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Transforming Pain Management: A Holistic Approach to Whole-person Care

Pain Management Pain Management
EuroMedica
 
Longevity By Nature

The Institute for Natural Medicine (INM) presents the Bridging the Gap series, exploring interdisciplinary care models, challenges and policy recommendations. This inaugural article delves into whole person pain care, focusing on integrative models in Federally Qualified Health Centers (FQHCs) and the Veterans Health Administration (VA).

Exploring Whole Person Pain Care

Our series kicks off with the topic of whole person pain care. Dr. John Finnell and Dr. Sharad Kohli delivered a virtual lecture addressing integrated whole person pain care models in FQHCs and the VA. The lecture, sponsored by the INM, was delivered in July 2023 at the University of Colorado Strauss-Wisneski Virtual Lecture Series and is viewable here: https://naturemed.org/whole-person-pain-care-virtual-lecture/.

Dr. Finnell, a naturopathic physician, acupuncturist and epidemiologist, focuses on the interdisciplinary management of chronic pain in veteran populations and sits on the INMs Research Committee. Dr. Kohli, a family physician, is the medical director of an integrative pain management program at a FQHC in Austin, TX. In their presentation entitled “Whole Person Pain Care: Integrative Models in a Federally Qualified Health Center and the Veterans Administration,” they highlight the definition and prevalence of chronic pain, emphasizing a holistic approach that considers biological, psychological and social factors. The lecture emphasizes the importance of non-drug approaches for chronic pain and presents major health care organizations’ recommendations for multimodal, multidisciplinary pain management strategies. Additionally, it addresses the need for policy changes to improve community conditions upstream, complementing individualized patient care downstream.

Dr. Finnell began by defining chronic pain as pain experienced for greater than three to six months. It’s the No. 1 cause of disability in the United States. There are 100 million Americans who suffer from chronic pain. Eighty-one percent of veterans are seeking care for some chronic pain condition and have a higher prevalence of chronic pain than in the civilian population. This experience comes with an associated increased risk of disability, insomnia, depression, anxiety and chronic stress.

Support for Multimodal, Multidisciplinary Approaches

In May 2019, the Pain Management Best Practices Interagency Task Force of the U.S. Department of Health and Human Services (HHS) released a report that more than 150 major health care organizations now support, including the American College of Physicians, the Joint Commission, the Centers for Disease Control and Prevention (CDC), and the American Medical Association (AMA). It recognized the need for a biopsychosocial approach while working in an individualized, multimodal, multidisciplinary fashion with an expanded toolbox.

The HHS report also stated that working in an individualized, multimodal, multidisciplinary fashion was important. The ultimate goal is to improve the patients’ experience for their physical functioning, activities of daily living, and quality of life. That report recognizes five categories of treatment approaches.

1. Medications that may include opioid and nonopioid therapies when appropriate;
2. Restorative therapies like physical therapy or physical massage therapy;
3. Interventional procedures like joint injections or nerve blocks;
4. Behavioral health approaches like cognitive behavioral therapy or mindfulness-based stress reduction; and
5. Complementary, integrative health, such as acupuncture and yoga.

With this expanded toolbox, patients can work with their health care team to develop an individualized program based on their preferences and comfort level. Patient-centered care is also interdisciplinary. Each patient gets a personalized treatment plan aligned with their desires and needs. This approach requires providers to be on board, working together and placing the patient at the center of the care decisions.

The VA Whole Health System of Care

The VA emphasizes a shift towards a holistic approach to health care. Supported by legislation such as the Comprehensive Addiction and Recovery Act of 2016, the VA established the Whole Health System of Care in 2018, aiming for a cultural transformation in healthcare delivery. Whole person pain care recognizes pain as a complex, multi-dimensional experience requiring comprehensive treatment addressing all aspects of a person’s health and life. Implementation of this approach involves integrating non-pharmacological approaches into patient care teams, utilizing telehealth services and addressing social determinants of health. The lecture highlights case studies illustrating the effectiveness of interdisciplinary pain management teams and the importance of stakeholder involvement in program development and sustainment. A naturopathic therapeutic order is presented as a step-care model aligning with the whole person pain care approach, emphasizing treating the whole person and leveraging evidence-based interventions. It is essential to address patients’ individual needs and experiences in achieving effective pain management and overall well-being.

Changing the Conversation From What’s the Matter to What Matters to You.

In 2018, 18 flagships were designated within the VA to create a cultural transformation of a whole health system of care. Then, in 2022, pain management, opioid safety and prescription drug monitoring programs were added. The flagships were tasked with developing a stepped-care approach to pain and medication management, taking the biopsychosocial approach, and having interdisciplinary pain management teams. The whole health system of care is meant to be an approach to health care that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. Rather than being a program within the VA, it’s seen as a cultural transformation of how we deliver care. Whole-person care carries an approach to pain that recognizes that pain is a complex, multi-dimensional, biopsychosocial experience. The treatment must focus on all aspects of a person’s health, life and relationships. Health includes the community and aspects such as the power of the mind, physical activity, environmental surroundings and personal development.

FQHC Clinic Innovation

Addressing the need for chronic pain treatment is also a priority in the civilian world. This need is being addressed through small clinics like the People’s Community Clinic in Austin, TX, where Dr. Kohli works. Their small six core staff clinic has an innovative pain management approach grounded in patient-centered care, interdisciplinary collaboration and addressing social determinants of health.

