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Case Management
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Institution
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Agency description
The selected department is U.S Department of Veterans Affairs (VA). Its mission is to fulfill the promise of President Lincoln, “caring for those who fight for us on the battle ground and their orphans” through serving and dignifying America’s veterans. Its vision revolves around the provision of excellent services and benefits to the veterans through sticking to the utmost levels of commitment, compassion, stewardship, accountability, integrity, excellence and professionalism. Their core values encapsulate integrity; practicing at the highest level of professionalism and maintenance of confidence and trust for veterans, commitment; fulfilling organization responsibilities and individual obligations, dignity; being veteran- centric and considering, identifying and advancing their interests appropriately.
The representative I interviewed was Mr. Richard Stone who currently serves as the Pain Manager in Veterans Health Administration (VHA). He has the full-fledge authority to perform duties and functions under Health Secretary in pain management department. The next section will represent the information attained from Dr. Richard about case management, its principles and goals, components and methods of service delivery. Case management will specifically encapsulate chronic pain management.
Principles and goals of pain management
Assessment of pain is usually done by using an objective scale having 0-10 measures where 0 means no pain and 10 means unimaginable pain. This scale only evaluates the severity of pain and is highly subjective in nature (Stuart & Stephen, 2000). The efficacy of therapeutic intervention cannot be reflected accurately through tracking client’s intensity of symptoms and application of interventions accordingly rather systematic goals of pain management must be applied based on client’s functional and behavioral aspects:
To manage client’s pain symptoms such that he reports 0-3 rating on the pain scale
To manage client’s pain symptoms such that he becomes enabled to execute his daily functioning properly
To manage client’s pain symptoms in such a way that he does not develop drug dependence in future
To manage client’s pain symptoms in such a way that he does not encounter relapse
To educate the client about do it yourself strategies of pain management
To educate client’s family about behaviors conductive to patient’s pain management
Components of pain management
Accessing and treating patient’s pain appropriately is the foremost ethical obligation of healthcare provider because pain is referred to as the fifth vital sign. Unfortunately, healthcare providers encounter various barriers while assessing and treating pain symptoms of patient. These barriers include disbelieving and disregarding patient beliefs about pain, underestimating pain severity reported by the patient, fear of causing addiction through over dosage of Opioids and their beliefs of drug seeking behaviors (Catherine, 2006). Following components of pain management help mitigate the above mentioned barriers (American Pain Society, 2007):
Asking the client about pain regularly
Client must be asked about the nature and severity of pain frequently because chronic pain might be intermittent, continuous or without sudden exacerbations. It might have various forms so it is important to keep a strict check on pain’s nature, intensity, frequency and duration.
Believing his reporting about pain severity
As mentioned above, pain might be severe or slight depending upon the biological, psychological and coping factors; which is purely subjective phenomenon. Client’s reporting about its severity should never be neglected for executing effective treatment and getting favorable ramifications.
Choosing appropriate pain management strategies
The biopsychosocial model of pain suggested that it is not entirely biological phenomenon rather psychological and social factors also play exceptional role in its determination (VHA, 2017). For example, client who is emotionally down might report sever pain symptoms as compared to what he reports during happy moods. Hence, all the aspects of pain must be taken under consideration before developing treatment plan.
Implementing interventions based at right time, place and condition
Again, it is important to develop and execute pain management plan based on all the potential etiology at the right time and condition. For example, medicine can be good option when assessment indicates biological cause behind pain, psychotherapy and social support can give effective results when underlying reasons include psychological and social factors (Chang et. al., 2015).
Four methods of pain management service delivery
Drug treatment
Opioids are commonly used for severe pain management when etiology lies in the biological roots. Aspirin, naproxen and ibuprofen are also used for pain management (Park & Moon, 2010). However, Opioids are highly addictive drugs and their over dosage may develop drug dependence and prescription drug abuse.
Exercise
Exercise regulates the movement of muscles and consumption of glucose due to which more and more oxygen reaches body for oxidative chemical reactions and activates our body organs to a great degree (Chang et. al., 2015). Exercise is helpful for people who report arthritis, lower back, psychosomatic and other pains.
Hypnosis and Cognitive behavioral approaches
Hypnosis is the most validated yet rare method used for treating pain symptoms. It requires trained profession for executing hypnotherapy in which patient is taken to the state of sleep where conscious and unconscious operate at the same time (VHA, 2017). Client becomes more receptive to suggestions and his pain symptoms are removed under the influence of favorable suggestions from the therapist. CBT practices are often combined with Hypnotherapy for pain management. Hypnosis is used when all the other treatments fail to develop desired results.
Social support
Sometimes patient feels deteriorated moods and develops severe somatic concerns when he has no one to nurture his sense of belongingness (VHA, 2017). For such instances, social support systems may help relieve client’s pain symptoms.
