Control Pain


Pain and dyspnea directly impact patient experience, patient function and quality of life. Measures of these conditions are included in calculations of Star Ratings and Home Health and Hospice Compare tools. Inadequate management of symptoms may be a factor in exacerbation of condition, emergency department visits, and possibly, readmissions.

Home-based care organizations can use palliative services in conjunction with traditional home health. ElevatingHome recommends that users also review the Blueprint for Excellence modules 
Hospice Best Practices and Hospice Symptom Management for intensive interventions to manage pain, dyspnea and other symptoms. Home-based care organizations should also consider how to facilitate a continuum of care for patients that includes Palliative Care Program Development.
 
Relevant Measures - Home Health:

  • How often the home health team checked patients for pain
  • How often the home health team treated their patients’ pain
  • How often patients had less pain when moving around
  • How often the home health team treated heart failure (weakening of the heart) patients’ symptoms
  • How often patients’ breathing improved
Hospice Item Set
  • Assessment and Management of Pain
  • Assessment and  Management of Dyspnea
Top Tip: Make Palliative Care nurse consultations available for complex patients and make pain assessment an “always event’. See Case Example: The Sutter Center for Integrated Care (SCIC) - Always Event

Best Practice Recommendations

Goal: Consistent use of clinical pathways to manage pain and other symptoms
Barriers:
  • Inconsistent assessment and interventions
  • Inconsistent physician care plans for pain and symptom management
  • Physicians not responsive to agency staff
  • Patient non-compliance with meds and body mechanics
  • Palliative care nursing resource shortage
Best Practice Interventions:
  • Use agency-level Nurse Council to develop standards of care and pathways for pain and dyspnea management
  • Adopt numeric thresholds or triggers for contacting physicians if patient pain or other symptoms are not controlled
  • Use faxed, email or phone SBAR reports to interface with physicians if patient symptoms are not controlled
  • Increase number of ELNEC trained clinicians in the agency with expertise in pain and dyspnea management
  • Develop relationships with that will enable palliative care nurse consults for patients with poorly controlled pain or dyspnea.  (Such arrangements may be made through by hiring a practitioner or establishing relationships with physician groups, or hospital practices.)
  • Make pain assessment “the 5th vital sign’ and as such is included with vitals at each visit
  • Educate staff on differences between chronic pain and terminal pain, and different approaches to management
  • Embed checklists or other key indicators of symptom management in EMR
  • Include rehab staff (PT, OT) in developing the care plan to ensure that the pain management plan promotes improved functional status
  • Educate referring physicians and hospitals on need for PT and OT involvement
Goal: Accurate initial assessment for pain and dyspnea
Barriers:
  • Inconsistency in OASIS scoring and assessment
  • Lack of awareness of tools among new staff
Best Practice Interventions: 
  • Use checklist or EMR prompt to ensure pain is assessed with movement and appropriate dyspnea assessment
  • Use standardized pain and symptom assessment tools
  • Use of “my shortness of breath” tool to gauge improvement with activity
  • Offer annual pain assessment in-service (may be included on online training system)
  • See also training recommendations in the Blueprint section, ‘Building a High Performance Agency’
Goal: Patient goals for pain management addressed
Barrier:
  • Patient fear of addiction or complications
  • Pain, pre- existing comorbidities that influence response (Anxiety, COPD)
  • Patients who have mental illness component of chronic opioid as a barrier
  • Environmental factors
  • Over-medication
Best Practice Interventions:
  • Make pain assessment and confirmation that the patient’s pain is managed an ‘always event’
  • Identify patient-specific goals for pain and symptom management
  • Include pain and symptom management as priorities in frontloaded visits
  • Use palliative care nurse specialist consultation for complex cases
  • Teach staff how to teach patients, focusing on patients with low literacy, limited English, anxiety and other factors common to home health patients
  • Provide patient education tools for staff to teach proper medication administration (including patient education videos, YouTube, leave behind materials
  • Educate patients and families on medication side effects, (constipation, addiction) and how to alleviate side effects
  • Recommend non-medication interventions for pain management, including heat, ice, breathing exercises, other exercise, massage and other therapies
  • For patients with an interest, discuss alternative therapies including acupuncture, meditation, yoga, chiropractic and others, and recommend the patient discusses these options with their primary clinician

ElevatingHome Best Practice Process for Pain Management QI:

  • Educate and refresh all clinical teams on pain screening and pain assessment in all patients and in cognitively impaired patients
  • Increase referrals to PT to manage pain and dyspnea with movement
  • Review internal management data and hospitalization data on regular basis to determine if pain is an underlying factor
  • Implement High Risk protocol for patients with unmanaged pain
  • Standardize patient education materials with hospital
  • For dyspnea patients, implement Better Breathing teaching overseen by PT

See also Hospice Best Practices - Symptom Management for recommendations for patients with severe pain and dyspnea.
 

Partner with referring clinicians and hospitals to develop programs and strategies to improve health outcomes and patient experience, and to help them meet accountability goals.
By effectively engaging patients and caregivers as partners in care, home-based care organizations improve experience, activation, and ultimately, outcomes.
Educate payers on opportunity to improve outcomes by more effectively caring for people in their homes. Drive smarter spending by preventing admissions and avoidable ED use.
Support clinicians and staff to practice in teams and at the top of their licenses, train for excellence, and recognize achievement.