Health Policy: Rural Health Agenda S.2408

keywords and phrases:  rural health care, funding/grants, federal funding, health policy, access to healthcare providers, Medicare, National Health Service Corps (NHSC), telemedicine, loan repayment models, social determinants of health (SDOH)

Outline

• The 2019 Rural Health Agenda
• Rural American Health Corps Act
• Rural Health Innovation Act
• Telemedicine Across State Lines Act
• Why these are important bills to track as healthcare practitioners
• Supporting publications for acupuncturists to be included as a distinct profession in these acts
• Rural Health Program Resources--general info
• Rural Health Program Resources--current grant applications are open from the HRSA Office of Rural Health Policy!!

The Hospital Practice Handbook Project

2019 Rural Health Agenda—One to Watch

Senator Marsha Blackburn (TN) began championing the Rural Health Agenda in August 2019. The Rural Health Agenda’s goal is to address health care delivery challenges in the rural United States of America to maintain quality care "close to home".

The rural Health Agenda includes 3 bills:

1. The bipartisan Rural America Health Corps Act, cosponsored by Senators Dick Durbin (D-Ill), Kevin Cramer (R-N.D.), Doug Jones (D-Ala) and Lisa Murkowski (R-Alaska).
2. The Rural Health Innovation Act is co-sponsored by Senator Murkowski.
3. The Telemedicine Across State Lines Act is cosponsored by Senator Cramer.

If you work or want to work in a rural area, contact your representative to get Licensed Acupuncturists (LAcs) added to the list of qualifying health care professionals. Get help from your state association on how to write a letter to your representatives.

Rural American Health Corps Act

Quote:

“This bipartisan bill, led by Senators Blackburn and Durbin, and cosponsored by Cramer, Jones, and Murkowski would enhance the National Health Service Corps (NHSC) to include a Rural America Healthcare Corps to incentivize academic medical centers and health care graduates to rotate through underserved communities, and a range of sites would qualify for the program. “The Rural America Health Corps Act…creates a new loan repayment program titled ‘NHSC Rural Provider Loan Repayment Program.’ Includes a range of providers such as nurse practitioners and physician assistants. Ensures practitioners would be eligible for loan repayment on a sliding scale, based on the severity of the shortage in that area. Waives any associated income tax liability for the loan repayment program.  Other than these provisions, the program would follow the same rules as the current NHSC program.” -Blackburn Unveils Rural Health Agenda

Rural Health Innovation Act

“This bill, co-sponsored by Senator Murkowski, incentivizes communities to leverage their existing resources to provide for the community’s urgent care needs. It would incentivize the establishment of robust Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) staffed with physician interns and residents, physician assistants, nurse practitioners, nurse midwives, and other advance-practice nurses. These facilities would have the equipment needed to triage and stabilize patients in an emergency, including a lab, X-ray machine, cardiac monitors, and more. These centers would serve the walk-in urgent care needs for a rural community and serves as a triage center and staging facility for necessary air or ambulance transports to area emergency departments.”   “This bill would also create a collaborative federal, state and local pilot program to expand rural health departments to meet urgent care needs, including a full range of necessary equipment, so these robust health departments can serve the walk-in urgent care needs of rural communities and serve as a triage center and staging facility for air or ambulance transports to area emergency departments.” -Blackburn Unveils Rural Health Agenda

Telemedicine Across State Lines Act

This bill “instructs the Secretary of Health and Human Services (HHS) to initiate a rulemaking to create federal telemedicine program best practices: the Secretary should consult with a range of stakeholders, including technology experts, primary care providers, specialists, academic medical centers, emergency medicine providers, federal agencies with expertise in this area, and more. The Secretary must report on the progress of the rulemaking to the Congressional committees of jurisdiction. [This bill] creates a grant program to incentivize the expansion of effective telemedicine programs to reach rural communities.” -Blackburn Unveils Rural Health Agenda

Sources for above information: 

• “Blackburn Unveils Rural Health Agenda” and “Blackburn Eyes National Telehealth Programs in Rural Health Strategy” 
• Sponsor of all 3 bills that make the “Rural Health Agenda” is Senator Marsha Blackburn (TN)
• The bill is S.2408.
• The “bill tracker” for this you can watch at this link.

Why do I want to see Licensed Acupuncturists (LAcs) included as providers in the Rural Health Corps Act, the National Health Service Corps, and the Rural Health Innovation Act?

