W. Va. Code R. § 85-20-49

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 85-20-49 - Treatment Guidelines: Multi- Disciplinary Pain Management

49.1. It is now well accepted that chronic pain treatment is a complex problem that involves physical, emotional and behavioral components. Chronic pain and treatment therefore, including multidisciplinary interventions, is only compensable if specifically diagnosed as caused by an injury received in the course of and resulting from employment.

49.2. Multidisciplinary treatment for chronic pain and related disability has been more rigorously examined than most other treatments used with chronic pain. There is strong evidence for the importance of the behavioral/psychological component of treatment in making meaningful changes in pain intensity, functional status and emotional distress.

49.3. The best predictors of disability and response to multidisciplinary treatment may not be a function of physical or medical variables; instead, psychological variables may be the best predictors in certain cases. Additionally, assessment of psychosocial "risk factors" for chronic disability done shortly after injury can lead to more effective management by identifying which patients are likely to benefit from multidisciplinary treatment.

49.4. Chronic Pain Syndrome: Chronic Pain Syndrome patients are defined by the following criteria:

a) Reports of persistent (i.e., at least four months duration) pain, which may be consistent with or significantly out of proportion to physical findings; b). Demonstrates or has demonstrated a progressive deterioration in ability to function at home, socially and at work; c) Shows or has shown a progressive increase in health care utilization (such as repeated physical evaluations, diagnostic tests, requests for pain medications and/or invasive medical procedures); d) Demonstrates mood disturbance; and e) May exhibit clinically significant anger, frustration and/or hostility.

49.5. Program Guidelines:

a. Program Goal: To address behavioral barriers, which inhibit return to work while increasing physical function in a protocol-based rehabilitation program.

b. If an injured worker is diagnosed with Chronic Pain Syndrome directly related to a compensable injury, any authorized pain management program shall contain the following objectives and guidelines.

1. To successfully return the patient to pre-injury work. If this goal is not realistically obtainable, then the goal is to have the patient demonstrate specific alternative work capabilities.

2. To develop work-related skills with work simulation activities.

3. To develop strength, endurance, movement, flexibility and motor control related to performance of specific vocational and avocational goals.

4. To identify and improve management of psychosocial barriers to facilitate return to work.

5. To demonstrate increased responsibility for their condition through the use of self-management techniques related to pain and associated psychological symptoms. This should be done with minimal ongoing medical intervention (decrease dependence on health care system).

6. To demonstrate understanding safe job performance, injury prevention and physical and psychosocial threats to relapse.

c. Program Direction: Responsibility should be assigned for program direction and for medical direction. The same individual may be responsible for both functions. Program direction need not be provided by a physician. Program Director may be an Allied Health Professional with an advance degree and state licensure appropriate to degree. Program Director must have at least one year's experience in interdisciplinary rehabilitation and participate in annual continuing education in this field. The participating physician must be board certified or eligible with annual continuing education in this field.

d. For an injured worker to be authorized to participate in a pain management program, the injured worker must demonstrate:

1) At least three months of ongoing pain-related temporary total disability or inability to safely return to work;

2) The need for such a program must be related to the compensable injury and subsequent consequences.;

3)The patient should be able to express a vocational goal whether related to return to work or retraining for return to work; and

4) Presence of psychosocial barriers to rehabilitation (such as depression, anxiety, fear/avoidance behaviors, poor coping/adaptation skills, anger).

e. Pain management program shall not be authorized if any of the following factors exist:

1) Presence of concurrent noncompensable health or mental health condition that would prohibit full understanding and participation in the program;

2) Medical instability that may warrant continued medical intervention (such as surgery, etc.); or

3) Presence of a substance addiction/dependence that prohibits safe and effective participation in the program.

f. Scope of Service/Program Organization: CPS patients are best treated in an integrated interdisciplinary program. The program needs to maximize continuity of care by employing a coordinated group of health care professionals (i.e., physicians, psychologists, physical and occupational therapists, vocational evaluators, counselors and specialty consultants) who evaluate and treat the patient as a team.

g. Evaluation: The treatment plan is developed through an interdisciplinary evaluation with a recommendation for either admission into the occupational rehabilitation program (ORP) or appropriate alternative treatment. The evaluation should consist of the following:

1) Review of records;

2) Quantitative evaluation by physical therapist to determine current level of functioning and anticipated outcome;

3) Psychological evaluation by licensed psychologist to identify behavioral barriers to return to work and to determine need for psychological intervention, if necessary; and

4) Medical evaluation by a licensed physician to identify any medical barriers to participation and to clear patient for physical restoration activity.

