The 9th Annual Pain Care Skills Training taking place at SOUTHCOM Conference Center of the Americas in Miami, Florida, brings colleagues and subject matter experts together to learn more about optimizing care and integrative approaches to pain management within the Department of Defense (DoD). The focus will be in sharing best practices, conducting hands on training and learning integrative approaches. The overall goal of the Pain Care Skills Training will be to promote readiness, restoration of function and relief of pain while decreasing the use of opioids.
Transcript
(audience chattering)
Okay, welcome back, everybody. We’re going to get started for our last session this afternoon. Before we do that, I do have a few announcements. First, when it comes to the surveys, we have two surveys you’re going to be receiving. One is our survey, an email survey immediately after the training and that’s about this training, and then you’re gonna have your CME survey, that’s the second survey. Please remember to fill out both of those. We have an overall certificate of completion. If you want a certificate of completion, please see the contract staff at the registration desk. Tomorrow morning, you don’t come here. You report directly to your workshop rooms and you all see where those are. There have been some changes also in terms of location so please double-check on the board before you leave. Yes. Finally, I have to do our thank-yous. We have so many people to thank for getting this program really accomplished. Believe it or not, it’s over a year in the making. We’re already planning our next year’s. There’s a lot of work that goes into that. With that, I wanna thank our staff here from the center. We have Barbara and Garrett. Please raise your hands. They have done such a great job for us. (audience applauding) Thank you, Barbara and Garrett. Been very responsive to whatever we needed. I’m trying to bring them to DC for the things that we do there. Anyway, they have been fantastic. And then we have Sergeant Rosario. Sergeant Rosario has been amazing from the day I came to do a site visit over a year ago. Really been helping with everything. Sergeant Rosario’s from the clinic (audience applauding) and has really been our right-hand person. We have our IT people and we wanna thank our DVIDS people for our live broadcast. Our DVIDS people and our IT people from here. Our IT people here have done a fantastic job, too. (audience applauding) Last, but not least, I have to thank Amy. Amy who does everything, everything for everybody. This is, for an example, and this is like a metaphor. At five o’clock this morning, I get up, I get ready, I’m getting my thing, and for some reason, my glasses got knocked off of my table. I couldn’t see a thing. I give a panic text to Amy at five in the morning. “Come to my room immediately!” Now, if that isn’t a little bit kind of creepy, (audience laughing) you don’t wanna, you don’t want ever to have your boss doing that, and for bosses, don’t do that. “Oh, are you okay?” It was a great commercial for LASIK because I would’ve had to have been led around by the hand all the way. I wouldn’t have been able to do this. A big thank-you, those are the things that Amy does, and a big thank-you to Amy. (audience applauding) Thank you, all. Yay. All right. We have one more talk today and we’re very, very fortunate to have Dr. Hunter, Dr. Chris Hunter. Navy captain. Public health.
Public health.
Oh, sorry, sorry about that. Public health captain. Dr. Hunter graduated university from Memphis, PhD clinical psychology, board-certified in clinical health psychology, 10 years in the Air Force, is an active-duty psychologist, currently works Defense Health Agency, Medical Affairs, and is really leading up our efforts for primary care behavioral health services. Again, I said, “Chris, we really need to hear “from the person who’s really making these policies “and doing this,” and Chris was like, “Absolutely, Chris.” Chris to Chris, and said, “Absolutely,” and came all the way to tell us a little bit about the DHA procedural health instruction. We’re gonna change our slides to that. And we will get going. That will be our last slide deck on the… Excellent, yup, that one. We’ll double-click on that bottom… Perfect. Chris, I’m gonna turn it over to you.
Thank you, Chris.
Thank you.
