3Brookdale 4Med-IQ 5Center
Senior Living, Brentwood, TN
LLC, Baltimore, MD
for Health Care Strategies, New York University Langone School of Medicine, New York,
NY
Abstract
Author Manuscript
Pain is underrecognized and undertreated in the long-term care (LTC) setting. To improve the management of pain for LTC residents, the authors implemented a quality improvement (QI) initiative at one LTC facility. They conducted a needs assessment to identify areas for improvement and designed a 2-hour educational workshop for facility staff and local clinicians. Participants were asked to complete a survey before and after the workshop, which showed significant improvement in their knowledge of pain management and confidence in their ability to recognize and manage residents’ pain. To measure the effectiveness of the QI initiative, the authors performed a chart review at baseline and at 3 and 8 months after the workshop and evaluated relevant indicators of adequate pain assessment and management. The post-workshop chart reviews showed significant improvement in how consistently employees documented pain characteristics (ie, location, intensity, duration) in resident charts and in their use of targeted pain assessments for residents with cognitive dysfunction. The proportion of charts that included a documented plan for pain assessment was high at baseline and remained stable throughout the study. Overall, the findings suggest a QI initiative is an effective way to improve pain care practices in the LTC setting.
Author Manuscript
Keywords Pain management; quality improvement An estimated 45% to 80% of older adults in long-term care (LTC) facilities experience significant chronic pain.1 Despite standards from the Joint Commission and other
Address correspondence to: Cary Reid, MD, PhD, Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, 525 East 68th Street, #39, New York, NY 10065. Disclosures: The other authors report no relevant financial relationships.
Reid et al.
Page 2
Author Manuscript
organizations that emphasize the right of patients to receive “appropriate assessment and management of pain,” pain in LTC residents is underrecognized and undertreated.2–6 Poorly managed pain negatively affects physical and mental health and impairs the overall quality of life in this vulnerable population.1,6–10 In addition, the consequences of untreated or undertreated pain further burden healthcare resources.1 The high prevalence of disability, dementia, comorbidities, and general communication difficulties among nursing home residents complicate efforts to assess and manage pain effectively. AMDA–The Society for Post-Acute and Long Term Care Medicine has developed clinical practice guidelines that seek to address barriers to optimal pain management in the LTC setting.11,12 However, systemic barriers such as drug costs, formulary restrictions, staffing challenges, and the lack of care coordination among health professionals make it difficult to apply the guidelines consistently.13
Author Manuscript
Studies show quality improvement (QI) initiatives can be effective tools for promoting adherence to treatment guidelines and other evidence-based practices. Boyle and colleagues13 conducted a series of continuing medical education (CME) workshops on diabetes care for clinical staff at two LTC facilities and subsequently observed significant improvement in various measures of resident health, including glycemic control. A welldesigned QI program begins with a systematic evaluation of processes at every level to identify steps that may contribute to performance gaps or inconsistencies in care. The team then develops and implements a strategy for improving existing processes and establishes a mechanism to test the real and anticipated effects of changes to the system.14,15
Author Manuscript
To investigate barriers to optimal pain management in LTC and help facilities implement strategies for overcoming these barriers, members of an accredited CME provider collaborated with representatives from a national consortium of LTC communities to design, implement, and evaluate a CME QI initiative for pain management. Our goal was to improve the ability of caregivers to recognize, assess, and manage pain in elderly patients according to evidence-based guidelines. We used various mechanisms to measure changes in caregiver confidence and performance after the educational opportunities.
Methods
Author Manuscript
Med-IQ, LLC, a company that provides continuing education opportunities for physicians, nurses, and pharmacists and is accredited by the Accreditation Council for Continuing Medical Education, coordinated a four-phase QI initiative to improve pain management for residents at Broadway Plaza at Cityview in Forth Worth, TX. Broadway Plaza provides independent living, assisted living, or skilled nursing care for seniors and is part of a nationwide network of LTC communities owned and operated by Brookdale Senior Living. Because this was a QI initiative and all data collected for workshop participants and residents were de-identified, we did not seek approval from an Institutional Review Board, however, the study’s objectives were communicated to all workshop participants.16
Ann Longterm Care. Author manuscript; available in PMC 2015 May 04.
