Editor's Note: Kaiser Permanente, the nation's largest integrated healthcare system, has initiated a Pain Service in the Sacramento, California area. The service coordinates the evaluation and treatment of members with chronic pain. Roger Johnson, PhD MBA, one of the program developers, offers this overview.

There's an elephant stomping through the middle of most healthcare systems and its name is chronic pain. Pain is the most prevalent reason people seek medical care. Yet, like the proverbial blind men who each touch and describe different parts of the elephant, many healthcare providers attempt to diagnose and treat chronic pain without an effective, integrated perspective. As a result, and despite good intentions, care is often fragmented, duplicated, or neglected. Clearly, a different perspective is needed to address the elephant for what it is.

We believe that three key shifts in perspective are needed for patients with chronic pain to effectively self-manage their condition:

1.         accepting diagnosis of chronic pain;

2.         understanding the mind/body connection with regard to pain symptomatology; and

3.         changing to an active orientation regarding self-management.

Unfortunately, chronic pain patients are often asked to make changes for which they are not ready. The Pain Service is designed to use the Transtheoretical Model of Change Stages to inform treatment recommendations. In this model, patients are assessed as to their readiness to change to a self-management coping style, according to the following stages:

• Precontemplation-no intention to change behavior in the foreseeable future

• Contemplation-developing awareness of the need for change

• Preparation-planning to take action within the next 30 days

• Action-steps taken to modify some behavior, experience or environment

• Maintenance-consistently engaging in new healthful behaviors

Using this model, care coordinators target stage-specific interventions to help move participants through earlier change stages so that they are prepared to take action steps when these are introduced. Sustained interventions are needed with chronic pain patients who may be inclined to look for relief through medical procedures and need to be regularly reoriented towards implementing self-care strategies.

Patient receives referral from physician to be evaluated by the Pain Service.

Care coordinators conduct a medical chart review as well as monitor care to ensure that all necessary steps of the treatment plan are taken with each patient.

 Assessment includes identifying the psychosocial factors that contribute to an individual's pain experience and that may inform motivational strategies for treatment. In addition, reviewing assessment results with patients clarifies for them differences between acute and chronic pain as well as the impact of chronic pain on their life and the rationale for recommended treatment. This clarity then provides the basis for added motivation for patients to move through the stages of change. Assessment instruments include:

•   Battery for Health Improvement (BHI™)

•   Survey of Pain Attitudes (SOPA)

•   Pain Stages of Change Questionnaire (PSOCQ)

•   SF36®

•   Pain Management Self-Efficacy Questionnaire (PMSEQ)

Additional medical or other procedures may be recommended to help diagnose, reduce, or eliminate pain.

Feedback to patients and referring providers includes a summary of evaluation results, treatment recommendations and alternatives, and suggestions for further treatment collaboration.

Evaluation results are explored with members so as to mutually refine an understanding of their "pain dynamics", especially how mind and body are interacting to produce the person's pain experience. Care coordinators help members determine the most suitable treatment options based on degree of impairment, practical considerations, and current motivation of the patient.

Members participate in ongoing programs of the Pain Service with the understanding that the intent of the program is not to eliminate pain but to enable them to become more functional and manage pain more effectively. They are guided and tracked through a spectrum of services in order to optimize functional outcomes and encourage cost-effective utilization of services.

Exit criteria focus on the member's willingness and ability to attain the goals of the care plan. Members are provided necessary treatment to increase self-management skills and reduce pain to a level where they are no longer seeking medical treatment for it. We intend to provide ongoing "booster" interventions as well as to monitor health care utilization.

Outcomes will be evaluated through patient, provider, and program-focused measures that help assess the clinical and programmatic effectiveness of the Pain Service.

In conclusion, Johnson's Law states, "The more essential a life skill, the less likely one will have received training in it!" For members whose daily functioning is impaired by chronic pain, self management skills are often the missing essential components for successful adaptation. Providing a thorough assessment is a necessary beginning for empowering people in acquiring these essential skills.

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