Thanks so much. Thank you for that introduction. I realize the context when I got here today that I’m the DHA guy, (audience laughing) coming to talk about policy at a skills-building conference directly after lunch and I’m the last thing in your way for freedom for the rest of the day. (audience laughing) So, I realize that context as we’re gonna go through this. (chuckling) Hopefully, we’ll have a little bit of fun and you’ll walk away with a little bit of knowledge as well. Go ahead and go to the next slide. Nothing to disclose. We’re gonna talk about a couple different things. We’re gonna talk about, one, what were some of the main forces that led us to come to this procedural instruction? What are some of the key concepts that are in it? What are a few of the measures that we’re looking at to see? Are we succeeding in what we’re doing across a range of services? And a little bit on the primary care implementation of the stepped-care model. Is there anybody in here who’s read this instruction? (audience chuckling) By hand, a couple. How many of you remember what’s in it? (audience laughing) Couple, okay. We’re gonna do a bit of a high-level overview. If you want to know the particulars of the instruction, you can certainly download that and read those before you go to bed, if you want to do that, and maybe facilitate other habits that you might wanna engage in. The procedural instruction’s actually being rewritten right now. There were some things that were a little fuzzy and people had questions on that. Just also, by raise of hands, did anybody have a part in writing this instruction? (woman chuckles) Anybody get a chance to review it? Because it went out to lots of people for review. (audience member speaking faintly) And just for clarification, while I do work at the DHA and I did review one of, some of the drafts of this, I was not a primary writer on this. There were a lot of people who had input on this so it really took a group effort. What really drove this was there were a number of publications, policies, starting with the National Defense Authorization Act in 2010, and you’ve got a list of the others there, that were really showing that we really have the opportunity to do a lot better job, in terms of how we’re doing with both screening, assessment, intervention, and treatment for folks that have acute and chronic pain, and that, really, in some areas, we’re really kinda doing a poor job and we need to make sure we do a better, from adding in evidence-based, evidence-informed, non-pharmacological interventions, as well as doing better with pharmacological interventions that we were better available to us. Next slide. The primary goal of this policy, and the way I like to think about policy is policy is necessary but it’s not sufficient in order to make change actually happen, but the policy really sets a standard or a benchmark that people can always go to. Now, if there’s nothing out there to help implement that policy, there’s no support, there’s no change, and I know, as you have all seen, here’s the policy, here’s the PowerPoint presentation, go out and do it, but we’re not gonna give you any feedback till you really screw up. Has anybody experienced that in their? You don’t have to raise your hand. Part of the goal was to, how can we take the best evidence that’s out there in our clinical practice guidelines, how can we incorporate that into a policy that really sets some minimum standards or benchmarks that promote non-pharmacological evidence-based interventions and allow us to prescribe in a way that decreases risk and can be most effective? Next slide. Just by show of hands, how many people have seen this diagram, this model, stepped-care model? I suspect that some of you, before this policy even came out, you knew about the stepped-care model. You may have been even effectively doing it at your base. Part of what we hope is that not only with, my primary lane is primary care but, also with specialty, that we’re gonna be able, from a DHA level, really be able to support you in making this happen, not only from electronic health record changes and discreet data pulls and feedback but being able to, no kidding, boots on the ground, what are you guys experiencing. Are there any Primary Care Pain Champions in here? Just by show of hands? Some of you are in the cohorts, I know, ’cause I recognize some of you who have already started this. We’ve already taken feedback from those cohorts who are implementing this in primary care and have already made changes in the way that we’re training it in our electronic health record. But with the stepped-care model, our goal is to, on the primary care side and the self-management side, how can we reach further down there? How can we make it as easy as possible for patients to do self-care? How can we really maximize what happens in primary care, in the patient-centered medical home and the entire team? Not only are we catching acute pain and treating that effectively and hoping to keep that from moving into a chronic pain condition, but how are we using a host of different professionals at the primary care level to manage chronic pain as well? And then how are we using that team to step it up to a tertiary level of care when that’s really the most appropriate (melodic chimes ringing) for that patient if they’re not responding? And then, sort of thinking about long-term, am I the only one hearing the cool music out there? (audience chuckling) Okay. I thought maybe it was just me for a second. Long flight. At that tertiary level, when they don’t need that level of service anymore, how can we make sure that we move that down? The pointer I have, I’m assuming it’s still not gonna work. Yeah, this is the invisible slide. You can see it, I mean the pointer, see it down here. But then when it goes up, boop, it