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RAI Compliance:

Take The Pain Out of Pain Management by Conducting Better Resident Interviews

Published on Mon May 14, 2012 Print Friendly and PDF PDF

Use 4 critical questions to hone your skills during the J0300-J0600 Pain Assessment Interview.

Your residents' pain levels could put you in a world of hurt come survey time, if you're not following some key assessment strategies.

As part of their investigative protocols, surveyors look to see whether a facility has implemented effective pain care for its residents, notes William D. Smucker, MD, CMD, medical director of the Altenheim Nursing Home in Strongsville, Ohio.

Facilities must be sure that they are properly assessing and documenting residents' pain and the interventions implemented, said Smucker during the "Taking the Pain Out of Pain Management: Basic Assessment and Management" session at the AMDA annual meeting in March.

"We are supposed to get our residents to the highest practicable level of physical, medical and psycho-social well-being and that includes pain control," Smucker emphasizes. But before you can effectively treat pain, you have to identify it in the first place, and the best way to do this is by conducting a thorough pain assessment interview with your residents.

In the instructions for the Section J0300-J0600 Pain Assessment Interview, the RAI manual states that resident self-report is the most reliable means for assessing pain. "Directly asking the resident about pain rather than relying on the resident to volunteer the information or relying on clinical observation significantly improves the detection of pain," emphasizes the manual.

However, residents may be reluctant to talk about their pain, or they may not have the vocabulary to describe it accurately, Peter Winn, MD, CMD, medical director of VistaCare Hospice in Oklahoma City, Okla., noted at the AMDA meeting. There are cultural aspects to pain beliefs that may make it very difficult for some residents to speak about their pain, he explains.

The RAI manual suggests that when conducting a pain assessment interview, the interviewer sit so that the resident can see his/her face. "Give an introduction before starting the interview. Suggested language: 'I'd like to ask you some questions about pain. The reason I am asking these questions is to understand how often you have pain, how severe it is, and how pain affects your daily activities. This will help us to develop the best plan of care to help manage your pain," the manual states.

1. Is pain by any other name still pain? (J0300)

The interviewer should then directly ask the resident each item in J0300 through J0600 in the order provided (see J0300 box). If a resident answers "No" to the question, "Have you had pain or hurting at any time in the last 5 days," Winn says the interviewer should probe further by using other common descriptors for pain. Residents may use other terms such as "achy" or "stiff" or "burning" or "pins and needles" to describe pain. "So you need to be proactive as you go through this process," he advises.

The RAI manual defines pain as "any type of physical pain or discomfort in any part of the body. It may be localized to one area or may be more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or with movement. Pain is very subjective; pain is whatever the experiencing person says it is and exists whenever he or she says it does."

In talking to residents about their pain, Winn stresses that it is very important to uncover more specifically the type of pain they are experiencing. "Is it nociceptive? Neuropathic? Inflammatory? Now, of course you are going to have to use other descriptors when querying your residents," he says. "So you should ask them, 'Is it a sharp pain? A deep pain? An achy pain? Are you feeling stiff? Do you have any burning or stinging sensations in your legs or feet? Do you feel pins and needles? Do you feel numb?"

Because many residents have 3-4 different medical conditions, they may be experiencing a combination of pain types. Getting this information will facilitate the appropriate selection of both pharmacologic and nonpharmacologic interventions, Winn explains.

2. How frequent is frequently? (J0400)

If a patient has experienced any type of pain during the five-day look-back period, the next item the interviewer needs to assess is how often the resident has experienced pain. The RAI manual suggests staff may want to present the response options to this question (see J0400 box) on a written sheet or cue card.

If the resident is unsure of how to characterize the frequency of their pain based on these options, the RAI manual recommends that the interviewer help clarify the best response by echoing the resident's own descriptions and providing some options. "For instance if a resident responds, 'I don't know if it is frequent or occasional. My knee starts throbbing every time they move me from the bed or the wheelchair.' The interviewer should say, 'Your knee throbs every time they move you. If you had to choose an answer, would you say that you have pain frequently or occasionally?'," the manual states.

If the resident is still unable to choose between the responses of occasionally and frequently, the RAI manual instructs the interviewer to select the response reflecting the higher frequency of pain response, in this case "frequently". (Editor's note: For more coding scenarios, see the Coding Quizzer on page 53 of this issue.)

3. Are you pain-free if you don't move to avoid pain? (J0500)

The next step is to assess the effect of the resident's pain on his/her ability to function. "Assessing whether pain interferes with sleep or activities provides additional understanding of the functional impact of pain and potential care planning implications," the RAI manual notes. This information can provide insight into the need to adjust the timing of pain interventions to better cover sleep or preferred activities.

If the resident's response to these questions (see J0500 box) does not lead to a clear "yes" or "no" answer, the RAI manual instructs the interviewer to repeat the resident's response and then try to narrow the focus of the response. "For example, if the resident responded to the question, 'Has pain made it hard for you to sleep at night?' by saying, 'I always have trouble sleeping,' then the assessor might reply, 'You always have trouble sleeping. Is it your pain that makes it hard for you to sleep?'," the manual states.

Smucker reminds facilities to stay focused on the goal of pain control. "If you ask a patient, 'How's your pain? And they say, 'It's fine as long as I don't move.' Well, that's not what you want. You want people to be able to move about if possible."

4. Just how bad is your pain? (J0600)

In interviewing residents about pain intensity, facilities may now use either a numeric (0-10) scale or a verbal descriptor scale (see J0600). The interviewer should try to use the same scale used on prior assessments for a particular resident. If the resident is unable to answer using one scale, the RAI manual says the other scale should be attempted. Winn suggests using the numeric scale by describing 1-3 as mild pain; 4-6 as moderate pain, 7-9 as severe pain and 10 as being excruciating pain.

Editor's note: Test your Pain Assessment Interview coding skills by taking the Coding Quizzer on page 53 of this issue.

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