drusso

Moderator Emeritus
Lifetime Donor
20+ Year Member
Nov 21, 1998
8,358
3,096
Over the rainbow
Status
Attending Physician
I would say "ditto" for addiction but both service lines are difficult to scale:


Clinical Pain Medicine

AUGUST 18, 2016


Importance of Integration of Psychology Into Pain Practices




By Joe H. Browder, MD


A growing body of evidence shows that an interdisciplinary approach to the treatment of chronic painful conditions is most beneficial to patients. A combination of medications coupled with psychological services, functional therapies and procedural approaches provides the best outcomes for patients. A full history and physical examination, including previous treatments, determines which of these approaches is appropriate for the patient. A diagnosis supported by clinical testing is essential.

This commentary focuses on the integration of psychological services into an interdisciplinary practice. Having a psychologist on-site in the clinical setting is by far the most effective mode of integrating psychology into a practice. This allows for easy communication and consultation concerning patients. The very presence of a psychologist as a colleague is a constant reminder of the need for inclusion of psychological services into any treatment plan. This also provides for crisis intervention, should it arise.

The most commonly employed method of having on-site psychological services is for the psychologist to be an employee of the practice. At Pain Consultants of East Tennessee, we have created a fairly unique situation in which the psychologist is an independent contractor who leases a small office, and is integrated into the scheduling and medical records of the practice. This arrangement allows the chronic pain practice to focus on its areas of expertise without worrying about the intricacies of billing, the capital expense of a salary or management of the psychologist.

The two psychologists we have are in the practice full time. Very few psychologists have formal training in chronic pain management. Those who do have training usually are familiar with cognitive-behavioral therapy but have little experience with other pain psychology issues, such as opioid risk assessment, addiction and medication abuse. Thus, establishing a process for on-the-job training is key. While formal training is helpful, the most important ingredient for a successful team is for the psychologist to be willing to learn and to have a strong team focus. The important caveat in having a psychologist with a background in addiction is that pain treatment is not a branch of addictionology. The vast majority of pain patients are not addicted.

The Role of Psychology

Psychological services are important in helping with medication compliance, attendance of functional therapies and completion of interventional procedures. Also essential are meetings of core members of the team, not necessarily to discuss patients but to go over the process of integration of all aspects of the practice. In our practice, psychological services include a formal psychological assessment, group education classes and short-term (four to six) individual sessions, either for crisis intervention or for specific personal or family issues. All of these psychological services include an evidence-based risk assessment for opioid and psychological comorbidities that could affect the overall treatment of the painful condition. Quick risk screens such as the Opioid Risk Tool exist, but many of these are essentially worthless in clinical practice.

Optimal is an hour- or 45-minute-long assessment by a psychologist using written tools, such as the Brief Risk Interview and mental health screening tools. A much less comprehensive, but still valid, risk tool that can be administered by a medical assistant is the Brief Risk Questionnaire (BRQ) consisting of 12 items, and can provide an accurate assessment of risk for opioid misuse. The BRQ is more helpful because it covers a wider array of psychological variables relating to risk than traditional risk tools. Psychological assessment should include opioid risk assessment, assessment of catastrophizing, depression, sleep, kinesiophobia, readiness for change and anxiety. The psychologist also assesses the need for referral to a psychiatrist for medication management for suboptimally treated bipolar disease, major depression, anxiety or other psychological comorbidities.

Our psychologist-led classes include an opioid medication class during which the risks, benefits and details of medication agreements are discussed. Also included in this discussion are expectations about pain management treatment and the need for increased function as opposed to simply a decrease in pain. This session helps patients have appropriate expectations for medications and overall pain treatment. We also offer a psychological skills class in which the five essential skills for coping with chronic pain are taught through one brief intervention session. These skills are understanding, accepting, calming, balancing and coping. Individual sessions to treat a patient’s specific problems, such as grief, anger or cognitive-behavioral therapy, are utilized. However, these individual sessions are limited by the reality of reimbursement and time management. Integrated psychological services offer key assessment, education and brief intervention services that are often lacking in single-modality pain services.

Single-disciplinary approaches, such as medication management or procedural blocks alone, are simply not effective in treating the vast majority of chronic painful conditions. Our interdisciplinary approach has been successful for over 15 years. As it has evolved, we have found that utilizing medication management, functional rehabilitation therapies, procedural interventions and psychological treatments is not only effective but cost-effective in a nonacademic outpatient setting. As our lead psychologist Ted Jones, MD, has said, “Psychological aspects are always involved in treating chronic pain, whether or not you have a psychologist available or not.” We have found that having integrated psychological services on-site is a very effective way for outpatient pain programs to offer high-quality, multidisciplinary treatment without financial loss.


Joe H. Browder, MD, is senior partner at Pain Consultants of East Tennessee (PCET), in Knoxville. He has practiced pain medicine since the early 1990s, and founded PCET in 1998. He is triple board certified in pain medicine (as a diplomate of the American Board of Anesthesiology with Added Qualifications in Pain Medicine, a diplomate and fellow of the American Board of Pain Medicine, and a diplomate of the American Board of Interventional Pain Physicians). He also is a Fellow of Interventional Pain Practice from the World Institute of Pain. PCET is an American Pain Society Clinical Center of Excellence in Pain Management and can be found online at www.painconsultants.com.
 

NJPAIN

7+ Year Member
Nov 28, 2011
1,722
711
New Jersey
Status
Attending Physician
Behavioral medicine is truly essential. However, payers don't want to hear that and certainly don't want to pay for that; especially worker's comp. If you mention the "P" word they will quickly send the patient elsewhere. It seems that the only way this service gets provided is if your practice is large enough and busy enough to support it as a necessary service you provide and often don't get paid for. Where I am, in solo practice, I can't find anybody qualified who is willing to see pain patients because of reimbursement issues.
 
