Home Health & Hospice Week

Learn some pain management lessons from the nursing home setting.

Poorly treated pain is a concern in every medical setting — but the challenges mount for home care patients, where advanced age, co-morbidities, and patients’ declining ability to communicate often complicate caregivers’ efforts to ferret out — and fight — pain.

The Centers for Medicare & Medicaid Services has focused on pain treatment as an area of improvement for nursing homes, and home health agencies can benefit from the initiative. Rather than retreat, redouble your commitment to assessing and treating pain, coaches Alexis Roam, MSN, RN, Program Manager, Nursing Home Services, with Primaris, Missouri’s quality improvement organization. There’s still room for improvement, especially when it comes to pain assessment for patients with dementia.

Pain focus ahead? In addition to improving the quality of care for your patients, bettering pain management may help with future CMS initiatives in the home health arena. Using OASIS items M1240 (Has this patient had a formal Pain Assessment using a standardized pain assessment tool [appropriate to the patient’s ability to communicate the severity of pain]?) and M1242 (Frequency of Pain Interfering with patient’s activity or movement), surveyors and others may move the nursing home pain campaign into the home care setting.

Bust These Pain Myths

The first step to better pain assessment is to cast outdated preconceptions out the door.

Don’t be influenced by the incorrect belief that the elderly do not feel as much pain as younger people and cannot tolerate pain medications, urges

Betty Frandsen, RN, NHA, MHA, C-NE, writing in a recent publication of the American Association of Nurse Assessment Coordinators. In fact, the ability to read between the lines is vital when considering statistics about the pain elderly patients feel, experts say. Learn from nursing home data available: according to CMS’s Nursing Home Data Compendium: 2012, 15.3 percent of residents report having experienced “moderate to severe” pain in the previous five days, on average. But it’s important to dig even deeper, pain experts say, looking at the numbers as they break down by age. Among residents aged 31 to 64 years of age, the rate of pain (moderate to severe in the last five days) was 24 percent, but among residents aged 85 to 94 years, the rate was just 11 percent — and the rate for those 95 years and older was an even lower 8 percent.

Does that mean that older patients are likely to be experiencing pain at much lower rates than their younger counterparts? Decidedly not. Rather, the statistics that show less reported pain in the older age group are likely to reflect an underreporting of pain among older patients, says Keela Herr, professor and associate dean at the University of Iowa College of Nursing and an expert on pain assessment.

To ensure that your pain management program will stand up the toughest scrutiny, start by revisiting these essential components:

Screening: Because patients with dementia aren’t reliably able to self-report pain, it’s important to use a team approach to screening. Careful observation is essential to keeping tabs on a patient’s pain, says Roam. Remember that frontline caregivers and family can both be important sources of information on a patient’s pain. While a formal assessment of pain is outside an aide’s or nursing assistant’s scope of responsibility; their use of a pain behavior tool can be viewed as screening, notes Herr.

Recommended reading: You may adapt for home care some ideas from a recent research paper which highlights the value of one such CNA-friendly tool, the CNA Pain Assessment Tool (CPAT): “The role of the CNA pain assessment tool CPA/T in the pain management of nursing home residents with dementia,” (Geriatric Nursing, 2012;33:430-438).

Comprehensive assessment: Have evidence- based tools for pain assessment at the ready, specifically ones validated for use among patients with dementia, Herr tells Eli. Monitoring: To ensure great care and survey results, document your efforts to monitor patients’ pain. Be sure to use an appropriate pain scale for those with cognitive impairment.

Related: Pain may also be under-reported and under-assessed among patients with psychiatric diagnoses, recent studies report.