APMHC Journal

Introduction

Chronic pain is the big elephant in the room of health care. It is the top reason people seek care, the #1 cause of disability and addiction, and the primary driver of healthcare utilization, costing more than cancer, heart disease, and diabetes [1-10]. The National Health Interview Survey (NHIS) found in 2016 that 126 million adults (55.7%) experienced a pain condition in the past year with 20.1% having daily pain and 31.8% experiencing severe pain [7]. In the United States, chronic pain accounts for over $600 billion in healthcare costs. When pain conditions become chronic, it is associated with addiction, depression, missed work, disability, and intensive use of high-cost high-risk interventions including opioid analgesics, multiple medications, and surgery [7-12]. These problems exist because over 50% of the people with common pain conditions continue to have pain 5 years later despite treatment, because patient-centered risk factors in a person’s life, that lead to stress, strain, and chronic pain, are not addressed in routine care [13-18]. Patient-centered risk factors such as poor ergonomics, repetitive strain, prolonged sitting, stress, sleep disorders, anxiety, depression, abuse, and many others increase peripheral and central pain sensitization, leading to chronic pain and its consequences [13-22].

If usual care fails, clinicians and patients often escalate care to passive higher-risk interventions such as opioids, polypharmacy, surgery, or extensive medical and dental treatment instead of training patients to reduce the risk factors that continue to drive the pain condition [5-9]. Yet, clinical trials have shown that the longterm outcomes of these passive interventions are less compared to patient-centered approaches that activate and empower patients with self-management strategies such as cognitive behavioral therapy (CBT), therapeutic exercise, and mindfulness-based stress reduction to help patients lower risk factors for chronic pain and addiction by implementing protective actions [11-40]. Thus, the National Institute of Medicine Committee on Advancing Pain Research, Care, and Education (2011) report on Relieving Pain in America states that health professionals’ primary role for pain conditions should be guiding, coaching, and assisting patients with day-to-day self-care to reduce these risk factors.[1]. However, this is rarely done as health providers lack the time, training, tools, and reimbursement to guide patients in self-care. Healthcare providers need a strategy to provide consistent, regular, real-time support and training on self-care to their patients.

Preventing Addiction and the Opioid Crisis

Chronic pain is often the primary reason to use opioids long-term leading to development of addiction to opioids and the current opioid crisis. According to the Centers for Disease Control (CDC), the most recent data estimates that 142 Americans die every day from a drug overdose. Since 1999, the number of deaths from prescription opioids has more than quadrupled and are now over 90,000 deaths per year, a greater number than from motor vehicle accidents and gun homicides combined [5]. From 20002021, there was alarming 800,000 deaths from opioid overdoses, with many under the age of 40 years. Most of these overdose deaths began with use of prescription opioids from physicians and dentists for pain conditions. In 2015, the number of opioids prescribed for pain conditions in the United States was enough for every American to be medicated around the clock for three weeks. Since the opioids are often blamed for this crisis, the solution many providers currently implement involves withdrawal and denial of the use opioids for pain conditions. However, as access to opioid prescriptions tightens, consumers in pain are increasingly turning to dangerous street opioids, including heroin and fentanyl. In 2015, 27 million people reported current use of illegal drugs or abuse of prescription drugs. According to the most recent National Survey on Drug Use and Health, only 10 percent of the nearly 21 million citizens with a substance use disorder (SUD) receive any type of specialty treatment for the pain or addiction. [5-6]. In addition, 40% of people with a substance use disorder also have a mental health problem such as depression, anxiety, and social conflicts. Less than half of these people receive treatment for these issues. The reasons for these treatment gaps are many, including the lack of strategies and readily available tools for health professionals to use prevent chronic pain and addiction.

National Initiatives Support Pain Prevention

The Pain Prevention Program (PPP) Integrates self-management strategies with treatment to engage, educate and empower people in preventing chronic pain, opioid abuse, misuse, and overdose. This strategy is consistent with the core principles by most major healthcare organizations including the Institute of Medicine, the National Pain Strategy, the Institute for Health Care Improvement, and the US Health and Human Services (USHHS) Strategy to combat the opioid crisis [1-6]. The PPP also addresses the Institute for Health Care Improvement’s triple aim to improve the patient’s experience of care, enhance the health of the patient, and controlling the cost of health care [40]. However, there are many barriers for health professionals to implement transformative care with self-management training. The lack of reimbursement, time burden, and inadequate training skills coupled with the lack of care coordination, fragmented care, poor communication, and conflicting treatments each interfere with patient-centered transformative approaches in clinical practice. The PPP was designed to overcome these barriers and support the health care system in shifting toward a transformative care approach.