  • Like
Reactions: jonnylingo

algosdoc

algosdoc
10+ Year Member
May 3, 2005
4,063
1,926
Florida
Status
Attending Physician
Doesnt work financially to integrate. What the TN practice is not integration...it is an independent contractor that rents space. There is no guarantee the psych will be given any referrals or that they will show up or will pay for services ...
 
OP
drusso

drusso

Moderator Emeritus
Lifetime Donor
20+ Year Member
Nov 21, 1998
8,358
3,096
Over the rainbow
Status
Attending Physician
Doesnt work financially to integrate. What the TN practice is not integration...it is an independent contractor that rents space. There is no guarantee the psych will be given any referrals or that they will show up or will pay for services ...
We employ both a mental health therapist and an addiction counselor. We have almost 5 years of experience with the model. Negotiating contracts for behavioral health within a private medical practice is very difficult. Addiction counseling services not covered---essentially they are "dependent" practitioners. In my state, Medicaid is a "closed shop" and all those patients must be seen in community mental health centers. That's fine.

Yet, *EVERYONE* insists that IPM should be addressing mental health. In our business, the whole service line runs in the red. Where's my subsidy/bail out?

Anyone else have practical experience scaling sustainable mental health services? Many people seem to "talk the talk," but I see very few executing.
 

Disciple

Senior Member
10+ Year Member
Oct 18, 2004
2,516
318
Status
Attending Physician
Look at our healthcare reform. The whole thing is "talk the talk".

I don't think any bail out coming. Not for us anyway.

Are you thinking about scrapping the model, phasing it out?
 

Ducttape

SDN Lifetime Donor
Lifetime Donor
7+ Year Member
Oct 7, 2011
8,451
2,115
Status
Attending Physician
No. I've been working for years to try to make it viable. As it stands, caid patients get referred to hospital behavioral health, which is less than adequate.

Private insurers will pay for psych, but the local psych providers, while good, have to cherry pick themselves because they are too overworked. Most focus on what pays best - SCS eval. There are a few lucky few patients, tho...

I've tried to "hire" 3 separate psychologists to "work" in the office, as private contractors, but HOPD rent here is approximately equivalent to Manhattan, believe it or not.

I've considered hiring psych NP, but have been discouraged from this model.

So I slog away trying to do some of this CBT myself, with no success...


Sent from my iPhone using SDN mobile
 
  • Like
Reactions: NJPAIN

NJPAIN

7+ Year Member
Nov 28, 2011
1,722
711
New Jersey
Status
Attending Physician
In my mind it is like treating mental illness with pharmacotherapy and excluding the behavioral component of treatment.


Sent from my iPhone using SDN mobile app
 

Disciple

Senior Member
10+ Year Member
Oct 18, 2004
2,516
318
Status
Attending Physician
Some of the large health systems have established, or are establishing these psyche inclusive FRP type programs.

Like health insurance carriers in respect to the exchanges, what happens when hospitals/health systems start losing interest in ACOs, etc.

Will the progressives ever come clean with the public?

"From our point of view, none of these treatments work, so we're not going to provide any. However, you do have the right to get your Norco, up to 80 MED, and argue with a doctor (or PA if one is not available) every 2-4 weeks, so long as that keeps you happy and providing good patient satisfaction scores."

My feeling is that when they finally admit the truth, they will push seriously for universal healthcare.
 

Extralong

7+ Year Member
Oct 17, 2011
324
89
I sleep with the fishes
Status
Resident [Any Field], Attending Physician
No. I've been working for years to try to make it viable. As it stands, caid patients get referred to hospital behavioral health, which is less than adequate.

Private insurers will pay for psych, but the local psych providers, while good, have to cherry pick themselves because they are too overworked. Most focus on what pays best - SCS eval. There are a few lucky few patients, tho...

I've tried to "hire" 3 separate psychologists to "work" in the office, as private contractors, but HOPD rent here is approximately equivalent to Manhattan, believe it or not.

I've considered hiring psych NP, but have been discouraged from this model.

So I slog away trying to do some of this CBT myself, with no success...


Sent from my iPhone using SDN mobile

Have you tried integrating a psychiatrist into your pain model? Not sure how big your practice is, but if you can hire another physician and are on the fence, consider a psychiatrist. Figure out a a system, as it would be super easy to refer straight to them. Also, they would have some idea as to referral for psychological evals if necessary.
 

Ducttape

SDN Lifetime Donor
Lifetime Donor
7+ Year Member
Oct 7, 2011
8,451
2,115
Status
Attending Physician
Most psychiatrists in the community are interested in med management model, not the psychological...

Unfortunately fee for service is more cost effective. That's what it's all about, apparently...



Sent from my iPhone using SDN mobile
 

SeniorWrangler

7+ Year Member
Nov 9, 2010
913
525
Status
Attending Physician
There are a few big obstacles to integration:
1) poor payment and lack of mental health benefits for lots of publically insured patients
2) poor compliance with mental health referrals -- the no-show rates for pain psychologists working in pain clinics is very high, even when they're co-located and the pain docs are very supportive and encouraging.
3) Some of the patients who do show up have very extensive psychiatric issues which go well beyond what you can handle in a pain clinic setting but it's hard to refer them out (see #1)

Some of my primary care colleagues have gotten good results with having an MSW counselor seeing patients and working through "Managing Chronic Pain: A Cognitive Behavioral Therapy Approach", by Dr. John Otis (2007), which is a really excellent book. They can't bill for as much but they also don't cost as much to employ and are resourceful at getting patients hooked up with other sources of help.
 
  • Like
Reactions: drusso