The Home Care Response To Pain

By: Edward Ratner, MD

When you see patients, how often do you consider "pain" as the primary diagnosis? Do you list it as a secondary diagnosis or include it on the patient's problem list? If you are like most physicians, you probably do not list it very often. Symptom management has not been a focus of our medical education. Our medical terminology is designed more for diseases and conditions than symptoms. Yet, pain remains, as it always has been, a key reason patients seek medical attention, regardless of the underlying cause.

In recent years, there has been growing attention to pain in the hospital setting. Pain assessment has been promoted as a "fifth vital sign." The Joint Commission on Accreditation of Health Care Organizations now requires interventions to assess and treat pain. These efforts are laudable, but rarely address pain in the setting where it is endured most of the time, the home. Chronic pain is obviously a home-based problem, but even post-operative pain has become mostly a home-based issue; hospital stays are now so short that discharge often occurs within hours after a patient's first dose of oral pain medications.

Fortunately, home health services are generally available and ideally suited to address both acute and chronic pain. This is clear from the inclusion of pain assessments in the standard admission (and recertification) tools mandated for use by Medicare-certified home health agencies. The tool includes two validated questions regarding pain, one assessing the frequency of pain, the other assessing the severity. For an assessment that is used on admission and then every 60 days, it is not the level of pain at the moment that is assessed (such as on a 0-10 scale), but the impact of the pain on function and activities. This is very appropriate in the home setting, where maintenance or improvement in function is often the key goal of care.

Home health providers (nurses, therapists, doctors or mid-level practitioners such as nurse practitioners or physician assistants), can do much more than just accurately assess pain. They are perfectly positioned to work with the patient to reduce and relieve pain, both pharmacologically and in other ways.

Analgesic medications are an obvious mainstay of pain management. In the home setting, a provider can accurately assess the patient's use of over-the-counter and prescription analgesics. During a home visit, outdated medications from prior episodes of acute pain can be discarded. Use of other family members' prescription medications can usually be recognized. The use of scheduled and/or prophylactic doses of analgesics, rather than waiting until after pain is severe to take "as needed" doses, can be taught and reinforced to patient and others who may assist in care in the home. Abuse or diversion of controlled analgesics is much easier to recognize during a home visit than in any other medical setting.

Non-pharmacological interventions for pain are important also and are easily planned as part of a home visit. For example, a physical or occupational therapist may be able to recommend easier and less painful ways to perform daily activities. A nurse, social worker, or physician may be able to identify and address psychosocial stresses in the home (e.g., family tension or financial difficulties) that may heighten the sense of or lower tolerance to pain.

In summary, pain has always been and remains a significant home-based health care issue. Home care providers can be key to assessment and management of both acute and chronic pain. Physicians should routinely consider the use of home health services or should make a home visit themselves as part of a comprehensive care plan for patients with pain.