Reid et al.
Page 3
Author Manuscript
Development and Implementation The study was conducted from April 2012 through March 2013. During phase 1 (needs assessment), we conducted focus group interviews among facility staff members and a retrospective review of resident charts selected at random to obtain qualitative and quantitative information about the facility’s pain management practices. The baseline information was evaluated and used to develop an educational intervention with specific learning objectives (Table 1). The workshops were open to all facility employees and to healthcare professionals from the surrounding community, some of whom also worked with residents at Broadway Plaza at Cityview.
Author Manuscript
During phase 2 (educational intervention), participants attended one of three identical 120minute live continuing education/CME–certified workshops. Prior to the workshop, they were required to complete a survey about pain management, consisting of two confidence questions and four knowledge questions. The confidence questions used a four-part Likert scale with answer choices being “not at all confident,” “somewhat confident,” “moderately confident,” and “extremely confident.” The knowledge questions were multiple choice and had only one correct response. The same survey was administered again immediately after the workshop. Phase 3 (evaluation) consisted of two steps. To measure the effectiveness of the educational intervention at meeting the learning objectives, we compared baseline responses to the survey with post-intervention responses. We also conducted chart reviews at 3 months and 8 months after the workshop to assess for changes in quality performance measures for pain management.17–19
Author Manuscript
In phase 4 (reinforcement), we sought to maximize the effect of the QI initiative by disseminating a 1.5-credit CME-certified publication emphasizing key lessons of the initiative. Findings from the evaluation stage were used to tailor the CME publication, which was distributed 6 months after the end of the last workshop.
Data Analysis For the survey data, the participant served as the unit of analysis. Chi-square and t-tests were used to compare responses to the pre-workshop survey versus the immediate post-workshop survey for the 68 participants who completed both questionnaires.
Author Manuscript
For the chart review, the resident chart served as the primary unit of analysis. To assess the short-term effects of the intervention, baseline charts were compared with charts 3 months after training. To assess long-term effects, we compared baseline charts with charts 8 months after training. For each chart review period, we used the single most recent pain assessment record to measure changes in pain assessment practices; and we used documentation of pain management strategies and interventions for up to 3 months’ prior to chart abstraction to measure changes in how resident pain was handled. Because the charts we assessed at each time point belonged to different individuals, analyses are based on unlinked chart review data. We compared categorical data using nonparametric tests (eg, chi-square tests). For outcomes measured using continuous scales, we calculated means and compared them with
Ann Longterm Care. Author manuscript; available in PMC 2015 May 04.
Reid et al.
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Author Manuscript
independent t-tests. We considered a result statistically significant if the probability value was less than 0.05.
Results
Author Manuscript
During the study period, 111 staff members at Broadway Plaza were eligible to attend the workshops. A total of 89 individuals participated in the QI initiative: 34 nurses, 23 certified nursing assistants, 11 pharmacists, 9 administrators, 6 physicians, 3 nurse practitioners, and 3 certified medical assistants. When the study was conducted, the facility had approximately 88 residents. Overall, we reviewed charts for 142 unique residents: 45 charts at baseline, 47 at 3 months’ post-intervention, and 50 at 8 months’ postintervention. The mean age of the residents was similar at each assessment (mean range, 84–87 years), and most residents were women (range, 69%–79%). The mean length of stay significantly varied from baseline to 3 months (128 days vs 311 days, respectively; P=.031) and from baseline to 8 months (128 days vs 419 days, respectively; P=.002).
Survey Findings
Author Manuscript
Approximately three-quarters of workshop participants (76%) completed both the pretest and posttest surveys. Survey responses showed significantly more participants were confident they could differentiate between nociceptive and neuropathic pain among LTC residents and identify barriers to providing residents with optimal pain management immediately after the intervention (Table 2). The percentage of participants with no confidence in their ability to differentiate between nociceptive and neuropathic pain was 16% before the workshops and dropped to 3% after the workshops (P
Ann Longterm Care. Author manuscript; available in PMC 2015 May 04. Published in final edited form as: Ann Longterm Care. 2015 February ; 23(2): 29–35.
