The scope of the problem of pain management in the elderly residing in nursing facilities is staggering. Generally, it is assumed that pain negatively affects quality of life and must be vigorously addressed when it occurs. Past studies indicate that 40% to 45% of persons in nursing homes experience persistent pain.1,2 In a more recent study, researchers found that fewer than half of the residents with recurrent, predictable pain in a nursing facility were prescribed scheduled pain medications.3 In addition, those who are cognitively impaired are often untreated, and this can lead to behavioral disturbances as these residents may not be able to effectively and appropriately communicate their pain to the long-term-care staff.4,5
Unfortunately, there are many barriers and myths to effective pain management for healthcare professionals, within the healthcare system, and for elders and their families. Healthcare professionals often have inadequate knowledge of pain management strategies and lack current skills to assess and address pain. Elders may underreport pain, being afraid that pain may signal an exacerbation of a disease, such as cancer. Elders may believe that their pain is a normal consequence of aging or may fear taking medications for pain may cloud their senses. If pain is not treated, an individual may not be able to perform daily routines, may become depressed, or have an overall poor quality of life. In essence, the undertreatment and undermanagement of pain in the elderly in long-term care are problems with major physical and psychosocial implications related to quality of life.6,7
Within the long-term-care industry, the Nursing Home Quality Initiative was launched in 2002 to ensure regulatory enforcement, provide consumer information, promote community-based nursing home quality improvement programs, and to create awareness through the Nursing Home Compare Web site reporting of the Nursing Home Quality Initiative Quality Measures using the Minimum Data Set (MDS) 2.0.8 There are two pain quality measures for nursing homes: one for short-term residents and one for long-term residents. The chronic pain indicator is triggered for long-term residents. The short-stay, post-acute pain indicator, is triggered for short-stay residents who are reported to have pain occurring daily, reaching a moderate level at least once during the assessment period, or horrible/excruciating pain at any frequency.
Using the MDS data, the Profiling Arizona's Nursing Home Residents, Update 2002, revealed that pain continues to be a quality measure of importance in Arizona. In 2002, 38% of nursing home resident admissions had pain on a daily basis. Thirteen percent of the nursing home admissions had mild pain, 42% had moderate pain, and 10% had severe pain. Similarly, 22% of nursing home residents had daily pain with the intensity of mild (32%), moderate (59%), and severe (10%). Additionally, 17% of persons had chronic pain in the past 7 days, 42% were post-acute care residents, and 25% of nursing home residents had chronic and post-acute pain.9
More recently, 6% of the long-term-care residents in Arizona triggered for chronic pain compared with 5% nationally. Twenty-nine percent of the short-stay residents in Arizona triggered the post-acute pain quality indicator compared with 21% nationally.10 Thus, although there has been some improvement in the data suggesting more aggressive treatment of chronic pain, more work is needed to provide pain relief for those with post-acute pain and for those whose pain is underreported. In June 2009, the Centers for Medicare & Medicaid Services enacted regulatory changes that required nursing facilities to develop methods and systems to support and improve pain management for nursing home residents (Table 1). Finally, the Advancing Excellence in America's Nursing Homes Campaign (2009) recently stipulated that the national average of moderate to severe pain for long-stay residents would be at or below 2% and at or below 16% for post-acute residents by the fourth quarter 2011.12 It is expected that there will be more attention to aggressive pain management in the time ahead.
After careful examination of past methods for recognizing and treating acute and chronic pain, the Beatitudes Campus determined that more was needed to be done to enhance the quality of life for elders. In essence, achieving comfort for everyone in the Health Care Center became nonnegotiable. The purpose of this article is to present the approaches and findings for the Campaign Against Pain, a pilot project designed to improve the overall comfort level of elders, improve pain management, and further enhance person-directed care. The Campaign plan and outcomes are presented.
THE CAMPAIGN AGAINST PAIN
Beatitudes Campus, a nonprofit, faith-based continuing care retirement community, serves 600 elders in Phoenix, Arizona. The Health Care Center is part of the complex, with 99 to 121 skilled nursing facility beds serving 296 people in 2008. The average age of the residents was 84.7 years, and 31% (n = 91) received hospice care. Of the 296 people, 48% (n = 143) were considered short-stay residents, receiving subacute care, and one-third of these residents (n = 42) came to the Beatitudes to receive rehabilitative services post-hospital stay. Overall, 90% of the short-stay residents (n = 128) remained at the campus after their acute needs were resolved, thus prompting the need to address pain management and incorporate palliative care principles early on during their stay.