• LAcs can help with the “opioid epidemic” by providing non-drug pain management treatment in community clinics and emergency departments (ED) as part of the healthcare team.
• makes available more access to non-drug pain management (opioid crisis)
• LAcs are well-trained in the health and wellness paradigm. They support positive health behaviors and manage chronic pain conditions through both treatment and teaching patients self-care, which may include acupressure, movement, breathing techniques, support healthful eating and positive healthy lifestyle behaviors
• Besides serving the rural and underserved communities this is an option for student loan repayment. Graduate school programs for master’s and doctorate degrees in our field are long and expensive.

The Bureau of Labor and Statistics (BLS) unique Standard Occupational Code (SOC) for our profession is 29-1291 Acupuncturist.

Some supporting published research and standards of care guidelines on acupuncture for pain management and wellness

• McPherson, F et al (2016) Health Perception and Wellness Behavior Survey among Military Beneficiaries. Ann Psychiatry Ment Health 4(2): 1060. 
• Acupuncture and Opioids
• The White Paper: Acupuncture's Role in Solving the Opioid Epidemic
• Fan AY, Miller DW, Bolash B, Bauer M, Faggert S., He H, Li YM, Matecki A, Camardell L, Koppelman MH, Stone J, McDonald J, Meade L, Pang J. Acupuncture's Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management--White Paper 2017. J Integr Med. 2017; 15(6): 411-425. https://doi.org/10.1016/S2095-4964(17)60378-9

• Acupuncture in ED reference information
• Interview with Dr. John Burns about his ED acupuncture feasibility study research paper and work.
• Burns JR, Kram JJ, Xiong V, Stark Casadont JM, Mullen TA, Conway N, Baumgardner DJ. Utilization of acupuncture services in the emergency department setting: a quality improvement study. J Patient Cent Res Rev. 2019; 6:172-8. 10.17294/2330-0698.1688
• https://digitalrepository.aurorahealthcare.org/jpcrr/vol6/iss2/5/
• Adam S. Reinstein, Lauren O. Erickson, Kristen H. Griffin, Rachael L. Rivard, Christopher E. Kapsner, Michael D. Finch, Jeffery A. Dusek; Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study, Pain Medicine, volume 18, issue 1, 1 January 2017, pages 169-178, https://doi.org/10.1093/pm/pnv114
• Acupuncture, general evidence-based publications
• “Overview of Treatment Guidelines and Clinical Practice Guidelines that Recommend the Use of Acupuncture: A Bibliometric Analysis”. The Journal of Alternative and Complementary Medicine. Vol.24(8). 6.18.2018. published online ahead of print. http://doi.org/10.1089/acm.2018.0092
• “Acupuncture: An Overview of the Scientific Evidence” from Evidence-based Acupuncture is available at their website.
• “Acupuncture Evidence-based Summary: Pain” by Evidence-Based Acupuncture
• The Acupuncture Evidence Project –A Comparative Literature Review 2017. Follow the link for a pdf download option. 
• Acupuncturists are an integral part of the VA Whole Health Programs
• What is the Whole Health program at the VA?
• I recommend watching this presentation of Dr. Tracy Gaudet’s work with this field-forwarding initiative to learn more. Dr. Gaudet’s lecture here is the NIH’s Stephen E. Strauss Distinguished Lecture, given November 29^th, 2018, “Transforming Veteran’s Health Care: The Whole Health System”.
• 3-minute YouTube video of Wayne Jonas, MD, Samueli Institute
• on shifting U.S. culture of health to one of community health, wellness, and prevention over disease-care-only as part of this idea of "on human flourishing".  It is a complex problem from health culture to socio-economic disparities. 

Rural Health Program Resources

• To learn more about issues in rural health, check out the National Rural Health Association and their annual conference. 
• The National Rural Health Resource Center
• The American Hospital Association (AHA) and their Rural Advocacy Agenda
• Health Resources and Services Administration (HRSA)’s Rural Health Program includes program funding and grants  HRSA is a branch of the U.S. federal Health and Human Services (HHS).
• The Rural Health Information Hub (a clearinghouse for information on rural health supported by the HRSA)  and their YouTube channel 

For those of you already working in rural communities…

There are funding opportunities, including grants from the HRSA Rural Health Program. These are currently open for applications! 

Source: HRSA Rural Health Funding Opportunities. 

The “Rural Health Network Development” has the following funding opportunities open:

• HRSA-20-025 | Office of Rural Health Policy
• Application Accepted: 08/14/2019 to 11/25/2019
• Projected Award Date: 07/01/2020
• The “Rural Health Network Development Plan”
• HRSA-20-026 | Office of Rural Health Policy
• Application Accepted: 07/23/2019 to 11/29/2019
• Projected Award Date: 07/01/2020

The ECHO Model--Hub and Spokes

Want to see a very successful telemedicine program set up with “hubs” of experts and “spokes” reaching providers in rural and/or underserved communities? 