Transformative Care: Integrating Training with Treatment

PPP (www.preventionprogram.com) and transformative car is a comprehensive therapeutic approach that is based on the Chronic Care Model (CCM) that designed to smoothly integrate selfmanagement training with treatment of pain conditions (Table 1) [46-60]. The PPP uses each of the 12 CCM principles of implementing evidence-based self-management as part of routine patient care [53-54] : 1) brief targeted assessment, 2) evidencebased information to guide shared decision-making, 3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, 5) collaborative problem solving, (6) self-management support by diverse providers including health coaches, 7) selfmanagement interventions delivered by diverse formats, 8) patient self-efficacy measured and trained, 9) active follow-up, reminders, and reinforcement, 10) guideline-based case management for selected patients, 11) linkages to social support and community programs, and 12) multi-faceted interventions.

PPP includes digital pain and risk assessments; micro-lessons for therapeutic cognitive-behavioral self-management training; personalized action plans; telehealth coaching; remote telemedicine monitoring, billing, documentation and reimbursement strategies that can easily be integrated into a person’s daily life and personalized to their individual characteristics (Figure 1). The program includes 3 tiers of lessons to provide immediate self-care relief, gradual healing of pain conditions by reducing the cause of the condition, and long-term recovery toward health and wellbeing. PPP also leverages the benefits of a support team including a telehealth coach, virtual reminders, and a social network for family, health care providers to enhance compliance and success. PPP tracks patient symptoms, life interference, adherence, and health care use and presents the data to patients, health coaches, and health professionals through a patient-centered outcomes dashboard to document the progress through the program, the resultant change over time, and present reminders and alerts when problems exist. Furthermore, since PPP is designed to be responsive to both smart phones and computers, it can be implemented anywhere at any time to integrate into a person’s daily lifestyle. It is also secure, confidential, transferable, and scalable as a cost-effective addition to a benefit package for employers, health plans, health systems, and health professionals.

Technology support for the Pain Prevention Program

The PPP and core technologies include:

• Pain Assessment: Digitally delivered validated assessments review patients’ signs, symptoms, pain severity, impact, functional status, past treatment, and current self-care to better understand a person’s personal characteristics, risks, and outcomes associated with algorithms to identify specific chronic conditions and develop personalized care programs.
• Risk Assessment: Digitally delivered validated assessments reviews patient risk and protective factors in all areas of a patient’s life, their readiness to change, and likely adherence to training. These innovative assessments were developed and tested for use by health coaches and health providers to better understand a person’s personal characteristics, risks, and outcomes associated with a specific chronic condition and develop personalized care programs.
• Telehealth Coaching: Telehealth coaches are both trained in advanced education programs and nationally board-certified by the National Board of Health and Wellness Coaching (www.NBHWC.org) in health and wellness coaching in order to support patients in making needed changes to prevent pain and illness. They provide on-line telehealth visits to support the patients in making the lifestyle changes needed to recover from pain conditions, in addition to their medical and rehabilitative interventions. Health coaching has been shown to improve outcomes (61-65). PPP leverages a supportive social network of family, friends, and health professionals to enhance motivation, understanding, and compliance, thereby improving long-term success.
• Digital Patient Engagement Platform: The digital platform can be licensed by individuals and health professionals using “software as a service” similar to electronic health record systems, except is focused on patient engagement. It integrates algorithms based on risk assessments to personalize self-management training of patients to reduce the causes of pain. It also documents outcomes with remote tracking for the provider and telehealth coach. The platform engages social support, allows for health coach documentation, and billing within a clinic setting to offer self-manage pain conditions. It also creates a virtual network of health care providers to document aggregate outcomes and allow for predictive analytics to improve long-term successful management.
• Reimbursement Strategy: The PPP platform provides a strategy for billing and documentation of CPT codes for health plan reimbursement by the clinic that implements the program with their patients.
• Remote Monitoring Dashboard: A HIPPA-compliant dashboard presents data to health coaches, healthcare providers, patients, and support teams to better understand the personal characteristics of patients and track their progress. The dashboard includes results of baseline assessment of each patient’s personal characteristics, pain characteristics, current self-care, risk factors, protective actions, patient engagement, pain severity, and life interference. In addition, follow-up assessments provide detailed data on patient progress of both engagement in self-management as well as improvement in pain and functional interference.
• Predictive Data Analytics: Proprietary algorithms and artificial intelligence leverage the data collected from PPP assessments and outcomes to identify the strategies and specific risk factors, and protective actions that could best improve long-term outcomes for a specific patient.
• Network and Training Program: Training programs are available for both health coaches and health professionals in the use of PPP (www.centerwithin.com/transformative-care-for-preventing-chronic-pain-and-addiction/). The goal is to establish a virtual network of health professionals, clinics, and health coaches to provide support for patient-centered transformative care and powerful predictive analytics.

