Pain Management In Nursing Homes

I am so mad today!  Why is it so hard to get through to some organizations that pain management in nursing homes is no different from managing pain in any other setting?!

This afternoon I accepted admission of two patients transferring from a large local hospital system.  Both patients have painful conditions (one had an orthopedic surgery) and neither patient was provided with prescriptions for pain medication on discharge from the hospital.

I have had problems with this hospital system since the DEA started enforcing more stringent regulations about the use of narcotic pain medication in the nursing home setting.  Several years ago, the DEA began cracking down on perceived risk of narcotic abuse and diversion in the nursing home setting.  It has become much more difficult to manage pain in the nursing home setting due to these new regulations.  Difficult (meaning more hoops to jump through) but of course still very necessary.

August Health Services, one of the medical groups I work with, is the largest physician-owned nursing home practice in northern Ohio.  We take care of about 400 nursing home patients in 9 different facilities.  We take our responsibilities to our patients very seriously.  Because of our responsibility to advocate for our patients, we have worked hard to coordinate with and educate the case management departments of the hospitals in the area about pain management issues in the nursing home.

When a patient is discharged from the hospital to the nursing home and is in pain, it can take hours to get medication from the facility’s pharmacy if there is no prescription.  If a patient comes in with a paper prescription for their pain medication, it can be faxed to the pharmacy right away and the delay is minimized.

So imagine for a minute that YOU are Mrs. Smith.  You have a knee replacement at a prestigious local hospital advertising “World Class Care.”  Your postoperative care goes smoothly but (because you’re older, frail, and don’t have family that can stay with you all the time) you need to go for rehab at a skilled nursing facility.

You are transported in a bumpy ambulance and are uncomfortable when you reach the facility.  Your nurse is very kind and attentive but there are three ambulances that rolled in before you with admissions as well.  The doctor that will assume your care at the facility is juggling admissions at the hospital and takes some time answering the page from your nurse.  Then your doctor must call the pharmacy to okay an emergency prescription, and the pharmacy must call the nurse with an okay to get your pain medicine from the emergency supply kept at the nursing home.

You can imagine that you’re in pain now.  Pain that is unnecessary but may be severe.

My group has worked very hard to educate the case management departments at our local hospitals about this matter.  University Hospitals Parma Medical Center has gone all-out to make sure patients have paper prescriptions when they go to the nursing home.  Southwest General Hospital has been very responsive as well.

I have personally spoken with individuals in the case management departments at our problematic large local health system.  They consistently tell me that their legal departments have advised that it is against DEA regulations to send paper prescriptions to a nursing home.  I believe this is clearly open to interpretation (since our partner hospitals and the OTHER large local health system have no problem with it).

What can you do to protect yourself and your loved ones?  If someone is hospitalized and then has to go to a nursing home for rehab, especially after an orthopedic procedure, make sure to speak to the doctor about pain management after discharge.  Specifically ask if they will send paper prescriptions with the patient to the nursing home.  If they say no, or that they’re not sure, you should consider seeing another doctor or having your procedure at a different hospital.

We and our partner hospitals are committed to managing patients’ pain appropriately.  Make sure YOUR hospital is committed to seeing that patients don’t suffer unnecessarily.  Forcing patients to suffer needless pain is definitely NOT “World Class Care.”

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