With the receipt of grant funding from the Arizona Department of Health Services, the Campaign Against Pain was initiated in 2008 to improve pain recognition and management for persons residing in the Health Care Center. The Health Care Center has three separate nursing units, two of which participated in the project. Approximately 35 elders, experiencing common comorbidities such as cardiac, renal, endocrine, muscular/skeletal and neurological diseases, reside on each unit. The third unit, housing 33 elders, is a dementia special care unit providing focused palliative care. This unit was not initially included in the Campaign.13,14
The scope of work for the project focused on two components: (1) provide a pain management best practice training program within a person-directed framework for the interdisciplinary team and (2) evaluate the impact of the entire Campaign with a completion time of 6 months. There were 113 staff available to participate in the training program, and a target goal of 75 was set. Several predetermined goals were identified:
1. Goal 1: Train 75 staff from the following key departments: management, environmental services, nursing, food service, social service, activities, physical and occupational therapy, and pastoral care.
2. Goal 2: Improve the quality measure for long-term care residents with chronic care pain to 1.2% or lower.
3. Goal 3: Improve the quality measure for short-stay residents with post-acute pain to 15% or lower.
Given the compressed time frame, it was essential to create specialized work groups to focus on different aspects of training and embedding best practices. Through consultation with management and staff, it was determined that a Steering Committee, Campaign Headquarters, Resident Education and Empowerment Work Group, Staff Education and Empowerment Work Group, and Evaluation and Monitoring Work Group were necessary to bring the program to fruition. The Steering Committee, which was composed of 12 leaders and project consultants, met monthly to assess the progress of the Campaign and determine next steps for improvement. The Steering Committee adopted three approaches to the project: education, evaluation, and efforts to embed pain management best practices with a focus on sustainability. It was the responsibility of Campaign Headquarters to schedule the educational programs, provide daily project guidance, and create a positive pathway for changing staff beliefs and processes. The three other work groups met as needed, usually twice a month to complete the assigned work. In addition, the institutional review board at the Beatitudes Campus reviewed and approved the training program and corresponding studies.
The Training Program
The Campaign educational program was modeled after the Palliative Care for Dementia program, already in place in the facility. The training program encompassed five education modules (Table 2). In Key Concepts Training: Person-Directed and Comfort Care, all staff learn about person-directed approach, comfort care, anticipation of needs, personhood, and staff empowerment. Comfort-Focused Behavior Management training assists participants in understanding the basic mechanics of human behavior and how to improve both pain and behavior management through examining what persons are communicating verbally and nonverbally and how staff members can change their approach to enhance comfort and minimize distress. In Magic of Making Meaningful Connections, direct-care staff learn about the importance of "knowing the person" and using the five senses to create moments of joy, thus diminishing discomfort. In the Assessing and Addressing Pain and Managing Pain: Pharmacologic and Nonpharmacologic Approaches, nursing staff participants learn about appropriate pain rating scales, other pain assessment tools, and pain management techniques. In addition, seven medical providers, which included physicians and nurse practitioners, received an overview of the Campaign before the formal training and work groups commenced.
Knowing that nursing home residents with cognitive impairment are often unable to communicate their pain other than through behavior prompted the inclusion of joint behavioral and pain management consults as part of the formal training program. The consultations were conducted by two expert clinicians: a pain management specialist and a behavior consultant, and were generated by referrals from staff members who identified residents experiencing either possible physical pain and/or behavioral concerns. The goal of these comprehensive assessment consults was to embed the training and incorporate new practice skills for the staff nurses, social workers, and certified nursing assistants by learning the connection between behavior changes, discomfort, and appropriate pharmacologic and nonpharmacologic interventions.
Resident Education and Empowerment Work Group
The Resident Education and Empowerment Work Group consisted of two dedicated teams: one composed of staff from multiple departments and one for residents. Prior to each resident advisory team meeting, staff members from the Resident Education and Empowerment Work Group developed specific questions to lead the discussion (Table 3).
The resident advisory group participants made recommendations on how staff and medical providers can best communicate with elders. These recommendations included using different pain scales, substituting the word "hurt" rather than "pain" during evaluation, and several ideas for minimizing pain on a daily basis. Most importantly, the participants voiced appreciation for the opportunity to be heard and taken seriously. Resident advisory group participants said, "This meeting was so nice-I'm glad you had this!" and "Pain is something that just keeps going and is different for everyone-it's hard for other people to understand how really discouraging pain can be." As a result of this feedback, several interventions related to resident education and nonpharmacologic measures were developed and implemented (Table 4).