Role(s) of the pain manager (Henderson, 2005)
Pain manager performs following roles and responsibilities:
He communicates with the client effectively
He makes effective assessment based on complete biopsychosocial information
He educates patient and his family
He chooses the best treatment option in collaboration with the client and his family.
Phases of pain management
Effective communication
It is important to develop effective rapport with the client using Carl Rogers’ three components of rapport building; empathy, congruence and unconditional positive regard (Chang et. al., 2015). Empathy enables the healthcare provider to enter client’s world and feel what he feels and effectively communicate what he feels about client’s feelings. Congruence is referred to as being genuine with the client and sharing experiences with the client for demonstrating integrity.
Unconditional positive regard is specifically effective when client demonstrates negative or unfavorable verbal or gestural responses. It directs the care provider to manifest positive response regardless of what client says or does. In this way, client finds a safer channel to express his feelings which might be the potential causes of pain symptoms e.g., psychological or social.
Careful assessment
Healthcare provider utilizes both objective and subjective measures to assess the nature and severity of pain i.e., patient’s self report on the rating scale, his behaviors and gestures validating pain intensity (restlessness, guarding and crying), history of disease, injury, medicine, and pain relief measures i.e., complementary and alternative therapies, massage, exercise and supplements.
In addition, psychosocial measurements include report of client’s pre-morbid functionality, influence of pain on patient’s life quality and intellectual working, developmental and cultural considerations, pain history regarding depression, violence, abuse and other psychopathology, family history of patient and his functioning during pain. Other objective assessments include Pain Brief Inventory (PBI), McGill Pain Questionnaire (MPQ), the FLACC scale, the Wong-Baker scale and the Numeric Scale.
Development, executing and monitoring of treatment plan
Pain management strategies must be developed in collaboration with the patient and his family and must be assessment specific (VHA, 2017). This step involves laborious decision making based on patient’s history, his effective and ineffective past treatments and risks. It includes both pharmacological and non-pharmacological approaches.
Non-pharmacological treatment encapsulates trans-cutaneous electrical stimulus (TENS), music therapy, biofeedback, imagery and relaxation techniques, cognitive behavioral therapy, acupressure or acupuncture, repositioning, physical therapy and range of motion, massage, immobilization, aromatherapy, decreasing environmental stimuli (temperature, sound, light), therapeutic touch, and distraction (Chang et. al., 2015; VHA, 2017).
Pharmacological treatment includes analgesic, non-steroidal anti-inflammatories (NSAIDs), tri-cyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), anticonvulsants, topical agents, anesthetics, and Opioids. This treatment must be used wisely and carefully because it may lead the patient to develop drug dependence (Park & Moon, 2010).
Education
Healthcare provider educates the patient and his family about various available treatment options, correct management and administration strategies, side effects of medications, and guidance about pain management resources. He also acts as an advocate for the patient to communicate his concerns to the authorities (McNamara, 2012).
Reflection
The above presented textual activity is based on the interview and observation regarding case management of chronic pain in the U.S Department of Veterans Affairs (VA). After deliberate observation and interview activity, it was analyzed that methods of pain management for veterans include drug treatment, hypnosis, exercise and social support and the role of pain manager revolves around assessment, intervention and education of patient about treatment and prevention measures. Pain management phases start from effective rapport building with the client using Rogers three components whereas next steps involve assessment, treatment and education. In a nutshell, this department follows best evidence based assessment and treatment practices to dignify the Lincoln’s promise to veterans.
References
American Pain Society (2007). Pain: Current understanding of assessment, management, and treatments. Glenview, IL: American Pain Society.
Catherine, H., (2006). Introduction of an intensive case management style of delivery for a new mental health service. International Journal of Mental Health Nursing. 15 (3), 157–62. doi:10.1111/j.1447
Chang, K. L., Fillingim, R., Hurley, R. W., Schmidt, S. (2015). Chronic pain management: non-pharmacological therapies for chronic pain. FP Essent., 432, 21-6. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25970869
Chronic Pain 101: Break the Cycle (2017). VHA Pain Management. Retrieved from https://www.va.gov/PAINMANAGEMENT/Veteran_Public/CHRONIC_PAIN_101.asp
Horbury, C., Henderson, A., & Bromley, B. (2005). Influences of patient behavior on clinical nurses’ pain assessment: Implications for continuing education. The Journal of Continuing Education in Nursing, 36(1), 18-24.
McNamara, M.C., Harmon, D., & Saunders, J. (2012). Effect of education on knowledge, skills and attitudes around pain. British Journal of Nursing, 21(16), 958-64.
Park, H. J., & Moon, E. D. (2010). Pharmacologic Management of Chronic Pain. Korean J Pain, 23(2), 99–108. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886242/
Stuart, G. W. Stephen Z. J. (2000). A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatric Services. 51 (11), 14-21. doi:10.1176/appi.ps.51.11.1410. PMID 11058189
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