Pain Management in Long-Term Care Communities: A Quality Improvement Initiative M C Reid, MD, PhD1,2, Kevin W. O’Neil, MD, FACP3, JaNeen Dancy, PharmD4, Carolyn A. Berry, PhD5, and Stephanie A. Stowell, MPhil4
Author Manuscript
1Joan
and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, NY
2New
York Presbyterian Hospital, New York, NY
3Brookdale 4Med-IQ 5Center
Senior Living, Brentwood, TN
LLC, Baltimore, MD
for Health Care Strategies, New York University Langone School of Medicine, New York,
NY
Abstract
Author Manuscript
Pain is underrecognized and undertreated in the long-term care (LTC) setting. To improve the management of pain for LTC residents, the authors implemented a quality improvement (QI) initiative at one LTC facility. They conducted a needs assessment to identify areas for improvement and designed a 2-hour educational workshop for facility staff and local clinicians. Participants were asked to complete a survey before and after the workshop, which showed significant improvement in their knowledge of pain management and confidence in their ability to recognize and manage residents’ pain. To measure the effectiveness of the QI initiative, the authors performed a chart review at baseline and at 3 and 8 months after the workshop and evaluated relevant indicators of adequate pain assessment and management. The post-workshop chart reviews showed significant improvement in how consistently employees documented pain characteristics (ie, location, intensity, duration) in resident charts and in their use of targeted pain assessments for residents with cognitive dysfunction. The proportion of charts that included a documented plan for pain assessment was high at baseline and remained stable throughout the study. Overall, the findings suggest a QI initiative is an effective way to improve pain care practices in the LTC setting.
Author Manuscript
Keywords Pain management; quality improvement An estimated 45% to 80% of older adults in long-term care (LTC) facilities experience significant chronic pain.1 Despite standards from the Joint Commission and other
Address correspondence to: Cary Reid, MD, PhD, Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, 525 East 68th Street, #39, New York, NY 10065. Disclosures: The other authors report no relevant financial relationships.
Reid et al.
Page 2
Author Manuscript
organizations that emphasize the right of patients to receive “appropriate assessment and management of pain,” pain in LTC residents is underrecognized and undertreated.2–6 Poorly managed pain negatively affects physical and mental health and impairs the overall quality of life in this vulnerable population.1,6–10 In addition, the consequences of untreated or undertreated pain further burden healthcare resources.1 The high prevalence of disability, dementia, comorbidities, and general communication difficulties among nursing home residents complicate efforts to assess and manage pain effectively. AMDA–The Society for Post-Acute and Long Term Care Medicine has developed clinical practice guidelines that seek to address barriers to optimal pain management in the LTC setting.11,12 However, systemic barriers such as drug costs, formulary restrictions, staffing challenges, and the lack of care coordination among health professionals make it difficult to apply the guidelines consistently.13
Author Manuscript
Studies show quality improvement (QI) initiatives can be effective tools for promoting adherence to treatment guidelines and other evidence-based practices. Boyle and colleagues13 conducted a series of continuing medical education (CME) workshops on diabetes care for clinical staff at two LTC facilities and subsequently observed significant improvement in various measures of resident health, including glycemic control. A welldesigned QI program begins with a systematic evaluation of processes at every level to identify steps that may contribute to performance gaps or inconsistencies in care. The team then develops and implements a strategy for improving existing processes and establishes a mechanism to test the real and anticipated effects of changes to the system.14,15
Author Manuscript
To investigate barriers to optimal pain management in LTC and help facilities implement strategies for overcoming these barriers, members of an accredited CME provider collaborated with representatives from a national consortium of LTC communities to design, implement, and evaluate a CME QI initiative for pain management. Our goal was to improve the ability of caregivers to recognize, assess, and manage pain in elderly patients according to evidence-based guidelines. We used various mechanisms to measure changes in caregiver confidence and performance after the educational opportunities.
Methods
Author Manuscript
Med-IQ, LLC, a company that provides continuing education opportunities for physicians, nurses, and pharmacists and is accredited by the Accreditation Council for Continuing Medical Education, coordinated a four-phase QI initiative to improve pain management for residents at Broadway Plaza at Cityview in Forth Worth, TX. Broadway Plaza provides independent living, assisted living, or skilled nursing care for seniors and is part of a nationwide network of LTC communities owned and operated by Brookdale Senior Living. Because this was a QI initiative and all data collected for workshop participants and residents were de-identified, we did not seek approval from an Institutional Review Board, however, the study’s objectives were communicated to all workshop participants.16
Ann Longterm Care. Author manuscript; available in PMC 2015 May 04.