Clinic Background: Austin’s People’s Community Clinic started as a free clinic in the 1970s, primarily serving UT (University of Texas) undergraduates without health care. Over time, it evolved into a federally qualified health center (FQHC) serving close to 20,000 patients, mainly Hispanic or Latinx, with many uninsured individuals due to Texas’s non-expansion of Medicaid.

Challenges in Pain Management: The clinic faces challenges in providing comprehensive pain management due to limited access to specialists and evidence-based non-drug treatments, especially for patients with complex trauma histories. The risk of opioid dependency is a concern, given the trauma backgrounds of many patients. Program Development: To address these challenges, the clinic developed an evidence-based non-drug pain management program focusing on relational health, trauma-informed care and patient-centered approaches. The program offers various services, including behavioral health, substance use treatment, medical-legal partnerships, nutrition, acupuncture, yoga, massage therapy and group medical visits.

Relational Health Approach: Building trusting relationships and fostering a sense of community among patients and providers is a central aspect of the program. Patients have autonomy in choosing services aligned with their needs and preferences.

Group-Based Care: Group visits provide opportunities for education, peer support and community building. Patients feel less isolated and more empowered to manage their health in a supportive environment.

Addressing Social Needs: The clinic employs a social needs screening tool to identify and address patients’ social determinants of health. Initiatives like the People’s Pantry provide free healthy food, while partnerships with community organizations help connect patients to resources.

Medical-Legal Partnership (MLP): Onsite legal services help address health-harming legal needs, such as housing instability or benefits denials, which can impact patients’ health and well-being.

Payment Model: Initially funded through grants, the program transitioned to a sustainable payment model, including fee-for-service and negotiated contracts with local health authorities.

Challenges and Future Directions: The clinic faces challenges such as limited resources, staff shortages and financial constraints. However, they remain committed to expanding and improving their integrated pain management program while sharing their experiences and lessons learned with other FQHCs nationwide.

Challenges include encouraging patients to participate in medically supported and goal-oriented groups instead of relying solely on online support groups. Drs. Kohli and Finnell point out the importance of recommendations from primary care providers, word of mouth from patients, and the desire to build community as factors influencing patient engagement in structured group programs.

Dr. Kohli explained that a biopsychosocial approach means looking at all factors that can impact pain. This may be damaged biological factors such as past injury, neurological deficits or genetics. It may also mean looking at psychological concerns such as mood or stress, or a previous history of trauma. Equally important are the upstream social and structural factors that impact health, the social determinants of health (SDH). Health status is often affected by the conditions one works or lives in, usually caused by cultural, political or economic factors.

Health care clinics are downstream from many of the conditions influencing a chronic pain patient, which results in care that does not address the root cause, resulting in incomplete solutions and recurrent patient visits.

Furthermore, Dr. Kohli touched upon the evolution of their approach to building and designing their model of care, emphasizing the importance of flexibility and alignment with values when adding new practitioners and services.

Challenges Remain

Challenges remain in adapting and improving the program to serve patients’ needs better while navigating challenges such as limited resources and reimbursement constraints.

Dr. Finnell noted that while the science supports the approach of focusing on relational health and complexity, policy and payment systems have yet to catch up. He emphasized the disconnect between what health care providers are encouraged to do and what is reimbursable, highlighting the complexity of the issue and the need for alternative payment methodologies. He mentioned their goal of using their program as a pilot for pain care and addressing relational health and complexity more broadly.

In Conclusion

Both doctors are encouraged by the work of the National Academy of Science, Engineering and Medicine studies on achieving whole health and transforming health care across the U.S. Dr. Kohli highlighted the connection between these studies and the interagency task force statements, plus the work the VA is doing with Whole Health. He emphasized that the changes observed in health care systems stem from individual clinics and providers innovating in their approaches, such as Dr. Kohli’s work at the People’s Clinic. He hopes these studies will influence broader conversations and regulations supporting various health care agencies, leading to policy changes that disseminate these innovative practices across all health care environments, not just the VA and FQHCs.

Michelle Simon, PhD, ND President & CEO, Institute for Natural Medicine
In 1992, the leadership core of naturopathic doctors established the Institute for Natural Medicine (INM) as a not for profit organization dedicated to advancing natural medicine. The purpose of the INM is to increase awareness of, broaden public access to, and encourage research about natural medicine and therapies. Among its milestones the INM counts the launch of the Association of Accredited Naturopathic Medical Colleges (AANMC) as an independent organization, leading California’s efforts to obtain licensure, developing an interactive childhood education program focused on healthy eating and lifestyles called Naturally Well in 2017, and expanding residency access by establishing and funding a residency program in 2018. INM has joined forces with the American Association of Naturopathic Physicians (AANP), serving as the charitable arm, to deepen access to naturopathic care, public education and research. Dr. Michelle Simon serves as president and CEO of INM, is a licensed naturopathic physician, clinician, educator and leader in many organizations dedicated to improving the quality and delivery of health care. In addition to holding a naturopathic doctorate from Bastyr University, she also holds a PhD in Biomedical Engineering from the University of North Carolina at Chapel Hill. Dr. Simon has served on the boards for the Integrative Healthcare Policy Consortium (IHPC), the AANP and the Naturopathic Physicians Research Institute (NPRI). Dr. Simon also served nine years on the Washington State Health Technology Clinical Committee which is part of the Health Technology Assessment program that examines the scientific evidentiary basis for efficacy, safety and cost effectiveness of health care technologies. She was also an invited participant for health care economics at “Summit on Integrative Medicine and the Health of the Public” at the Institute for Medicine (IOM) in 2009. Dr. Simon was recognized as the 2018 Physician of the Year by the AANP.
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