disappears. (audience member laughing) (chuckles) Yeah, you’ve got, the patient is right here in the middle. And so, keeping in mind this is a patient-centered approach, it doesn’t mean that the patient gets everything they want. But how can we work collaboratively along this continuum to provide the right care at the right time? Next slide. There are a number of keys concepts that the policy is pushing. One, and I think you all are, should be familiar with this, is the DVPRS being pushed out and being the measure of, that’s in the procedural instruction. So, this is the method we should be using. A focus on functional and qualitative outcome or impact, not just what is your pain rating today and trying to move that rating down. Focusing on non-medication interventions at that early level and/or at a tertiary level. So, thinking about involving physical therapy, yoga, mindfulness, cognitive behavioral interventions, massage. Having a host of tools or registries where we can get people transparent information about what their prescribing practices are, where we can have them be proactive before they’re seeing patients and have the data right at their fingertips so that they can have those discussions with patients and make decisions about what is truly gonna be the best care for that patient, given what they’re willing to take on at that particular point in time. Next slide. Here are some of the key measures that we are looking at. These are getting reported on pretty much a monthly basis to Dr. Cordts, who’s the senior executive staff lead at Medical Affairs. So, hey, no kidding, we’re really looking at this and we’re really looking at things to change or be different. Now, if they don’t, well, we wanna kind of look at what’s happening. Is that getting washed out in average? Are certain clinics doing better than other clinics? But not for it to be a punitive thing; for it to be an informative thing. We’re really looking at how can we decrease the frequency or the duration of certain kinds of treatments, how can we reduce the level of those treatments, how can we look at other polypharm and how that might be with benzos and how that might be increasing risk, and looking at, for folks that might particularly need it, how do we make sure that we have a safety net for those folks who are on long-term therapy. That’s not the only stuff that we’re looking at. Yeah, go to the next slide. Here’s just an example of some of the key measures and what we’re trying to move up and down. We’re also getting assigned Primary Care Pain Champions. They’re gonna be the primary folks training the implementation of the stepped-care model in their clinics. There are other implementation measures that we’re looking at but I didn’t wanna overwhelm you. Again, this is a skills-building conference, not a, oh my gosh, please don’t show me any more metrics kinda conference. (audience chuckling) Go ahead (chuckling) and go to the next slide. Within all of that, I knew from my 10 years in the Air Force and now my 11 years in the job I’m in and the iterations of this job that if we didn’t put together the implementation support for this, it was gonna crash and burn. I knew it was. And so, I had the opportunity to be the primary care clinical community interim chair back in 2017. One of the things I pushed is how can we make sure that we provide primary care, because that is my swim lane, the support they need to implement this model? Because we know that clinical practice guidelines are great, right? It gives you all the best science of what you’re supposed to do, what kinda outcomes you might get with that, what are the risks for doing different kinds of things. We also know that just because a CPG is there, after you’ve read through the 35 pages of wire diagrams, that you don’t necessarily remember what you need to do or when or for how long. Complexity does matter. So, part of, at least the way that I look at DHA and my role, part of my job is, at least in primary care and when I can influence other things, is how can we make it as easy as possible for you to clinically engage with that patient? Not have your EHR overwhelm you either because it’s got the spiral of death going, (audience chuckling) and we wanna talk about MHS GENESIS ’cause I’m afraid of what might happen in this room for those of you. Anybody on MHS GENESIS right now? A couple of you. I know there have been big leaps and bounds and improvements and ultimately it’s gonna be, I think, a really cool thing. We’ve got two thumbs down. (audience laughing) Two thumbs down. (chuckling) Okay. You can stop crying now. It’s okay. But complexity matters and so we want it to make as easy for primary care teams to be able to implement this. Next slide. We spent over a year bringing in a multitude of subject matter experts to create what are we gonna do, and that just didn’t include folks from DHA or folks at the higher service levels. We brought people in who are actually in the clinic. We ran everything through your PCMH service lead, got their approval and everything. We spent over a year creating how is this gonna look, what are the trainings gonna be like, how are we gonna fund the trainings, and that went through a lot of different iterations, how are we gonna pull data ’cause we need to know if what we’re doing is having an impact. That data includes both implementation data, are you doing what you’re supposed to do in the pathway, yes or no, are you doing it right, yes or no or maybe, and then if you have those things, what kinda outcomes are you getting. It was important for us to modify the EHR so that it was consistent with what the pathway is and agreed upon, knowing that we’re going to get it wrong at the beginning and we’re gonna need to change it. No matter if we spent three years on it, we’re still gonna get part