By Lori A. Burkhart
THE CHIROPRACTIC PROFESSION GOT OFF TO A GREAT START in 2015 as the Joint Commission revised its pain management standard to include chiropractic services. Clinical experts in pain management who provide input into the commission’s standards affirmed that treatment strategies may consider both pharmacologic and nonpharmacologic approaches. Previously nonpharmacologic approaches were not included. Services provided by doctors of chiropractic (who were recognized in 2009 as physicians by the commission) and acupuncture are now included in the standard of care for pain management, effective January 2015.
The new standard also advises organizations, when considering the use of medications to treat pain, to weigh the benefits to the patient, as well as the potential risks of dependency, addiction and abuse of opioids. The change allows the chiropractic profession to help more patients who might not previously have been informed by their health care system or doctor of non-drug approaches to pain management.
The news of this guideline change reached ACA via Karen Erickson, DC, FACC, who sits on the board of trustees at New York College of Chiropractic. She is an ACA media spokesperson and owns a practice in New York City. Dr. Erickson previously worked with the two non-chiropractors responsible for the guideline change.
Having chiropractic mentioned in guidelines that apply to every hospital and most major outpatient centers in the United States is of great consequence, even though guidelines are not a mandate. “What’s important is that it changes the culture of health care,” Dr. Erickson notes. “It’s like redrawing a map; the new map’s contours now have two categories for pain management — there is the pharmacologic category and the nonpharmacologic category,” she says. In essence, a new paradigm has been created, where providers will become educated about nonpharmacologic approaches to consider, including chiropractic and acupuncture.
“It’s also significant from a cultural point of view that the commission uses the words ‘chiropractic’ and ‘osteopathy’ and didn’t use ‘manipulation,’” Dr. Erickson points out. “It’s of cultural significance, because there has been a tendency even in excellent chiropractic research literature to use the word ‘manipulation.’” She says using chiropractic “puts us on the map and correctly identifies our profession.”
Dr. Erickson makes clear that this win for chiropractic at the Joint Commission was accomplished by Arya Nielsen, PhD, director of the Acupuncture Fellowship for Inpatient Care, Mount Sinai Beth Israel Department of Integrative Medicine, with support from Ben Kligler, vice chair of the department of integrative medicine at Mount Sinai Beth Israel.
Dr. Erickson’s role at the Beth Israel Medical Center from 2001 to 2004, tells a lot about the early history of chiropractic and integrative health care. She was the first clinician hired at the Continuum Center for Health and Healing, part of the Beth Israel Medical Center, in New York City (since bought by Mount Sinai so its name has changed), which is the largest integrative health center in the United States. Her practice at the center was the largest.
When the executive director, Woodson Merrell, MD, author of The Detox Prescription and chairman of the Department of Integrative Medicine at Beth Israel Medical Center, invited her to join the Continuum Center, Dr. Erickson became the first chiropractic physician credentialed at a major teaching hospital in the United States. At the time, there were no credentialing guidelines for a DC.
The Continuum Center is an outpatient center located off the Beth Israel campus, and it has department status at the hospital. Beth Israel needed to create credentialing guidelines for DCs. Initially an outside consultant worked with the credentialing committee and Dr. Merrell to negotiate guidelines; Dr. Erickson found them unacceptable.
These proposed guidelines said a DC could practice at the Continuum Center, but patients would be required to obtain a letter from their MDs saying there were no contraindications to chiropractic care. “I thought that was outrageous, regressive, insulting and patronizing on every level,” says Dr. Erickson. “In one fell swoop, they had wiped out 30 years of work done to gain parity by the chiropractic profession.”
Dr. Erickson believes the chiropractic profession owes a debt of gratitude to Dr. Merrell for what he did next. He reconvened the committee and had her negotiate the credentialing guidelines. The credentialing committee is made up of every department head at the hospital. The re-negotiated guidelines allow DCs to practice within their scope in New York State. “Dr. Merrell truly understands the importance of having chiropractic physicians practicing at a major teaching hospital like Beth Israel,” Dr. Erickson says.
Great value came from her opportunity to teach during grand rounds held every week within the center. “All physicians collaborated. I learned a lot about medicine and how MDs clinically think about and treat conditions; I also had the opportunity to educate medical doctors and other clinicians about how DCs think clinically, approach different conditions and embrace the chiropractic philosophy of health,” she says.
Dr. Erickson left the center and returned to private practice in 2004, but sees a patient referred to her by doctors at the center on a daily basis. The MDs that Dr. Erickson worked with became quite sophisticated about chiropractic. “The patients they refer to me are the most complex and interesting: chronic sinus infections, intestinal dysfunctions, headaches and tinnitus,” she says. “MDs are thinking deeply about the potential of chiropractic for their patients.”