• Check out the University of New Mexico’s ECHO model. When I worked at the Madigan Interdisciplinary Pain Management Clinic, I participated as a hub expert in my discipline (TCM, acupuncture) as part of my team’s field (interdisciplinary pain management, functional rehabilitation, and return-to-work care model).
• YouTube video (one minute): https://youtu.be/VAMaHP-tEwk 

More Blogposts Related to Health Policy

• The Fall Health Policy News Roundup
• Summer Health Policy News
• The CHRONIC Care Act
• Congressional Integrative Health and Wellness Caucus
• Moving Beyond Medications, the Infographic
• The VA Whole Health Program
• 37 Attorney Generals Push Incentives for Non-Pharm Pain Management Therapies
• The White Paper: Acupuncture's Role in Solving the Opioid Epidemic

More on Federal Occupational Codes: BLS and VA Staffing Codes published in 2018

• BLS SOC is 29-1291 Acupuncturist
• Acupuncturists are an integral part of the VA Whole Health Programs

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Acupuncturists Working in the Emergency Department at the Aurora Health System of Wisconsin: A Success Story

key phrases:  interview, acupuncture programs, acupuncture for acute pain, acupuncture in the ER, examples of incorporating acupuncture into healthcare systems and hospitals

Who:  John Burns, DPT, MSOM, Manager of Acupuncture at Aurora Health Care, Milwaukee, Wisconsin

Organization:  Advocate Aurora Health Care

Location:  Milwaukee, Wisconsin and surrounding suburbs

What:  Providing services in 11 oncology clinics, 7 OP clinics, 1 ED, 2 IP

website:  www.aurorahealthcare.org/services/integrative-medicine/acupuncture

Dr. Burns with his poster at the AIHM conference. #AIHM18
photo credit Megan Gale

Quick Outline

1. Introduction
2. The Study
3. The Program
4. References

Introduction

Wouldn’t it be great, as a patient, to have access in your local emergency room (ER) to non-pharm therapy option for relief of your strong pain, nausea, or GI symptoms, especially if you have adverse reactions to some medications?  Wouldn’t it be useful, as a provider in the Emergency Department (ED), if you had the ability to refer to a non-pharm therapy within your ED to help ease common ED presenting symptoms of pain, anxiety, stress, and nausea?

I met John Burns, DPT, MSOM, at the Academy of Integrative Health and Medicine (AIHM) conference #AIHM18 in San Diego in September where he was presenting his ED work at Advocate Aurora Health Care of Milwaukee, Wisconsin, in a poster session.  His study looked at the practicality of offering acupuncture services in the ED of a Wisconsin hospital. And, with enthusiasm, I watched him receive first place in the poster session for his team’s work!

Background

Dr. Burns has a doctorate degree in physical therapy and a master of science degree in oriental medicine from Midwest College of Oriental Medicine, Racine, Wisconsin.  For the past 4 years Dr. Burns has been the manager of the acupuncture services program at Aurora Health Care, Sinai Hospital.  During a lunch break at the AIHM conference, I interviewed Dr. Burns about his ED study from the poster, and about the Aurora Acupuncture program.

Part 2:  The Study

More about the AIHM Research Poster Submission

Site of the study presented in the poster:  Emergency Department, Aurora West Allis Medical Center, West Allis, WI. 

What was Dr. Burns’ inspiration for the project? 

With a smile, Dr. Burns notes it was the research study on acupuncture into the ED setting of the Allina Health system of Minnesota by Adam Reinstein and Jeff Dusek that inspired him. The Allina ED study was published in 2017 in the peer-reviewed scientific journal, Pain Medicine[1].

Poster Title

“Utilization of Acupuncture Services in the Emergency Department Setting:  A Quality Improvement Study” by John Burns, DPT, MSOM, Jessica J.F. Kram, MPH, Vashir Xiong, MSOM, Jeanne Stark Casadont, MSOM, Tiffany Mullen DO, Nancy Conway, MS, Dennis Baumgardner, MD

 

Dr. John Burns awarded first place of the
 AIHM 2018 posters.
photo credit Megan Gale

Background and Reason for this ED Pilot

Patients often present to the emergency department (ED) for pain.  Acupuncture may decrease acute pain experienced by patients seeking ED services.  Acupuncture is an evidence-based, non-pharmacologic option for pain relief and pain management[2].

Goal of the Pilot

Dr. Burns notes: “the major purpose was to determine acceptability of acupuncture in the ED as either adjunctive or optional care for patients.”  The study was the first to assess the impact of acupuncture in the ED for pain management in the Aurora Health system.  The researchers wanted to determine acceptability of the acupuncture program by the patients and the ED staff.  This was a quality improvement study.