of it wrong ’cause we’ve gotta test it out. There was a lot of time and effort. I suspect, although this isn’t my lane, that a similar effort is going to happen in the near future with tertiary care. Basically, what we want is for any patient who goes to any clinic for direct care in the MHS that has the same kinds of services, for that to look pretty much the same. We wanna have a baseline of standardization and you only have variance when that variance is warranted based on the unique presentations or circumstances of that patient. Next slide. I’m gonna go ahead and read this because I think clinical pathways and clinical practice guidelines get confused all the time. Let me go ahead and read this. A clinical pathway is a documented sequence of clinical interventions placed in an appropriate timeframe, written and agreed to by a multidisciplinary team. They help a patient with a specific condition or a diagnosis move progressively through a clinical experience to desired outcome. It’s not one individual provider doing their own individual thing based on what’s in the CPGs that they wanna focus on. Now, the clinical practice guideline recommendations are part of what’s in that pathway but it’s a no-kidding, whole-team kinda here’s the pathway we’re rolling out, here’s how the electronic health records changed, here are the kinds of services that we expect, here are the kinds of outcomes. When you see patient X that has this, you might wanna bring the Pharm.D. in, you might wanna bring your IBHC in, you might wanna bring PT in. This patient looks like they really need to go to tertiary care because they’ve got all of these factors going on. And trying to make it as easy as possible. And for some of you cohorts out there, we’ve changed some of the training. We think it’s better. We’ve changed some of the EHR. We’re still working on that. I think we’re close to being able to launch a parallel process in GENESIS. We’ve been working on that for a while. Next slide. Ultimately, what we wanted this pathway to do was to allow the whole team to understand what are the whole constellation of variables that impact acute and chronic pain and people that maybe move from an acute to chronic pain state, how do you think about screening in a consistent team way that has a biopsychosocial approach. So, kinda look at where are some of those targets that we might bring in, those non-pharmacological interventions? How do you work with the patient to have their self-management goals? So, asking them what’s important to them. Providing educational materials for the team to use. How can the team, if they’re going to prescribe opioids, prescribe them in a way that mitigates or minimizes that risk? There’s a variety of different trainings. Go to the next slide. The Primary Care Pain Champions have webinar trainings. They also have an eight-hour face-to-face training, and I think that’s really important because they are, get a chance to ask all kinds of questions, get to talk with their counterparts, and they get a chance to practice teaching this because they’re gonna be responsible for making it happen in their clinic. The internal behavioral health consultants, they get eight hours worth of webinar with expert trainers that listen in to their skills-building so we have breakouts in that webinar. We’ve changed the IBHC’s Tri-Service Workflow forms as well so we can pull data on all of their patients. We are providing support with follow-up phone calls. We’re gonna be giving data back to the Primary Care Pain Champions on, hey, here’s what the variables look for your clinic, here are the things that looks like you’re doing well on, here are some things that you might wanna look at and target one of those to improve over the next three months. So, it’s an ongoing process and this is, this isn’t gonna go away. The data on this stuff is gonna get reported to Dr. Cordts on a regular basis, it’s gonna end up in reports to Congress. Our goal, like I said, is to make it as easy as possible for folks to do this. We’re gonna wanna hear feedback from the field, what’s working, what’s not working, how can we change that. Next slide. As promised, even faster than you thought, right? (audience laughing)
Bravo! (audience murmuring)
I am completely open to questions. That was sort of a fast overview of what the policy was geared towards. We didn’t do a deep dive. We could’ve spent more time on those slides but, again, this is a skills-building conference. One of those skills is to know what the policy is and what the targets are. Yes, we have a question over here.
[Audience Member] Yes, thanks for your talk. The purpose of the stepped model of care is to get the right patient the right care at the right time. Just from the field, what we’re seeing, I’m wondering, I guess my question, doing a kinda long talk about it before I, I’ll get to the question first. What is being done and developed to have other things available such as TRICARE pain for acupuncture, TRICARE pain for chiropractic, et cetera? ‘Cause it’s great to have this training, eight hours, and this is how you do the stepped model of care. But in the field, what’s happening is the providers know at the medical home this patient does not need opioids, they need functional rehabilitation. And so, the stepped model of care is your chronic pain patient, go to the IPMC. That’s still the model of care we have because there aren’t, because we have the resources of the IPMCs to provide them with that. So, we’re providing basic education that should be done in the PCMH. I was just wondering if there’s any other resources going into starting programs where they, patients get the basic education and counseling and then movement therapies, et cetera, as opposed to you have this at the tertiary care level even though, because we have the resources.