Staff Education and Empowerment Work Group
The Staff Education and Empowerment Work Group was composed of representatives from nursing, administration, dietary, and social service. They met regularly to review, revise, and create pain management policies; develop pain management care plans; improve communication strategies between staff and residents; implement new documentation forms; and develop educational tools for clinical staff (Table 5). The Staff Education and Empowerment Work Group worked closely with the Resident Education and Empowerment Work Group to ensure that the concerns and challenges identified by the resident advisory team were addressed.
Evaluation and Monitoring Work Group
The Evaluation and Monitoring Work Group consisted of the MDS coordinator, health information and medical systems manager, and research consultant. This work group was responsible for evaluating the areas of need related to documentation of pain in the medical records and developing the methods to be used for evaluating the efficacy of the Campaign. First, a quality improvement in pain management evaluation plan was developed. This plan identified multiple approaches to quantify improvement in pain at the facility, resident, and staff levels. The plan corresponded with the research and evaluation measures to ascertain success in meeting the target goals. The group created the Pain Management Audit Tool that was adapted from the Pain Process Review Tool.10 The audit tool was piloted and used twice for data collection, and reports were submitted to the Steering Committee and Health Care Center Continuous Quality Improvement Committee. In addition, quarterly run charts were created, which used MDS information specific to each nursing unit, to determine the overall impact of the program on the selected quality measures.
FINDINGS
The training part of the program met the target metrics for Goal 1. Over 4 months, 91 staff members, or 81% of all staff eligible to participate, attended one or more training sessions. In addition, there were 257 individual educational encounters for a total of 422 hours of staff training across 31 individual training sessions.
Pain and behavioral consultations were conducted with individual staff and residents on the two units. Eleven residents were referred by staff nurses to the pain consultant for reports of mild to severe pain, of which nine had somatic pain, two had neuropathic pain, and one had visceral pain. The primary location of the pain reported was in the back. Opioids and acetaminophen were the most frequently used pharmacologic interventions. The following nonpharmacologic methods were used to enhance individual comfort: hand and foot massages, improved repositioning of wheelchair-bound elders, assisting residents to lie down when physical pain increased, and multiple offerings of food and/or music to further minimize distress.
Three of the 11 residents were also referred for a behavioral assessment, and all three residents had a diagnosis of dementia, exhibited noticeable signs of memory loss, had limited decision-making ability, and had communication deficits. Observable behavior concerns included physical and verbal resistance to caregiving tasks, resistance to taking medication, and repetitive calling out. The behavioral assessment consisted of screening for depression and identifying antecedent conditions for dementia-related behavior. In two of the cases, there were subtle signs of depression, and a trial of an antidepressant medication was instituted. In all cases, the actual trigger for the behavior concern was identified, and a care plan that focused on both pharmacologic and nonpharmacologic interventions was developed. There was improvement in the overall pain management strategy and a decrease in the frequency of dementia-related behaviors for the residents who received the consultation. One of the serendipitous benefits of these consultations was an increase in use of hospice support. Of the 11 patients referred for consultation, six had hospice support prior to their death.
To address Goals 2 and 3, quality measure run charts were developed, and data were entered every quarter during 2008 through the first quarter in 2009 for moderate to severe chronic and post-acute pain. The x-axis represents each 3-month interval, or one quarter in the calendar year. The y-axis represents the percentage of the incidence of moderate to severe chronic or post-acute pain. Minimum Data Set data are collected for each resident on admission to the facility and every quarter or 90 days. Each unit was tracked separately so that staff could see changes as a result of their efforts. The reported facility data includes Unit A, Unit B, and the dementia unit.
The average for the incidence of chronic pain in Arizona ranged from 6.4% to 7.2%, and the national average for chronic pain ranged from 5.0% to 5.2% for the corresponding period. Unit A was the pilot unit for the implementation of the new forms and revised policy and procedures, which commenced in September 2008. Both units successfully reduced the incidence of chronic pain over the duration of the project. Overall, the facility incidence of chronic pain (0.0%) improved substantially, met the target for Goal 2 (1.2%), and compared very favorably to the MDS-recorded state and national statistics (Figure 1). There was a slight increase to 1.6% in the fifth quarter; however, overall trending indicates a drastic reduction in chronic care pain during the Campaign. Thus, Goal 2 for the improvement in the pain quality measure for chronic pain was met for the facility and the two nursing units.