Methods

This was a retrospective observational study of patients in the Emergency Department. 

Patients admitted to the ED were offered acupuncture treatment for their acute pain condition based on their:

·         Emergency severity index (ESI)[3]

·         Reason for visit

·         Their physician’s approval

What Electronic Health Record (EHR) program do you use?

Aurora uses EPIC for documentation.  Dr. Burns worked with IT staff to create a specific data field in the EHR to track outcomes from the acupuncturists’ progress notes. 

Measurements/Metrics Used in ED study

In the ED study, they tracked patient-reported outcomes.  The top 3 measures were:  pain, stress, and anxiety.  The symptoms were measured on the numeric rating scale (NRS), of 0-10 for each.

Striking aspects to note about the study

The demographics of the patients treated represented the demographics of the local ED.

When patients were treated by the ED acupuncturist, they received only acupuncture.  For example, some patients had less than 8 needles per acupuncturist’s discretion, and some did not retain the needles past 20 minutes due to other services needed (such as x-rays).

What are important points/take-aways from this study?

• Acupuncture reduced acute pain.  In the study, patients who received acupuncture reported 50% pain relief (average)
• Acupuncture reduced symptoms of nausea by about 60%
• Acupuncture in the ED setting is feasible

Where is the Emergency Department (ED) research published?

Dr. Burns’ paper was published April 29th, 2019, in the peer-reviewed scientific journal, Journal of Patient-Centered Research and Reviews (JPCRR).  See reference section below for citations and links.

Review of Clinical Program Implications for this Study

Availability of acupuncture services in the ER increases ease of access to non-pharm pain relief. And, for someone admitted to the hospital, having acupuncture as an option in the ER and the inpatient unit may decrease the complexity of their medication panel.  It may reduce the medication panel complexity because it reduces the common symptoms of nausea, stress, anxiety, and pain without medication (non-pharm therapy).

Considerations for future studies

Dr. Burns noted: “This [study] was only a pilot program to determine if acupuncture would be accepted by ED patients and staff.  This was not a controlled study or a study that followed patients over a period to determine changes in their behavior.” 

He says, “Next plan is to repeat the study with a different demographic and provide free follow-up care.”

• Reproduce the ED project in Milwaukee, WI, in next year with different patient demographics
• Track whether availability of acupuncture in the ED reduces opioid prescriptions
• Follow up with patients who receive acupuncture in the ED at an outpatient clinic.  No follow up with the patients was performed for this pilot program due to study limitations.  They found that "following discharge from the ED, less than 2% received acupuncture services within 30 days."  Assumptions about why this may be:  patient choice, lack of reimbursement, even though outpatient services were available at the West Allis site.

Part 3: Acupuncture in the Aurora System

The acupuncture program at Advocate Aurora began in 2002 with one acupuncturist.  The program now employees 11 acupuncturists, full-time and part-time, who provide care in 11 oncology clinics, 7 outpatient clinics, 2 inpatient units, and one emergency department. Acupuncturists in the program are employees of Aurora.

The acupuncture program is part of Aurora’s Department of Integrative Medicine (IM).  The IM department employs practitioners who provide the following services:  massage therapy, chiropractic care, acupuncture, aromatherapy, and mind-body exercise.  The mind-body exercise therapy program is at Aurora’s psychiatric hospital.

Program Funding and Sustainability

How do they sustain the program?

Program is sustained through philanthropic funding and cash-based service.

Outpatient acupuncture services are cash-based except for the ED study program.  The ED program is sponsored by Aurora at no charge to the patients.  The oncology clinic acupuncture program is supported through both philanthropic funding and cash-based services.

How is program success or failure measured?

The Aurora IM programs are measured with the new model of care: value-based metrics, particularly outcome-based measures.  Program success is not measured solely by RVUs or patient load.

More about what Dr. John Burns does and where he works

Dr. Burns teaches Tai Chi and Qi Gong to patients in the mental health clinic and psychiatric hospital.  This clinical care has been well-received by patients and by staff who have seen patients’ positive response to it.  Dr. Burns also does in-service presentations to the following provider types: acupuncturists, physical therapists, nurses, occupational therapists, and physicians.

Dr. Burns’ Vision for the Aurora Acupuncture program:

Dr. Burns believes acupuncture, as an integrative health paradigm, has a “patient empowering philosophy”.  His hopes to see acupuncture available in all services lines, but especially incorporated into the following services:  neurology, palliative care, and the back and spine group.  He feels the integrative medicine program will benefit when acupuncture services are covered by the following insurances:  Medicare, Medicaid, and the Aurora employee health benefits system.  He would like to bring acupuncture into the mental health clinic as part of the substance abuse treatment program. 