That’s a excellent question. Let me see if I can answer and if I miss it, let me know how I’ve missed it and I’ll try again. (chuckles) I think for what we’ve done in primary care is we have created educational materials for PainX handouts that talk about what are the cognitive and behavioral things that can be done in primary care. We’ve created educational trifolds. Every primary care clinic that has at least 3,000 adult enrollees is mandated by DOD instruction to have one full-time IBHC as part of that team. They’ve been trained specifically with a standardized, modulized manual on how to do behavioral interventions for chronic pain and acute pain. That’s part of it. I think the other part goes to what about clinics that don’t have Pharm.D.s? What about clinics or MTFs that don’t have PT? In terms of some of the other things that you talked about, acupuncture, some of that comes down to money. I think it varies amongst the services about, and larger MTFs tend to have more resources, they tend to have more there. And so, part of what I hope we’re able to do in primary care is stem the tide of it basically being just a punt for anybody who comes in with chronic pain to go to tertiary care. Because I would hope that we would want you all to focus on the patients that truly need to be at that level of care. I’ve used this example all the time. It’s like somebody coming in to primary care with a headache. Well, we don’t want the primary care provider punting to neurology every time somebody comes in to a headache, in for a headache, but if there are certain criteria that that patient meets, well, yeah, we probably want to get a more specialized referral. That’s sort of an ongoing concern and money is huge at this point. I think some of the other clinical support services that you talked about, I think those are being discussed in the clinical support services community and the pain work groups that are happening at the DHA in the service level. If anybody wants, knows, is involved in that and wants to comment more, please do so. Did I mostly answer your question or did I whiff on it?
[Audience Member] No, it’s helpful. It’s just the stepped model of care starts with not treating the patient but educating and counseling the patient. I just don’t know if there’s a standardized thing that we’re doing, that patients should get this type of counseling of what chronic pain is at the medical home, this type of counseling or they need to be engaged in their care and they do rehabilitation as opposed to treatment and being fixed, getting that mindset started. And then hey, maybe they need to have the first, the stepped model of care then says physical therapy might be appropriate, the next model. But I guess it’s a work in progress and we are seeing improvement.
I think you’re right, it’s a work in progress. I think you make a good point. I think we’ve put together an algorithm that helps the primary care team think about that and we’ve attempted, or we’ve given an initial shot, at providing them with materials and how they think about, and what patient goes to self-management, what patient do you bring to IBHC on, what patient do you initially want to go to PT as their first line, what patient just doesn’t do anything, they have, you know, ice, compression, and elevation on their, you know. Do keep that in mind. I think that’s part of what we will be looking at. How many of these folks are staying in primary care, are getting services, and then what’s the functional outcome? ‘Cause that’s really, to me, at the end of the day, what it is. I think we’re always gonna be wanting to look at how can we make it better, how can we improve it, and we have to start somewhere. I think we’ve got probably an 80% solution. But yeah, good point.
[Audience Member] If I may, sorry about that. Sorry, I’m hearing in my back but I gotta talk to the mic. To answer your question about the, again, Mr. Moss, OTSU, Army pain. To give you the ante Army Family Action Plan, 697 and 698, is routing for a rule change in Tri-Care to be a covered benefit. We’re expecting the first quarter of 2021 that active duty members will be able to get chiropractic care and acupuncture care outside the walls of the MTF. I hope that that address your question about the acupuncture and the chiro.
And my hope is when, assuming that that policy gets in and is paid for, that we have some standardization so that we have quality control. ‘Cause that’s always my fear. When something goes outside of the MTF, I don’t know what they’re getting. No idea. But that is something that is being discussed on a regular, almost weekly, basis at Medical Affairs, that roughly, I think it’s roughly 60% of our services network, not direct care. What quality controls do we have over that? That’s why I always wanted to keep the patients in the MTF, you know, ’cause I know what’s going on there. I can look at what’s happening. I can see the medical record and at least glean kind of what’s happening out of that. Oh, wow, there’s so many questions. So glad I only took 25 minutes. There was, I think, a question here and then one back here. Uh-oh, I’ve done something. The teacher’s coming. (audience chuckling)
[Chris] Vice principal. Vice principal.
