88 - Standing in the (Pain) Gap -- Why You Need a Clinical Social Worker in Your Primary Care/Rural Health/Rheumatology Clinic
Lubbock, Texas, USA
Purpose “If you don’t shut the gate, all the animals get out.” -- This is the long-standing premise of the Gate Theory of pain development (Mezack & Wall, 1965).The sooner one can close the gate, pain is decreased. But who mans the gate? The patient, of course! How does the patient obtain the knowledge, tools, commitment, and experience to do it effectively? Enter the Multidisciplinary Pain Team—In theory. In actuality, little of this is happening in the US, is targeted to special populations or urban areas, and few physicians employ Clinical Social Workers. This paper will discuss the critical issues primary care and other physicians face with chronic pain patients, gaps in service, and how employing a Clinical Social Worker may improve patient outcomes and clinic success. WHY IS THIS NEEDED? There are two main considerations: Quality of Care and Retention: Pain patients can be difficult to work with. Their condition is bio-psychosocial in nature: Physiologically the experience of pain is like a fire alarm that never stops. It is overwhelming and all-consuming. Driven by the human need to “avoid pain”, the psyche creates elaborate measures to attempt to cope-- based on experience, resiliency, and learned behavior. Socially, the pain patient is too distracted to engage effectively at work, with family, or in the community. And yet the pain patient is not an island; everything and everyone they touch is impacted by their pain. Some support systems help, others are detrimental. Pain patients need quality care that addresses every issue. According to Margaret Caudill, MD, PhD, MPH (2016), it is important for patients, specifically chronic pain patients, to cease looking for a cure, but rather, manage pain.. When patients believe their needs are not being met by their physician, they will shop elsewhere. Often this is interpreted as “Dr. shopping/med-seeking”; or they are seen as non-compliant. Retention occurs when patients believe their physicians “really care” about them. According to Caudill, it’s important for a behavioral health provider in clinics to teach patients to evaluate their expectations of their physicians and to learn to communicate effectively with their treatment team. Methods The author searched the American College of Rheumatology database for a sample of rheumatology clinics/hospitals in the state of Texas. Searches on the Commission for Accreditation of Rehabilitation Facilities, the Joint Commission on Accreditation of Healthcare Facilities, and Substance Abuse and Mental Health Services Association were also retrieved, using the term “Multidisciplinary Pain Clinics”. Content was researched from the PubMed database related to Fibromyalgia, Lupus and connection to childhood trauma. The author also retrieved information from the United States Health and Human Services Pain Task Force, the NASW response to the task force, USA Jobs and VA careers. Additional references were sought from PAINWEEK Journal (Vol.8, 2020) and “Managing Pain Before It Manages You--Fourth Edition” by Margaret Caudill, MD, PhD, PH (2016). Results The author identifies the following services to be provided by the primary care/rural or rheumatology clinic: Screening of all patients for Substance Use Disorders using ASAM criteria Screening for ACE: Adverse Childhood Experiences, anxiety and depression Primary Pain Screening Tools (FABQ, Pain Catastrophizing Scale, etc.) Assessment for psychiatric emergency and referral Brief crisis counseling, PRN Individual Counseling utilizing Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, Mindfulness and Meditation and Motivational Interviewing. Enhanced trauma therapies could include EMDR, hypnosis, EFT, and other experiential therapies Pain management support groups/family education Case Management and community referral to CAM, social services and specialized mental health (chemical dependency treatment, neuropsychological testing, etc) WHY AN LCSW AND NOT ANOTHER DISCIPLINE? On March 26, 2019, the National Association of Social Workers submitted their response to the draft produced by the Pain Management Task Force: “3.3.3 Workforce. NASW supports expanding nonphysician, behavioral health specialists in pain care, particularly clinical social workers who have the skills and expertise to treat pain from a holistic approach.(Gap 1, Recommendation 1c).” Social Workers work with special populations such as indigenous persons, refugees, child welfare, geriatric care, veterans and military, homeless, etc. This is why there are certain payors/systems that actually prefer and require clinicians to be Social Workers. The VA and Medicare reimburses Social Workers and Psychologists only. A physician hiring a Clinical Social Worker with experience in chemical dependence or chronic pain counseling will be ahead of the game. For Rural providers, having an LCSW on the team meets one of the major gaps stated by the Pain Management Task Force. A Clinical Social Worker can be credentialed by many insurance providers. Given the preference by the VA and Medicare or Medicaid, the Clinical Social Worker will meet the need for veterans, seniors and disabled. Clinical Social Workers can provide Tele-for health severely disabled patients, or those with transportation issues. If office space is a barrier, services can be provided through Tele-health; the only exception would be pre-service screenings, group or family work. The LCSW may be trained and credentialed through Workman’s Compensation, as well as EAP services. Conclusions There are too many gaps in services to our pain patients. Physicians wanting to provide quality pain management are burdened by managed care, federal regulations, the opiate crisis, an aging population, liability and many other issues. Interdisciplinary pain management seems like an impossibility. A good first step would be to add a Clinical Social Worker to the practice. Social Work training is not one of psychopathology, but rather strengths-based. They study family systems, role theory, culture, ethnicity, race, gender, sexual orientation, age, disability, religion, socioeconomic and other social systems. Social Workers are trained to be gatekeepers and connectors. They make connections to community resources where another type of behavioral health provider may say “You might want to look for a support group”. A Clinical Social Worker will help” shut the gate” before the “animals get out”...and everyone’s pain is out of control.