When Dr. Erickson worked at Beth Israel’s Continuum Center for Health and Healing in New York, Dr. Nielsen’s office was next to hers; they spent time together clinically and shared patients. She had the same relationship with Dr. Kligler, who specialized in family practice. Dr. Kligler is involved in re-envisioning medical education in the United States and pioneered residents gaining training in integrative health care. The best medical schools in the country now teach residents about natural health care approaches like chiropractic, homeopathy, acupuncture, nutrition, etc., in great part due to efforts by Dr. Kligler.
Dr. Nielsen and Dr. Erickson shared a dream when they worked together of bringing healing inside hospitals to offer services beyond tests and surgery. They wanted patients to have access to healing practices in the hospital like chiropractic and acupuncture.
Dr. Nielsen accomplished a good deal of that by working with a team at the Center for Health and Healing that is dedicated to integrative medicine. With that team, she developed and directed the Acupuncture Fellowship Program for Inpatient Care at Mount Sinai Beth Israel. Through the fellowship, acupuncture therapies are available to inpatients in the departments of surgery, orthopedic surgery, internal medicine, family medicine, oncology and pediatrics.
Part of her work investigated using modalities other than pharmacological to deal with pain and helped lead to the evaluation and change in the guidelines starting in January 2015. (See sidebar, “How the Standard Was Changed,” by Arya Nielsen, PhD.)
The Joint Commission guidelines, because they are used for credentialing more than 20,500 hospitals, will change the culture of how institutions operate. For example, when Dr. Erickson worked at Beth Israel in 2003, it was undergoing JCAHO credentialing. When the Joint Commission team members arrived, they asked to see the chiropractic records. Dr. Erickson’s records were properly documented.
Now the commission team will come in and ask how various hospital departments are implementing non-pharmacological approaches to pain and how pain is being assessed. “When we were reviewed by the Joint Commission in 2003, the big issue was to make sure every patient was being assessed for pain, and the push was to have all providers use the 1-to-10 numeric pain scale,” Dr. Erickson says.
Hospitals, in order to be in compliance under the new pain guidelines, will now consider what they can offer patients as a non-pharmacologic alternative. “The new guidelines will change the discussion from simply using the 1-to-10 numeric pain scale and what are you offering patients for pain, to what are the pharmacologic and nonpharmacologic pain options, how do you decide and what options do you offer?” says Dr. Erickson. “That is going to change the culture; it doesn’t mandate DCs on staff, but the 20,500-plus healthcare facilities will now begin to document that they make chiropractic referrals, in their attempt to offer patients nonpharmacological approaches to pain.”
What Is the Joint Commission?
An independent, not-for-profit organization, the Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States, including every major hospital. Joint Commission accreditation and certification are recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. For more information, visit http:// bit.ly/1qEuR0e. To learn more about the Joint Commission, go to www.jointcommission.org.
How the Standard Was Changed
by Arya Nielsen, PhD
A review of the pain management standard was requested by a team at Mount Sinai Beth Israel (formerly Beth Israel Medical Center) Department of Integrative Medicine in April 2013. The team consisted of Arya Nielsen, PhD; Marsha J. Handel, MLS; and Ben Kligler, MD.
They first submitted a literature review for acupuncture therapies consolidated by Dr. Nielsen as part of the Acupuncture Fellowship for Inpatient Care and presented at hospital department grand rounds. Members of the Consortium of Academic Centers for Integrative Medicine signed on to support the request for a review. The Joint Commission responded positively and convened two expert panels to review the standard. Dr. Nielsen served on one of these expert panels in January 2014. The team subsequently submitted reviews on massage therapy (with the help of Janet Kahn, PhD) and on relaxation therapies as the intention was to include nonpharmacologic therapies, not any one therapy alone. The mission of integrative medicine is to provide sound options for patients.
This initiative represents a team effort and a responsive Joint Commission committee and will foster options of care for patients across the country.
Summary Pain Management Revision:
Effective January 1, 2015: For ambulatory care, critical access hospital, home care, hospital, nursing care center, and office-based surgery accreditation programs.
Standard PC.01.02.07: The [organization] assesses and manages the [patient’s] pain.
[Revised] Rationale for PC.01.02.07 [New for ambulatory care and office-based surgery practice]
The identification and management of pain is an important component of [patient]-centered care. [Patients] can expect that their health care providers will involve them in their assessment and management of pain. Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. The following examples are not exhaustive, but strategies may include the following:
Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy
Pharmacologic strategies: nonopioid, opioid, and adjuvant analgesics
EP 4: The [organization] either treats the [patient’s] pain or refers the [patient] for treatment.
[New] Note: Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a [patient]-centered approach and consider the patient’s current presentation, the health care providers’ clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.