(gasps) Oh. Vice principal in charge of discipline. (woman chuckles) Go ahead.
I’ll go first since I’m in the corner here. Jeff Teadam, chief of pain at (speaks faintly). When we look at the stepped model of care, the elephant in the room is that most of the patients that require tertiary care, the etiology behind that, most of it is Axis II disorders or even secondary gain type issues, if that makes sense. That’s the elephant in the room, right? And so, you have to see a specialist to get an MRDP statement in the Army. I was wondering if there’s thought or process where we could screen out basically the soldiers that don’t wanna be soldiers so we don’t waste precious resources whether it be inside the MTF or sending them outside for never-ending chiropractic care for a soldier who is not going to be a functional soldier anyway.
So, you’re saying this is complex. (audience laughing)
[Jeff] I’m saying that we are wasting an unbelievable amount of money right now on very high-expense, low-quality care in a system where there’s a secondary-gain issue that politically is not being addressed.
Right. I know as of last week, there were at the Clinical Community Advisory Council, which is where all of the communities meet, there was some discussion about how are we gonna get better transparency so that hey, no kidding, people are consistently put on a right profile and if they’re not better after X number of months, that they’re either gonna meet a med board or be discharged or whatever the right way happens to be. I believe you were in that. I think, yeah. One, it’s hard to diagnose a personality disorder. As a clinical psychologist active-duty military, I probably diagnose maybe three on Command Directed Evaluations ’cause I had enough data to do it. So, I think, at the end of the day, for me, personally, for active duty, and I don’t mean this to sound harsh but it’s going to, the military health system is not a rehabilitation system. We’re going to give you the best care we can, whether that’s direct care or network, we’re gonna try to get you well, and at some point, you’re either well and you’re fit for duty, or you need to be profiled and will be fit for duty doing something else, or you need to meet an MEB. How that works? I think you’d wanna standardize it, have very specific tick marks. Can we set up the electronic health record that automatically flags a certain cluster of appointments or behaviors or diagnostic categories? I agree with you. When I was active duty, I would see at Lackland Air Force Base, that’s where all the new recruits come in, and I see them come in and they go to the behavioral analysis service and it’s like, wow. What we need to do is put the contingency on the recruiter so that they only get credit if somebody stays in at least a year and then we’re gonna get different people coming in here. (audience murmuring) (audience applauding) But that’s a whole other, that’s a whole other line kind of issue. But yeah. Those are the kind of ideas and information that we really need to hear up from boots-on-the-ground folks at DHA because that’s part of our mission. Part of the clinical community’s mission is, and you will see this as we get closer to 1 October and as the different clinical communities stand up and become more robust, there’s gonna be dialogue back and forth. We need to know what you need us to do, and part of my job at DHA is to attempt to make that happen. Or to bring in my colleagues (chuckling) or my bosses to help make that happen.
[Major Freeman] To follow up on that real quick, the, over here, Major Freeman. We reach those year-plus temporary profiles and we try to send them to IDES and they basically say, “You have not reached MRDP,” even though the standard is if they’ve been on profile for over a year, they need to be sent through the MEB. And they’ll kick them back repeatedly without going to the tertiary specialist. That needs to change. Because if the regulation states a year, not gotten better, then we need to evaluate and send them on their way.
Not throwing any service under the bus but it has been my experience, while I’ve been at DHA, that the services have, at times, decided they’re going to do what they wanna do, that it doesn’t matter whether there’s a DHA policy or a DOD instruction. In fact, commanders will just kinda say, “Yeah, I know that’s fair. “I’m gonna do my own thing.” I think that approach will be largely met with failure after 1 October (chuckles) ’cause the DHA is gonna have authority, direction, and control. And so, hey, no kidding, that’s why all these procedural instructions and these procedural manuals are coming out and there’s going to be monitoring with dashboards to make sure that things happen and people will be held accountable at the market and local level. Or at least that’s my understanding. And it’s gonna take time to change because there are gonna be certain people who, you know, always gonna have laggards who are gonna wanna try to game the system or gum things up.