On being a manager of an integrative health program:

Dr. Burns has been in a management position for 4 years.  He wants his LAcs maintain work-life balance.  He understands that clinician resilience and program sustainability are inter-related.  So, he makes this a priority in his role as program manager.

What learning opportunities are available to integrative health students and practitioners interested in hospital-based practice?

Shadowing opportunities are available in his program.  The integrative health courses that teach self-care may be soon be open to the public.

Part 4: References

Contact information for Dr. Burns and the Aurora Acupuncture Program

• email:  john.burns@aurora.org
• program website: https://www.aurorahealthcare.org/services/integrative-medicine/acupuncture

Links to related publications on the Aurora ED Study

• April 2019 updates
• research was published April 29th, 2019 in the Journal of Patient-Centered Research and Reviews (JPCRR), “Utilization of acupuncture services in the emergency department setting: a quality improvement study”
• citation is: 
• Burns JR, Kram JJ, Xiong V, Stark Casadont JM, Mullen TA, Conway N, Baumgardner DJ. Utilization of acupuncture services in the emergency department setting: a quality improvement study. J Patient Cent Res Rev. 2019; 6:172-8. 10.17294/2330-0698.1688
• April 9, 2019, Medscape article.
• “Needles Help with Pain in the ER. No, Not that Kind. (Acupuncture tied to less pain, stress, anxiety)” by Judy George
• Video from Wisconsin TV station, Fox6Now. 
• October 10^th, 2018.  “’It’s great to have alternative’:  Aurora West Allis offering acupuncture in the emergency room” by LeeAnn Watson and Mary Stoker Smith
• Medscape article
• “Acupuncture in the ED Cuts Pain, Reduces Stress, Anxiety” by Pauline Anderson.  Nov. 12^th, 2018.  

References

• Tick H, Nielsen A, Pelletier KR, et al.  Evidence-Based Nonpharmacological Strategies for Comprehensive Pain Care. The Consortium Pain Task Force White Paper.  2018. DOI:  https://doi.org/10.1016/j.explore.2018.02.001. 
• Adam S. Reinstein, Lauren O. Erickson, Kristen H. Griffin, Rachael L. Rivard, Christopher E. Kapsner, Michael D. Finch, Jeffery A. Dusek; Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study, Pain Medicine, Volume 18, Issue 1, 1 January 2017, Pages 169–178, https://doi.org/10.1093/pm/pnv114 

Related Blogposts

• The Directory of Hospital-based Learning Opportunities for Acupuncturists or the website version of this directory
• Consortium Pain Task Force White Paper and the Moving Beyond Medications infographic

Videos highlighting the Aurora integrative medicine program

• Interview with Aurora acupuncturist Steven Mui on the tai chi offered in their healthcare system.  
• spring 2019, the Aurora integrative health in oncology program

Tags:  #AIHM #AIHM18 #EDacupuncture

Advocate Aurora's Oncology Acupuncture and Integrative Therapies Program (update Oct 2020)

• New* in Sept 2020, published in JACM, with information on Advocate Aurora's (Wisconsin) oncology acupuncture and massage therapy programs. "A Quality Brief of an Oncological Multisite Massage and Acupuncture Therapy Program to Improve Cancer-Related Outcomes" by Jennifer Fink, John Burns, Ana Christina Perez Moreno, Jessica J.F. Kram, Melissa Armstrong, Sara Chopp, Scott J. Maul, and Nancy Conway. The Journal of Alternative and Complementary Medicine (JACM), Sept 2020. 822-826. https://doi.org/10.1089/acm.2019.0371.
• More on the topic of oncology acupuncture programs and defining "success" at this post.

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[1] Adam S. Reinstein, Lauren O. Erickson, Kristen H. Griffin, Rachael L. Rivard, Christopher E. Kapsner, Michael D. Finch, Jeffery A. Dusek; Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study, Pain Medicine, Volume 18, Issue 1, 1 January 2017, Pages 169–178, https://doi.org/10.1093/pm/pnv114

https://academic.oup.com/painmedicine/article/18/1/169/2924684 

[2] The Consortium’s Pain Task Force White Paper. 

Tick H, Nielsen A, Pelletier KR, et al.  Evidence-Based Nonpharmacological Strategies for Comprehensive Pain Care.  The Consortium Pain Task Force White Paper.  2018.