PPP Integrates Evidence-based Self-Management Training into Routine Care

Clinical studies and systematic reviews evaluating each component of the PPP including health coaching, healthy habits, mindful pauses, calming relaxation, and on-line training has demonstrated

positive evidence-based outcomes (Table 2) [60-83]. For example, reviews of social support and health coaching show that they can improve functional recovery from chronic pain [60-73]. Clinical studies and systematic reviews of randomized clinical trials of webbased cognitive behavioral therapy, exercise, and lifestyle changes show significant improvement with chronic pain [74-79]. Clinical studies and systematic reviews of mindfulness-based stress reduction demonstrate a significant impact in reducing chronic pain [20-30], as did systematic reviews of meditation and relaxation training [31-34]. By integrating these strategies within PPP e-health training platform, it can better engage, empower, and educate patients in understanding and reversing the pain cycles that are driven by a combination of risk factors and then learning the skills of long-term self-management of them while implementing protective actions to relieve chronic pain [80-97]. Table 1 lists the sequence of learning modules in the PPP. Table 2 reviews the characteristics and scientific efficacy of each component of the PPP including identifying the risk factors that drive chronic pain cycles [80-97]

Table 1: Assessment and Self-Management Training Tools help patients and their providers understand pain condition and how each of the 7 realms of our lives can either contribute to pain as risk factors or help relieve and prevent chronic pain and addiction.

Table 2: Characteristics and scientific efficacy of each component of PPPs program.

PPP Supports Patient Change with Telehealth Coaching

Telehealth Coaches are an integral part of the Pain Prevention Program (PPP) and collaborate directly with the referring provider as part of the interdisciplinary team for pain management, similar to health psychologists and physical therapists. Health Coaches are trained with academic health degrees and then are nationally board certified by the National Board of Health and Wellness Coaching (www.nbhwc.org). Health and wellness coaching is a relationship-centered, client-driven process designed to facilitate and empower a client to achieve self-determined goals related to health and overall well-being. While client goals may be informed by or suggested by others, such as an individual’s physician or other health provider, the selection of the goal and exploration where one is relationship to the goal is up to the client. Telehealth Coaches within PPP are well-trained to review risk assessments and provide self-management training and support to patients with pain conditions to facilitate their knowledge and skills necessary for self-management. The process incorporates the needs, goals and life experiences of the patients and is guided by evidence-based interventions for the target condition. Systematic reviews of social support and health coaching show they improve functional recovery from chronic pain (61-66). Individuals may be in any phase of readiness to make changes in their life to improve pain and illness. Health coaching provides a safe and consistent space to support positive change in health and well-being. Health Coaching is a methodology that differs from health education or counseling or therapy, though it can work well in combination with those other practices. Health Coaching has the potential to help individuals, families, and groups achieve improved health and well-being by;