Reid et al.
Page 3
Author Manuscript
Development and Implementation The study was conducted from April 2012 through March 2013. During phase 1 (needs assessment), we conducted focus group interviews among facility staff members and a retrospective review of resident charts selected at random to obtain qualitative and quantitative information about the facility’s pain management practices. The baseline information was evaluated and used to develop an educational intervention with specific learning objectives (Table 1). The workshops were open to all facility employees and to healthcare professionals from the surrounding community, some of whom also worked with residents at Broadway Plaza at Cityview.
Author Manuscript
During phase 2 (educational intervention), participants attended one of three identical 120minute live continuing education/CME–certified workshops. Prior to the workshop, they were required to complete a survey about pain management, consisting of two confidence questions and four knowledge questions. The confidence questions used a four-part Likert scale with answer choices being “not at all confident,” “somewhat confident,” “moderately confident,” and “extremely confident.” The knowledge questions were multiple choice and had only one correct response. The same survey was administered again immediately after the workshop. Phase 3 (evaluation) consisted of two steps. To measure the effectiveness of the educational intervention at meeting the learning objectives, we compared baseline responses to the survey with post-intervention responses. We also conducted chart reviews at 3 months and 8 months after the workshop to assess for changes in quality performance measures for pain management.17–19
Author Manuscript
In phase 4 (reinforcement), we sought to maximize the effect of the QI initiative by disseminating a 1.5-credit CME-certified publication emphasizing key lessons of the initiative. Findings from the evaluation stage were used to tailor the CME publication, which was distributed 6 months after the end of the last workshop.
Data Analysis For the survey data, the participant served as the unit of analysis. Chi-square and t-tests were used to compare responses to the pre-workshop survey versus the immediate post-workshop survey for the 68 participants who completed both questionnaires.
Author Manuscript
For the chart review, the resident chart served as the primary unit of analysis. To assess the short-term effects of the intervention, baseline charts were compared with charts 3 months after training. To assess long-term effects, we compared baseline charts with charts 8 months after training. For each chart review period, we used the single most recent pain assessment record to measure changes in pain assessment practices; and we used documentation of pain management strategies and interventions for up to 3 months’ prior to chart abstraction to measure changes in how resident pain was handled. Because the charts we assessed at each time point belonged to different individuals, analyses are based on unlinked chart review data. We compared categorical data using nonparametric tests (eg, chi-square tests). For outcomes measured using continuous scales, we calculated means and compared them with
Ann Longterm Care. Author manuscript; available in PMC 2015 May 04.
Reid et al.
Page 4
Author Manuscript
independent t-tests. We considered a result statistically significant if the probability value was less than 0.05.
Results
Author Manuscript
During the study period, 111 staff members at Broadway Plaza were eligible to attend the workshops. A total of 89 individuals participated in the QI initiative: 34 nurses, 23 certified nursing assistants, 11 pharmacists, 9 administrators, 6 physicians, 3 nurse practitioners, and 3 certified medical assistants. When the study was conducted, the facility had approximately 88 residents. Overall, we reviewed charts for 142 unique residents: 45 charts at baseline, 47 at 3 months’ post-intervention, and 50 at 8 months’ postintervention. The mean age of the residents was similar at each assessment (mean range, 84–87 years), and most residents were women (range, 69%–79%). The mean length of stay significantly varied from baseline to 3 months (128 days vs 311 days, respectively; P=.031) and from baseline to 8 months (128 days vs 419 days, respectively; P=.002).
Survey Findings
Author Manuscript
Approximately three-quarters of workshop participants (76%) completed both the pretest and posttest surveys. Survey responses showed significantly more participants were confident they could differentiate between nociceptive and neuropathic pain among LTC residents and identify barriers to providing residents with optimal pain management immediately after the intervention (Table 2). The percentage of participants with no confidence in their ability to differentiate between nociceptive and neuropathic pain was 16% before the workshops and dropped to 3% after the workshops (P