[3] Emergency Severity Index (ESI) is a triage algorithm that measures urgency of case on a scale of 1 to 5. “1” indicates the highest degree of urgency and “5” is the lowest degree, developed by Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services (HHS). https://www.ahrq.gov/professionals/systems/hospital/esi/index.html

Congressional Integrative Health and Wellness Caucus

key words: advocacy, integrative health, opioid crisis, non-pharm options in healthcare, patient-centered care models, Congressional Integrative Health and Wellness Caucus 

When our politicians learn more about the integrative health and wellness movement as part of mainstream U.S. healthcare from recognized experts, they can make better informed decisions when voting on health-care related legislation.

What
Invite your U.S. House Representative to the March 15th, 2018, D.C. luncheon, Congressional Integrative Health and Wellness Caucus to learn more about Integrative Health during lunch.

How

Call or Email to your U.S. House (federal) representative, with a link to this invite. 

Not sure who your U.S. House representative is?  Use this look-up tool.

Sample Script 

Here is a sample script for your email: 

Share a brief personal reason why this issue is important to you (constituent/voter).

"Hello, I am ___(name)__ and my zip code is ___.
As your constituent, I urge you to attend the Congressional Integrative Health and Wellness Caucus on Thursday, March 15th.
  

Event details are here:  https://www.eventbrite.com/e/amidst-opioid-crisis-new-caucus-will-focus-on-integrative-health-solutions-registration-42686697060  

This is an introductory educational briefing with lunch. 

Health care and access to integrative health as part of my health care team is important to me and my family.  I hope you are able to attend this briefing or meet with one or several of the speakers."

If it is after March 15th, you can still contact your representative and connect them to some of the resources that were available at the luncheon.  Here are the published contact details:

What is the Integrative Health and Wellness Caucus?

The Integrative Health and Wellness Caucus is a bipartisan Congressional effort.

Published Schedule and Speaker Panel for the 2-hour luncheon, March 15th, 2018:

Background
What is the Integrative Health Policy Consortium (IHPC)?

It is a national policy and advocacy voice of integrative health and wellness healthcare professionals.  It represents 24 health professional organizations and 600,000+ healthcare providers.

Resources
New Congressional Caucus on Integrative Health and Wellness Formed

Moving Beyond Medications, the Infographic

keywords:  pain management, integrative health, communicating with primary care providers, communication with biomedical providers, provider communication, non-pharm pain management, non-drug pain management, the opioid crisis, integrative health as part of the integrative pain management models of care

topics:  pain management, communication with biomedical providers, opioid crisis

I have recommended this infographic in previous blogposts on the subject of pain management and the opioid crisis.

Moving Beyond Medications is a useful one-page infographic for primary care providers looking for a quick reference point for referrals for non-pharm pain management.

"Non-Pharmacological Approaches to Pain Management and Well-Being:
 In response to the current public health crisis of opioid abuse, overdose, and death, many organizations have issued guidelines and recommendations for treating pain, including the former Surgeon General’s “Turn the Tide” campaign. Similar to other guidelines, this campaign recommends non-pharmacological approaches as first line pain treatment, with opioids to be considered only if these and non-opioid pharmacological treatments are ineffective. This document expands upon those recommendations to help primary care clinicians and their patients with this approach."

This infographic, available for free, was created through a collaboration of several national organizations:  The Academic Collaborative for Integrative Health (ACIH, the "Collaborative"), the Academic Consortium for Integrative Medicine and Health (the IM Consortium), the Academy of Integrative Health and Medicine (AIHM), and the Integrative Health Policy Consortium (IHPC).

The Consortium Pain Task Force published a related white paper, Evidence-based Nonpharmacologic Strategies for Pain Care.  Free copies are available for download here.

Want to learn more on documenting clinical change in your patient-centered practice? 
Take our Metrics short courses.  The short courses are based on the popular metrics blogposts with downloadable pdfs, examples, and templates.

The metrics series blogposts: The Pain Scale and Medication Review:  Calculating Morphine Equivalent Dose (MEQ).

Related Blogposts

• More about research related to acupuncture and mu-opioid receptor
• The Field of Acupuncture Research in Just 10 Minutes, another video with Mel
• More about the Acupuncture in the Opioid Crisis, including resources on calculating morphine equivalent dosage (MED, MEQ), and review of systems with focus on side effects of opioid medications
• The Pain Scale, DVPRS, for your patient-centered care model
• The Opioid Epidemic, a Joint Pain Education Project video, within a blogpost filled with resources
• Research Review:  Key Studies to Understand when Discussing Pain Management with a Physician

If you have found this blogpost useful, please consider contributing via the website to help support this resource.  Thank you. 