• Setting goals. While a person’s goals may be informed by the condition, such as the reduction of pain, or suggested by others, such as a health professional or the on-line training such as to increase physical activity, the health coach will help with customization of the goal and exploration of where one is relationship to the client-identified goal.
• Practice grounding and calming. The first step in coaching is to help a person be grounded in the moment to practice calming.
• Facilitating Change. Individuals may be just beginning to consider a change, may be exploring aspects of preparing for a change, or may be ready to implement actual actions. In a safe, consistent, non-judgmental, and supportive space, clients can explore their thoughts, emotions, and actions, in a way that allows them to recognize the power of their own choices to impact their overall wellbeing.
• Empowering people. Health coaches help individuals identify and nurture their resources and strengths, connecting with their intrinsic motivation and the energy needed to accomplish their desired goals.
• Engaging responsibly. Health coaches assume that people will function autonomously and competently, and are able to realize positive change within a safe and confidential alliance with the health coach. The coach relationship is one of inspiration, respect, and non-judgmental support.
• Achieving goals. By applying clearly defined knowledge and skills, the health coach can support individuals or groups in mobilizing their internal strengths and external resources to achieve sustainable changes in thoughts, beliefs, emotions, and behaviors to achieve their goal of improved health and wellbeing.

PPP Engages and Empowers patients

The key to the success of any self-care preventive program is the ability to engage the participant in making needed changes to improve their pain. PPP works to maximize engagement with the following strategies;

• Engaging Health Professionals: PPP engages the healthcare provider and patient to implement transformative care that integrates training with treatment. This is done by stating to the patient; “I am happy to do my best to treat your condition, but it is more effective long-term if we also train you to reduce the lifestyle causes of your pain. Are you interested?” If consenting, the provider would l enroll the patient into PPP, and then follow-up with the patient using the dashboard to track and reinforce progress.
• Support by Tele-Health Coach (THC): THCs are well-educated and board-certified health professionals who can support success of a participant’s self-management training. The health coach helps the participant understand their goals, risk factors, protective factors, barriers, and individual skills and talents to help them through the program.
• Structured pain management program: The program provides pain assessment, multi-dimensional risk assessments, personalized risk reduction training, and patient-directed health coaching in each of the seven realms of a patient’s life: Mind, Body, Lifestyle, Emotions, Spirit, Social Life, and Environment (Table 3).
• Shift to patient-centered paradigms: PPP will help the patient, health professional, and the health care system shift to more patient-centered clinical paradigms that facilitate patient empowerment and improved long-term outcomes.
• Accessible by any device: PPP is delivered through a responsive website and mobile app that can be accessed via smart phone, tablet, or computer (www.preventionprogram.com)
• Supported by Family and Friends: Having friend or family team member who can support participants and encourage them along their journey is important. Each participant can sign up any teammate at the beginning or at any time, using the team link of the dashboard.
• Understanding the whole person: In contrast to the limited scope or fragmentation of many pain training and treatment programs, PPP is intended to help people evaluate all aspects of their life including the body, mind, lifestyle, emotions, spirit, social life, and environment. To engage the patient in learning, there are various interactive playful, gaming components, including bursting the benefit bubbles, breaking barrier bricks, interesting stories of people, and acronyms of phrases to help patients remember the concepts.
• Simple Action Plan: An action plan that is generated for each module includes 3 components: Healthy HABITS, daily mindful PAUSEs, and CALMING relaxation practice. Overcoming barriers is discussed to help individuals complete the action plans.
• Dashboard: A dashboard based on the pain assessments is provided to track participant engagement in the program, pain, interference, action plan status, and risk factor assessment.
• Reminders: The program sends out reminders to the participant to reinforce success and encourage completion of the program.
• Handouts: The program also has many resources that provide written documentation for each lesson including an action plan summary, a daily log, and worksheets for each lesson.

Table 3: A Guide for Patient Services in Pain Prevention Program.

Research and Development Methods

With funding from National Institutes of Health (R34DE024260 and U01DE025609), the PPP was developed to integrate robust self-management training with treatment to improve long-term outcomes of people with pain conditions. Table 4 describes the development of the PPP using standard processes for Innovation and change within healthcare. The process was implemented in collaboration with faculty, researchers, clinicians, and developers at the University of Minnesota, HealthPartners Institute, and a supportive input from health plans and pain clinics.

Table 4: Addressing the chronic pain and opioid crisis by employing the process of Innovation and change in healthcare.

