Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
Every night Kris Mastrangelo and I talk about the day’s events and the hot topics infiltrating the industry. These days, our conversations jump subject to subject given the volume of regulatory changes impacting the healthcare industry. Most recently, the topic that is recurring is Pain. Kris mentioned in her last 3 speaking engagements, the subject of pain is a common discussion item for industry leaders, and I, with my daily audits in facilities from Hawaii to New York, also see pain as a quality measure raising the most questions and concerns. Our process includes a review of the “Sweet 16” Quality Measures that impact the Five Star Quality Rating System. A deep dive into the facility specific areas of opportunity (area of Pain), are worth sharing to help you improve your process and ultimately your Quality Rating.
What we have found, is the coding of Pain highly dependent on the interview. However, we are also seeing that many facilities are faced with the challenge of some residents’ perception and reporting of pain. Ongoing education with the resident is a critical element for effective pain management. The care provider must take time to explain the purpose of the interview in assessing if the current interventions are effective in addressing the patient’s unique pain. While honing in on the residents awareness of the pain process, one must also consider the vantage point of the patients clinical stays.
Of note, a high number of residents reporting pain also have a high PHQ-9 or PHQ9-OV Score, suggesting depression and or mood symptoms. The Harmony HealthCARE Specialists continually reinforce the value of psychiatric services involvement in addressing pain (as pain may also be an indicator depression).
“On average, 65% of depressed people also complain of pain. Conversely, up to half of people who have chronic pain also suffer from depression.”
“Depression and chronic pain share some of the same as well as some of the same nerve pathways, and depression and pain can interact in a vicious cycle. Depression magnifies pain, changing the brain’s sensitivity to painful stimuli and reducing a person’s coping skills. And the constant stress of experiencing chronic pain can lead to a cascade of other medical problems linked with depression, making it still more difficult to break the cycle.” (University of Michigan Depression Center).
Furthermore, a visual tool for describing pain should be utilized along with a detailed explanation of the meaning of each of the 0-10 pain levels. It’s important that the resident and interviewer are speaking the same language.
The Pain Quality Measure will report Long Stay residents and Short Stay patients who report the following:
- Resident reports daily pain with at least one episode of moderate/severe pain. Both of the following conditions must be met:
- Almost constant or frequent pain (J0400= [1,2]) and
- at least one episode of moderate to severe pain (J0600A = [05, 06, 07, 08, 09] or J0600B = [2, 3]).
- Resident reports very severe/horrible pain of any frequency (J0600A =  or J0600B = )
Defining the Various Ratings of Pain Levels
0. Pain free
(Nagging, annoying, but doesn't really interfere with daily living activities)
- Pain is very mild, barely noticeable. Most of the time you don't think about it.
- Minor pain. Annoying and may have occasional stronger twinges.
- Pain is noticeable and distracting, however, you can get used to it and adapt.
(Interferes significantly with daily living activities)
- Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time, but is still distracting.
- Moderately strong pain. It can't be ignored for more than a few minutes, but with effort you still can manage to work or participate in some social activities.
- Moderately strong pain that interferes with normal daily activities. Difficulty concentrating.
(Disabling; unable to perform daily living activities)
- Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep.
- Intense pain. Physical activity is severely limited. Conversing requires great effort.
- Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably.
- Unspeakable pain. Bedridden and possibly delirious. Very few people will ever experience this level of pain. In other words, the pain is so intense you will go unconscious shortly. Most people have never experienced this level of pain. Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss, have experienced level 10.
It is extremely important to perform the interview in an optimal setting and timing. Give an introduction before starting the interview. The RAI User’s Manual has suggested language: “I’d like to ask you some questions about pain. The reason I am asking these questions is to understand how often you have pain, how severe it is, and how pain affects your daily activities. This will help us to develop the best plan of care to help manage your pain.”
- Who is completing the scripted interview?
- Is the individual comfortable having this discussion with the interviewer?
- Is the individual familiar with the interviewer? The individual may be more at ease and forthcoming with a familiar interviewer.
- Where is the interview performed?
- Is the interview being completed in private and in a quiet environment free from overstimulation?
- Is this the best time to perform the scripted interview?
- Is the individual currently comfortable or experiencing pain, this may impact their overall pain perception. Is the individual currently experiencing active acute medical or emotional issues?
- Does the individual understand the reason for the interview?
- Clarify the intent of the interview is to best identify pain characteristics, frequency, intensity and developing an individualized care plan to address active pain issues.
- Does the individual understand the various levels of rated pain?
- Use visual tools to assist in accurately depicting pain levels
- Educate the individual in the various levels of pain
Strategies to address pain from a Clinical and Quality Measures perspective
- Consider completing a “pre-interview” for individuals with known pain issues. This additional interview if performed on an ongoing basis as well as two weeks prior to the assessment period, along with other nursing quarterly assessments. It will assist in identifying pain issues that have not stabilized. It will essentially help identify sooner and on an ongoing basis, if pain is not in good control.
- Look at potential contributing factors, such as depression or neuropathy etc. Involve therapy for screening for modalities that may assist in reduction of pain.
- Implement resident specific pain interventions to address the specific type of pain.
- Assess for effectiveness of these interventions with the next interview on or just before the ARD of the upcoming assessment and on an ongoing basis.
- Follow up with change in interventions for ongoing pain management.
- Continually update the Care Plan with interventions and outcomes.
Need additional training or a better understanding of Quality Measures, especially in regards to pain? Join us for our upcoming MDS Competency Courses (CHHi-MDS). Click here to see the dates and locations.
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