Do you want to follow our work at the Hospital Handbook Project?  Just join the contact list on the website, subscribe to the blog, and like our Facebook page.

The Pain Scale in Your Chart Note, using a Validated Tool: Focus on the Defense and Veterans Pain Rating Scale (DVPRS)

November 2017

Keywords:  documentation standards, pain scale, validated measurement tools for clinical work, SOAP note, metrics, clinical outcome measures, tracking outcomes, measuring change, visual analog scale (VAS), Defense and Veterans Pain Rating Scale (DVPRS), pain management

Topics:  documentation standards, SOAP note, clinical care, metrics, using validated tools, the Pain Scale in clinical use

update April 2018:  This information is now available as a mini-course, How to Use a Validated Pain Scale in Your Chart Note, in our online school.  100% of proceeds from the course go toward the Hospital-practice Handbook Project.

What this is: A discussion about using the Pain Scale

1.       what Pain Scale we use in clinical practice

2.       how to use one that is a validated tool, and

3.       why it matters. 

Focus today is on the Defense and Veterans Pain Rating Scale (DVPRS)

What is a pain scale?

The pain scale is what we clinicians use when we say to a patient: “how do rate your pain, on a scale of 1-10, 10 being high?”

However, what is less commonly discussed, is that this scale is not arbitrary.  It is a scale that has been validated through research.

There are two main pain scales that are free for clinical use in the U.S. that have been validated: 

1.       The Visual Analog Scale (VAS) and

2.       The Defense and Veterans Pain Rating Scale (DVPRS)

What does it matter if a scale has been validated through research studies? 

When a tool is validated through research it means that it has been tested thoroughly and often.  Its results are repeatable and can be consistently used to measure change.

Why does that matter?

If you are using a tool in clinical practice, you need it to be consistent so that, when change occurs, you can measure that change.

For example, you measure a child’s growth with a height chart.  Four cm on a height chart is a consistent measurement.  Johnny and Maggie both had growth spurts in the past 6 weeks.  Using the height chart, you determine how much they changed height.  Maggie grew 4 cm in 6 weeks and Johnny grew less, just 2 cm in 6 weeks.

A validated tool ensures the accuracy of its use within one patient (Maggie 6 weeks ago vs. today) and accuracy of its use to measure change across the population (in the 6-week time Maggie is growing faster than Johnny).

When you (practitioner) use a subjective tool, like a Pain Scale, you must apply it in a consistent way.  This means:

• Ask the question the same way
• Explain it the same way to each patient

“Given the opioid crisis and [EAMP]’s ability to treat pain, we as a profession need to consistently document patient pain levels.  And, of course, this is what L&I as well as most health insurance plans will pay for!” --Lisa Taylor-Swanson, Advisor, WEAMA L&I Committee

Using a Pain Scale in Clinical Practice, the L&I Acupuncture Pilot Project

The Washington East Asian Medicine Association (WEAMA) L&I Committee (and myself, as a former member of the committee) strongly recommend practitioners in the WA State L&I Acupuncture Pilot to use the DVPRS as their pain scale.  

Why?

·        It is a validated tool.  It has been validated in the military and veteran population, which is a similar population to the “working age” population of civilians in the workers’ comp system

·         It is free to use

·         It’s user-friendly

·        On the back of the scale are some simple biopsychosocial measures of health that pain affects:  activity, mood, sleep, and stress

Does WA L&I Require me to do this? [updated July 2019]

No.  However, it is: 

• a biopsychosocial measure 
• a tool validated by research
• a patient-centered metric
• it helps you measure subjective functional change 
• and it fits well into L&I's "Healthy Worker 2020" goals. 

And using validated metrics as part of your clinical practice is just a usual part of professional practice standards. 

Why use this Pain Scale Tool?

• Patients are coming in with a symptom of "pain", you measure pain.
• Since you are already measuring it, use a validated tool.
• Using a validated tool in your chart note template makes it consistent for your use and measurement.
• When all practitioners in a program or clinic use the same tool and are using it in the same way, the tool becomes as consistent as that ruler when measuring change.
• So, if someday in the future, say 2-5 years from now, your clinic or program does a retrospective data pull, looking at metrics collected in your chart notes, the validated tools you and your colleagues used would be useful data points for measuring change. 

How do I use the DVPRS as my pain scale in clinical work?

See this 4-minute video overview of what the DVPRS pain scale is and how to use it.
When you ask your patient, “How is your pain today?”, have a copy of the DVPRS nearby.  You can have a copy of it on your computer or printed and laminated as a visual tool in your treatment room—whichever helps you in your quest to use it consistently with every patient and every treatment.