h. Treatment: Individual treatment plan will address the following:

1. Frequency and Intensity of the program: The frequency, intensity and duration of the program should be sufficient to demonstrate improvement in the following areas: work capabilities, strength, stamina and psychosocial barriers to improved functioning (may include fear avoidance, depression, anxiety, coping strategies, anger...) In order to achieve these goals through an interdisciplinary approach and simulate a typical work day, this treatment requires a minimum of five (5) and a maximum of eight (8) hours per day, five (5) days per week. Daily attendance is therefore imperative and integrated into the goals of the program (see section 7). Provision of services will include both daily behavioral/psychological and physical restoration activities. Effective outcome from interdisciplinary treatment is usually accomplished within a maximum of 20 treatment days. Thus, this 20 treatment-day upper limit for intervention with CPS patients is recommended;

2. Extensions To Treatment: Occasionally, there may be justifications for extended treatment beyond the 20-day program. Any such extension needs to be documented, time-limited and monitored on a case-by-case basis. The following should apply to potential extension situations:

1) The patient has clearly shown significant and objectively documented progress within the initial 20-day treatment protocol;

2) Further functional gains that increase the patient's likelihood to return to work are likely within the extension period;

3) Extension periods should be time limited and should not exceed 10 treatment days.

i. Treatment Team Members:

1. Services should be provided by a coordinated interdisciplinary team that includes a core team of individuals who are specifically assigned to the program. The following disciplines, and others as may be designated by the program director, shall constitute the core treatment team: participating physician, clinical psychologist and physical therapist.

2. Dependent on the needs of the patient, the following practitioners may also be involved: case manager (internal or external), psychiatrist, nurse, occupational therapist, vocational specialist.

j. Services Provided: Services shall include, but not be limited to:

1) Medical assessment;

2) Weekly staff meetings that include the core treatment team (or their assigned representatives).;

3) Ongoing reappraisal of each participant's clinical and functional work status;

4) Performance of appropriate medical diagnostic and treatment procedures;

5) Providing information needed to assist participant to return to work;

6) The practice, modification and instruction of component work tasks through real or simulated work;

7) The development of strength and endurance of the participant related to the performance of work tasks;

8) education to teach safe job performance and prevent re-injury;

9) Promotion of self-management strategies; and

10) The development of attitudes and behaviors that will improve the ability of the participant to return to work or benefit from other rehabilitation.

k. Space: Services consistent with the needs of the program shall be provided in settings as follows:

1) A physical therapy setting that allows for conditioning and strength training. An area that supports a work-related treatment environment, which would include work simulation activities, is also needed;

2) Classroom and conference space is required for individual counseling and educational sessions.; and

3) The program may be provided as a private or group practice, hospital based program or freestanding program. All services provided should ideally be performed at a single campus setting. Services should not be performed at more than two locations within a given treatment day.

l. Documentation:

1. Whenever possible, pain management programs shall offer outpatient rather than inpatient services and clear and convincing documentation proving that outpatient treatment is inappropriate in a particular claim is required before inpatient treatment can be authorized. Documentation of interdisciplinary evaluation prior to admission shall include:

a) A quantitative report by a licensed physical therapist that documents current level of functioning and anticipated outcome;

b) A psychological report by a licensed psychologist that documents behavioral and/or emotional barriers to return to work and identifies the need for psychological intervention (if necessary); c) Medical report that documents any barriers to participation in the program and gives medical clearance for the patients participation in physical restoration activity; and e) Post-evaluation summary report that documents specific treatment recommendations.

2. Treatment documentation should include at a minimum:

a) Daily progress notes;

b) Weekly Staffing Summaries which document progress toward goals, current functional status, and newly identified barriers to participation; and

c) Discharge Summary which documents progress achieved in functional, work-related goals, work capability at discharge, progress in addressing psychological barriers to improved function, medical status, and recommendations. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will determine the standards by which this will be reported and the timeframe for such reporting.

m. Discharge Criteria: Discharge of a participant from an interdisciplinary rehabilitation program shall be based upon the following:

1) Goals of the program have been achieved;

2) The injured worker has failed to fully participate and/or comply with program requirements;

3) The physician of record has discontinued the program for the participant;

4) A condition has arisen directly related to the compensable injury requiring further medical or other health care intervention, not present at initiation of the program.;

5) Prior to completion of the program, it is determined by the service provider or attending physician that the client will be unable to accomplish the goals of the program. This determination can be based upon a combination of objective and subjective criteria; and

6) The participant has excessive absences.

W. Va. Code R. § 85-20-49