[Captain Montes] Yeah, Captain Montes, sorry. If I may add, the Integrated Disability Evaluation System will remain all the responsibility of the services. In this case, OTSG will remain the helms of readiness. It’ll be a slight difference across services because of the mission of land, air, and sea, so there’s differing components of that. But just two points that I wanna mention. That the challenge is that not that we’re not blind when you look at the sticker model. There’s two main challenges when you look at that. One is that we don’t have the capacity to implement the model as depicted because all the roles conduct to the third level of care. I mean, in IPMCs and in the Army, we got 12. The Navy got five. There’s not enough. We shared the comment when we got the town hall. There’s more to follow on that to see what venue we’re gonna do. And then the next comment I got is that if you look at the model, if we implement the model as depicted, we’re violating one of the core principles which is prevent chronicity, because we’re saying you need to advance and get more complex. It’s not from the beginning, from the acute phase, that you will be referred to the IPMC. Therefore, you have to be chronically ill, you have to be on opiates, you got to be really in bad shape and not be able to be faced by the PCM to see that their level of care. But wait a minute. Didn’t we say that part of the principle is to prevent chronicity? So, again, there’s some flaws, it’s not perfect. So, just to be mindful that those are the challenges that we are facing when we look at the sticker model. Sorry I got long-winded. Thank you.
Thanks. Dr. Passamani?
Yeah, hi. I’m gonna make an argument here that you guys are looking at the wrong problem. I think that one of the problems is that currently we’re doing a significant disservice to our service members. We have every single soldier, I work at The Warrior Clinic, I’ve been working there now 11 years, and I’m 30 years in the Army, still in the Army. I can guarantee you almost every single soldier that walks into my clinic has chronic knee and back pain. Almost I would say 98%. So, that tells me two things. One, we’re not doing the right thing in the field. So, we gotta stop talking about kicking soldiers out when we’re not doing the right thing to keep them in. One. Two, I think our rehab system, and this is not on any of these people because we’re doing the best we can in the system we can, but the system is not right. We need to be like EXOS. I’m gonna just give you a quick example. A patient had an IDEO brace. He’s been having knee pain for months and doing standard PT, as best as PT can in an hour. Then he goes to the EXOS center, they start teaching him all this stuff, and I know that the PTs would love to have something like that, be able to spend this time with soldiers. And I’m like, “Why aren’t we doing this?” Our frontline soldiers should get frontline care. They are like professional athletes. If we don’t treat our infantry soldiers who are on the frontlines, our special forces who are on the frontline, like professional athletes, we are not doing our job and then we’re gonna kick them out after a year of injuries? We’re not doing right. We need to do better at doing this. I’m gonna give you an example of this is not a new thought. In 2000, in maybe ’03 or ’04, I was at Fort Stewart, and our orthopedic surgeon there wanted to do, he was doing more arthroscopies than the program that he was gonna go train in, wanted to do a rapid PT program where they do surgery right away on these soldiers, get them in, do therapy, an advanced, basically, get-back-to-work program. That was not adopted but that’s the kinda thing that people of I know in the field have thought about for many, many years, but we’re not doing. So, if we don’t do that, we’re not doing the right thing for our soldiers. And I think we have to look at it from that standpoint. If we don’t treat them like professional athletes, try to get them fixed and out and quickly, and with lots and lots of really good evidence-based therapies, which are out there, but one hour or two or three times a week is not gonna do it, guarantee you any PT would love to have more time with their soldiers than that, we’re not gonna do right for these soldiers. Thank you.
Agree. I think if we can prevent injury, absolutely. And I think it’s, the statement that you have made, those are the kind of quadrupling performance plan things that we want folks at the MTFs to put in. We think we have a better way to do this. Here’s how we think it should go, here’s our pilot data, we need money to do it. Because that’s being looked at the DAD-MA level. We saw all the market’s QPP plans. They got sent to all the SMEs and we read through them. And so, we want to support, especially if they need funding. Those are the kind of ideas that we absolutely want coming from you all.
[Dr. Passamani] Just to follow up on that, though. If PTs monitor, just like the rest of us, and I’m not a PT so I’m not gonna speak for them, but if they’re monitored the way we all are as primary care and basically they’re primary care for physical therapy, and it’s all about the numbers game, no one’s gonna give them the time to say, “Oh, why don’t you start this program up? “We’re gonna take you out of the regular numbers count “when you’re already low staff “and can’t even see who you got in the network. “Do this wonderful program for your soldiers “and let’s try it out.” Who’s gonna pay for that? The reality is no facility right now is gonna sponsor that because they don’t wanna lose that provider to do that kind of research. I mean, anyone here anc or PT, please tell me otherwise but I don’t think that’s the case.