Run charts were also constructed to capture the incidence of moderate to severe acute pain for short-stay residents over the same five quarters (Figure 2). The state of Arizona average for post-acute pain ranged from 24.10% to 25.80%, and the national average for post-acute pain ranged from 20% to 20.9% for the same period. Upon implementation of the educational training program and creation of new resident medical records forms, the incidence of post-acute pain spiked at first but then dropped significantly for the two nursing units, ranging from 0.0% for Unit B to 8.3% for both Unit A and the facility in the fifth quarter. Of the 143 persons admitted as short-stay residents, 31% of them (n = 44) had moderate to severe pain upon arrival to the facility from the hospital, which automatically triggered the quality measure. Overall, the facility improved substantially and met and exceeded the target for Goal 3 (15%) while comparing very favorably to the state and national statistics and the Advancing Excellence in America's Nursing Home Campaign pain goals.
DISCUSSION AND IMPLICATIONS
As a result of the comprehensive nature of the Campaign, there were positive results on many levels. The residents at the Beatitudes Health Care Center benefited most from this project. Because of the booklet of pain information, residents participated more fully in their pain management. In addition, staff noted less calling out and behaviors from those who were cognitively impaired. Overall, the resident satisfaction scores were very high.
The facility benefited from the project in that several mechanisms were put in place to assess, implement the education program, revamp policies and forms, and monitor the progress and results of the Campaign. By developing work groups charged with tackling the oversight, scheduling, and staff and resident education components, consensus and commitment were instituted and sustained over the length of the project and beyond. Because the work groups cut across disciplines and departments, each person genuinely adopted and endorsed the changes, most of them witnessing firsthand improved outcomes for the elders. It is anticipated that the education and support rendered for the program will continue because of the positive reinforcement from management and key members of the work groups who will champion the change. The run charts documented progress. Finally, the dementia special care unit was also incorporated into the Campaign near the end of the project; thus, the entire facility benefited. In essence, the facility and staff embedded the practice changes within the culture of the organization.
In the end, pain did become everyone's responsibility with a collective awareness to not accept pain as a normal part of aging. By the time the formal program ended, staff were deeply committed to improving pain management by regularly discussing pain at care plan meetings, role modeling best practices for fellow staff members, aggressively pursing nonpharmacologic interventions, and using more scheduled pain medications. The phase "no complaints of pain" is no longer a cliche in the staff vocabulary. As the direct-care staff became more knowledgeable about pain management strategies, it became easier to communicate pain assessment findings, and they became more conversant with medical providers regarding pain interventions. Through the pain and behavior consultation process, staff learned the connection between discomfort, communication, and human behavior. By identifying this connection, staff have additional tools to create a more comfortable experience for residents. Successful outcomes were achieved, based on patient or staff perception of pain relief, in all 11 patients in the consultation program.
There were several limitations to accurately evaluating the project. First, if a person had moderate to severe pain on admission, the quality measure was already triggered, yet the facility had no control over the preadmission status of each short-stay resident. Thus, as the project moves forward, more attention will be made to promote communication to referring facilities to address pain management prior to the resident's admission into the facility.
Second, run charts could be created only quarterly and in tandem with the normal data collection using MDS quality measures. Thus, there were no statistical controls, and only percentages were calculated. In addition, the project team did not identify primary diagnoses, which could have been helpful in ascertaining primary pain interventions based on etiology. Finally, the run charts represent a snapshot of the status of pain in the facility; thus, other objective measures could be used in the future to ascertain impact over time in the continuing effort to ensure the lowest percentage of chronic and acute pain.
CONCLUSION
In these times of limited resources, movement toward measurable outcomes that support best practices is necessary. The education of staff and elders in pain management can facilitate these outcomes. In addition, a committed set of staff and administration is necessary to achieve these objectives. With a calculated education and evaluation plan focused on best practices in pain management and quality improvement, facilities can document interventions that create positive and sustainable end results that could be replicated and tested further in future programs and studies.
Acknowledgments
The authors thank Joseph M. Bestic, NHA, BA, director, Nursing Home, Health Services Advisory Group, Inc; Maribeth Gallagher, MS, NP, and Gillian Hamilton, MD, PhD, Hospice of the Valley; and the Beatitudes Health Care Center Team.
References