Patients and doctors are frequently unsure as to what actually happens following a referral to the Pain Services.
It is important that the Pain Services are able to screen patients who will benefit from their interventions versus those who have little chance of a meaningful rehabilitation.
Since May 2013 Waitemata Pain Services have changed the way we manage our patients with persistent pain. The reasons are simple. Our team is small, the resources are limited and the referral rate is high. Even more importantly patients are waiting more than 6 months to even see us! The traditional model that has been used for many years is flawed and we needed to become more innovative. We based our changes on the following key areas;
- Patients should be assessed quickly after initial referral.
- Interventions should be started as soon as possible.
- Patient non attendance and non compliance should be minimised
- A closer relationship and shared care model should be developed with primary care
- Inappropriate long term follow up should be minimised
- A multidisciplinary model is followed.
- Medicalisation should be minimised.
- Web based education for patients and GPs along with education on persistent pain for health care providers and users should be introduced.
As such the following process is now the basis of our management plan. We are reviewing its success and benefits to patients and healthcare providers. We have just begun looking at patient outcomes using questionnaire tools and will soon be asking primary care to also provide feedback on the new process.
ENHANCED REHABILITATION AFTER PAIN PROGRAMME (ERAPP)
1. Patient is seen by GP or Specialist and after consideration of potential benefit a referral is sent to Waitemata Pain Services. This is via e-referral, letter or fax. Please remember not all patients are appropriate or will benefit from our services. We realise this is disappointing but what we are hoping to do is provide the best treatment for those with the best chance of improving.
2. Referral is reviewed by clinical triage team. At this time a specialist pain physician or nurse may call GP directly and offer advice on care to begin a management plan before review. In some cases the referral may be considered inappropriate and if this is the case we will communicate directly with your GP. A questionnaire is sent to you at this time. It is extremely important that this is returned. We cannot proceed with any further management until this is done. We do this because it indicates how much you are prepared to take part in your own rehabilitation.
If you cannot complete the forms due to issues with reading, understanding or language phone the pain services or get a friend to contact us on your behalf!
3. If the questionnaire is not returned we will discharge patient back to care of GP but in many cases we will also communicate with referring doctor about possible community and primary care treatment options.
4. When the questionnaire is returned you are invited to take part in a introductory workshop at NSH. This enables our team to highlight the management options to you. Importantly it gives you the opportunity to see how you pain is going to be managed and understand the key role that you play in your own rehabilitation. The multidisciplinary nature of our service is emphasised. After this session you are invited to contact the Waitemata Pain Services and confirm your ongoing commitment to the management programme. It may be that the programme is not for you, or that you don't see any benefit in what we do and that's alright as well. After all its your decision.
Some patients may be directly screened to an intervention without coming to workshop (e.g. extremes of age, specific medical issues)
5. A second questionnaire is sent out. Again this is essential to be returned as it allows us to stream patients into appropriate intervention groups. This provides some important but different information from the first one.
6. You are then invited to attend the following clinics. This is based on the referral letter, results of screening questionnaires as well as a review of your hospital notes. In many cases we will combine several interventions.
7. Management Interventions
a. Medical review- medication optimisation, assessment for nerve blocks or invasive intervention to optimise pain management. This is based at NSH.
b. Psychology review- this may be one on one or via a workshop setting. The one on one sessions are at NSH and Waitakere. Whilst the workshops are held at Waitakere. The workshops consist of 8 two hour sessions held weekly.
c. Physiotherapy review- this will be one on one. This is based at NSH and a patient specific programme will be created and reviewed.
d. Nurse led interventions- this may be medication reviews working with you and your GP/ practice nurse, workshops for sleep hygiene, and other lifestyle interventions.
e. Research. In some cases we may ask patients to participate in research focussed at improving outcomes for patients with persistent pain.
f. Referral to other centre. At times we may refer some of our patients to Auckland Hospital if we feel they would benefit from their 3 week Pain Management Programme or have an invasive intervention such as a spinal cord stimulator inserted.
8. Discharge. When you have completed your interventions we will discharge you back to your GP. Our focus is maintaining close communication ties with our GP colleagues. We are now running weekly virtual clinics on Friday mornings when GPs can call our service directly and get advice form either a Specialist Pain Physician or Pain Nurse Specialist.
9. Re-referral. Due to pressure on our service, if you have already undertaken a management intervention, it is unlikely an benefit would be gained repeating the whole process.
However we do encourage GPs to contact the Pain Services directly and we can provide additional advice and support on how you can move forward.