My hope is that that will change and that funding will be provided at the market level for that to happen. I mean, if you’re understaffed, again, we need to know about that. (audience chuckling) Hey, let’s keep it… (audience laughing) Keep in mind, keep in mind, currently you’re understaffed. That’s not, that wasn’t DHA’s call, right? Now’s a chance for it to change, okay? Now, I can’t promise you that the money will happen because I can’t make that call. But yeah, do we need to focus on access? Yes. Do we wanna focus on RVUs? No. And I know that’s a big Army thing. They’re still gonna have trouble dropping that. But I don’t know, I guess what I’m saying is I hear your frustration, I can see that you’re really passionate about what you do and you want something to be different, and I would hope that you would be part of that agent of change moving forward.
We’ll take maybe one more question and then Dr. Hunter will be up here. Everybody’s pointing this way. Okay. (audience chuckling)
Hi, William Lawrence, Primary Care Pain Champion of Fort Bragg. Just had one comment and then one question. The comment echoes what he said up front as far as family members in the stepped-care model. With the family members, we can basically give them a referral covered by Tri-Care to pain management or to physical therapy. But none of the other ancillary services are covered under Tri-Care for family members so it makes it very difficult for the stepped-care model. The question is, when this gets implemented, are commands gonna be told to block off time so the average healthcare provider has time where they’re trained on this or is it just gonna be an Outlook message with an attachment? Over. (audience chuckling)
I can tell you how it’s supposed to happen and I can tell you we’ve gotten feedback from the field is that the Primary Care Pain Champions are supposed to go back and train this in person with your entire clinic. I believe there’s roughly, well, depending on who you include, there’s roughly four hours of training that would happen face to face.
Yeah, at our clinic, we have no time blocked off for staff meetings. It’s all just see patients and that’s all. That’s why a directive from Health Affairs, if they want this to actually be implemented, to commands where there is blocked-off time so that the average provider can be educated would be beneficial.
The way that we’ve been handling that is if you as a Pain Champion get blowback from your command, you let Dr. Bell and I know and we will write on email like we did the other day. I see you shaking your head. You’re saying it’s not gonna work.
No, no, it’s not gonna work for the average provider ’cause Health Affairs is saying you have to have all these access appointments per week and that’s what the command is being told. They will not allow time to be blocked off to educate the average healthcare provider.
Sometimes, there’s a miscommunication between what’s in policy and what actually happens boots on the ground. If you’re getting that blowback from your local command, contact me and Dr. Bell and we will work it out. Because this needs, this isn’t an Outlook message. This needs to be face-to-face, real, no-kidding training ’cause it’s not going away. We’re gonna be pulling numbers on all the primary care clinics. And I get where you’re coming from ’cause I’ve, excuse me, I’ve lived that in the past. And yeah, primary care, you’re supposed to have 100 available appointments, based on the new DHA PI that’s gonna come out. If you’re available for clinic, if you are taking time out for training, that doesn’t matter, that doesn’t count. Put it in your DMHRSi so it’s accounted for. We’ve been able to, at least so far, communicate effectively with local command to help them understand. You’re still checking ID, probably need to talk with me later and we’ll see what we could do with that.
With that, Chris, I wanna thank you again. (audience applauding) Really appreciate… Thank you, Chris.
Thank you.
Again, this rounds out our plenary session for this year. I think we had a fantastic group of speakers, a diversity, from neuroscience, clinical, policy, with our patient. A couple of announcements. I thanked everybody but I forgot to thank each and every one of you because you all came and taken time away from your families, your clinics, and I really do appreciate that here. As we build this community of practice, we’re gonna be talking amongst ourselves, with each other, teaching each other all of these things, and I do appreciate that. Thank you all for coming. The bus will be here in 15 minutes. Remember, tomorrow, the coffee shop in the hotel opens at five a.m. They’re opening early for us. And the restaurant is going to open at six a.m. Again, they’re opening early for us. I do apologize for the little delay on the lunch. I think we’ll have that glitch worked out, again, tomorrow. Thank you, all. Enjoy an evening, afternoon in Miami. See you all tomorrow. (audience applauding) Thank you.