1. So, go here to print a copy of the DVPRS for yourself and your treatment space:  The DVPRS tool, both sides, with concise instructions  
• I like to print it in color on paper with the visual scale on one side and the biopsychosocial quick questions on the back side and then laminate the double-sided tool.
• If you want to print just one side at a time, without instructions, here is the front side and the back side.
2. When you ask, “how is your pain today?”, 
• hand the DVPRS visual tool to your patient to review and give you a descriptive answer.
• The back side, the 4 questions (activity, sleep, mood, and stress) are there to prompt the practitioner to ask how the pain affects those aspects of life.
  

Why use both DVPRS and MEQ as metrics when you treat a Chronic Pain Condition?  

Applicable settings:  private practice, return-to-work clinic models, pain management

Disability questionnaires (like the ODI) and chronic pain scales (like a GCPS) can be challenged [by researchers, policy-makers, program directors, program-funders] as influenced by patient perception or by practitioner bias.  Bias or perception can be mitigated, however, when you have another tool (DVPRS pain scale) that can be compared to them.

Example
For example, you have treated Ann who has mechanical low back pain with a course of acupuncture at 2 tx/week for 8 weeks and you measured, at specific points in treatment (initial, mid-tx re-evaluation, and discharge/re-evaluation), not just her pain level (DVPRS), but also her MEQ (during medication review), range of motion of the low back, and a functional questionnaire (ODI).  At the initial visit, her pain level was 8/10, MEQ was 70, ODI was 85% and she was not able to work due to the pain.  At the discharge visit, her pain level was 3/10 with no flare-ups for the past 2 weeks, MEQ is 0, ROM has improved 30%, and ODI is 20% and she will be starting work tomorrow.

This combination of metrics shows:

1. her pain decreased
2. her function has improved, and
3. she is no longer dependent on opioid-based medications for pain relief or basic function

Because of this combination, she is already going back to full-time work, the same type of work, the same job, and able to operate machinery again.

So, because you used this combination of metrics, you are able to demonstrate to both the referring provider (or program director, department head, etc) that your clinical work has been clinically significant (30% or greater change in numbers) and it has been cost-effective. This patient, who is returning to her same job with no restrictions and good functional recovery, now has no or minimal long-term disability risks.

Review:  Using this combination of metrics, DVPRS + MEQ, is essential to be able to measure-ably demonstrate your patient care is clinically significant and cost-effective.

copyright Megan Kingsley Gale

Do not reproduce without author's written permission

Thank you

Thank you to Dr. Fujio McPherson and Dr. Lisa Taylor-Swanson for their help and support on this article.

The Short Course on Using the Pain Scale for Practitioners
Want to learn more about how to use this Pain Scale as a metric in your clinic's patient outcome measures toolkit?  Take our new mini-course, "How to use a validated pain scale in your Chart note".  It contains this post as a download-able pdf, some simple templates you may use for recording this tool in your chart note, as well as videos that walk you through how to use it, and information to dive deeper into related resources.

100% of the proceeds from this course go towards supporting the Hospital-practice Handbook Project.  Take the course and build the project with us!

References

• A 4-minute video overview of what the DVPRS pain scale is and how to use it.
• An 8-minute video overview of the history behind the DVPRS and why to use it.
• The DVPRS tool to download or print, front side and backside, the biopsychosocial questions.  
• The DVPRS tool, both sides, with concise instructions
• Reference website for the DVPRS tool:  The Defense and Veterans Center for Integrative Pain Management  (DVCIPM)

Research, DVPRS validation study

Rosemary C. Polomano, Kevin T. Galloway, Michael L. Kent, Hisani Brandon-Edwards, Kyung “Nancy” Kwon, Carlos Morales, Chester ‘Trip’ Buckenmaier; Psychometric Testing of the Defense and Veterans Pain Rating Scale (DVPRS): A New Pain Scale for Military Population, Pain Medicine, Volume 17, Issue 8, 1 August 2016, Pages 1505–1519, https://doi.org/10.1093/pm/pnw105

Research paper citation on history and usefulness of the older pain scales:  Visual Analog Scale (VAS), Graphic Rating Scale (GRS), and Numeric Rating Scale (NRS)

Haefeli, M, and Elfering, A. (2006). Pain assessment.  European Spine Journal, 15 (Suppl 1), S17-S24.  http://doi.org/10.1007/s00586-005-1044-x

Related Blogposts

• Calculating Morphine Equivalent Dose (MEQ)
• Medication Review and Review of Symptoms:  Side Effects of Opioid Meds
• Joint Commission Pain Management Standard 2017 clarification
• The White Paper 2017:  Acupuncture's Role in Solving the Opioid Epidemic

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