Pre-Development

A complimentary on-line course on Preventing Chronic Pain and Addiction was developed through the University of Minnesota at www.coursera.org/learn/chronic-pain to review the evidence-based knowledge on preventing chronic pain. The course uses both creative and experiential learning to better understand chronic pain conditions and how they can be prevented through self-management within cognitive, behavioral, physical, emotional, spiritual, social, and environmental realms. Preliminary data from the initial complementary offering of the online training program for preventing chronic pain is presented in Table 5. In a study of training people to prevent chronic pain [46], 771 participants with pain enrolled, with 93% completing the on-line training program. The 6 most common pain areas included neck and back pain (26%), head, jaw, and face (21.5%), leg, knee, and feet (21.5%), arm, elbow, and hand (10.5%), shoulder, chest, and abdomen (9.9%), and pelvic and hip (6.6%). The severity of pain (0-10) scale was 8.2 and interference (0-10) was 7.1. In the past year, they had seen on average 9.2 healthcare visits for their pain, with many also having surgery or emergency visits. In response to the question on change, 93% of these participants with pain noted that it changed their life to improve their pain, In addition, 85% of the health professionals who enrolled (n= 290) stated that changed their care plan to include self-care strategies. Comments from the training included:

“Absolutely fascinating and enlightening...should be part of every health care educational program!”

“This course has really helped me to understand myself better and why I think, act and see the world as I do.”

“I am eternally grateful for taking the time and energy to provide this beacon of knowledge to the world.”

“I think this course is a wonderful gift, because pain is an avoidable part of our life. I have learned so many things.”

Table 5: Preliminary outcomes for PPPs-based online self-management training without health coach. (n=771 with 93% completing entire online training) {46].

PPP Clinical study

A randomized clinical study was completed at a large health group (NIH U01DE025609) with a sample of 81 patients who were randomly assigned to PPP or usual care (Table 6) [52-54]. Usual care consisted of self-care handouts with standard treatment of pain conditions including non-surgical rehabilitation, physical therapy, and medication. The pain outcomes found that worst pain severity, average pain severity, pain interference, limitation in daily activity, and sleep all improved over 16 weeks within PPP group compared to usual care. In addition, protective factors including physical activity, patient activation and self-efficacy all improved over 16 weeks with PPP compared to usual care.

Table 6: Results of using PPP for chronic pain population in Randomized Clinical Trial compared to usual care—A Transformative Self-Management Program for Chronic Pain Utilizing On-line Training and Telehealth Coaching (50-52).

Clinical Implementation

PPP has been developed and tested to be an easily implemented and reimbursed in both primary and specialty care. It can be set-up to enhance care without significant disruption or changes to current daily schedules. Providers can engage health and wellness coaches who are nationally board-certified (www.nbhwc.com) and trained in the PPP as pain prevention specialists. If a health professional is interested in using the PPP, the team will register each provider and staff from their health group. Each healthcare provider can then refer and enroll patients in PPP, provide training and health coaching support and track progress. The PPP can help support health professionals office team in billing to health plans using a variety of CPT codes depending on the health plan. Automated encounter plans for the PPP can be set up in the clinic’s electronic health record to provides clear documentation, order sets and billing, brief explanations for the patients on their role in managing their illness long-term, and scheduling an initial visit with the pain prevention specialist.

The training of health professionals in the implementation and use of the PPP is available at an on-line course at https://www.centerwithin.com/transformative-care-for-preventing-chronic-pain-and-addiction/. This course covers the following objectives:

• Understanding the transformative care model in order to implement treatment plus patient self-care training using technology and coaching
• Understanding the goals of PPP in implementing transformative care and telehealth coaching for patient self-management of pain training
• Understanding the pain and risk assessments and how they personalize training.
• Understanding the patient-centered paradigm shifts required in transformative care
• Connecting teams you with a nationally-certified telehealth coach.
• Explaining the critical role of the patient in treatment planning with PPP
• Enrolling participants, reviewing consents, establishing reimbursement processes, and scheduling the first introductory coaching visit with patients
• Billing of PPP services using CPT codes including risk assessment and training and telehealth coaching to Health Insurance
• Tracking participant engagement and progress within the dashboard