Pain remains an important cause of morbidity for frail, older persons in nursing homes. As high as 83% of nursing home residents voice complaints of pain. Often, nursing home residents' complaints of pain are not recognized or not appropriately treated. A substantial scientific evidence base attests to readily available pharmacological and non-pharmacological modalities to treat pain. Research utilizing continuous quality improvement, including a recently completed study by Center for Gerontology and Health Care Research in cooperation with RI Quality Partners, has impacted on nurses' behavior in the assessment, documentation, and the use of non-pharmacological treatment of pain. This study resulted in 33% reduction in pain. However, our intervention did not significantly impact on physician proscribing behavior. Based on debriefing of nurse coordinators and others research, nurse-physician communication and physicians' lack of knowledge are two important barriers to appropriate pain management. In this R21 application, we propose to develop and pilot test a Personal Digital Assistant (PDA) based decision support intervention for pain management in long term care. This decision support will assist the nurses in conducting a pain assessment, provide treatment recommendation(s), and print a summary report to be fixed to the physician office. Existing guide lines from the American Geriatric Society, American Medical Director Association, and AHRQ pain management guidelines as well as the advice of expert panel will be utilized to formulate decision support tool. In the development of this intervention, we will conduct focus groups with end users (long term care nurses and physicians), utilize cognitive testing, and conduct a six month pilot test that will examine the use of the decision support application in two nursing homes in RI (one academic base NH and one community base NH). An evaluation will collect information on the time to decision recommendation, acceptability of the PDA application, whether recommendations were utilized, and the reported level of pain prior to and after the use of decision support. If we are successful in development of this intervention, a R01 research application will be prepared to conduct a block randomized trial of whether this intervention when combined with the rapid cycle continuous quality improvement intervention improves quality of pain management. ? ?
