Nurocoach

The Current Psych Clearance Model: What's Missing?

The psychological evaluation, or "psych clearance," for chronic pain procedures like Spinal Cord Stimulator (SCS) and other neuromodulation trials, has long been a required but often undervalued step in pain care. Nurocoach, understands the critical need for mental health integration, recognizing that the current model falls short in several key areas.

The Problem with the Status Quo:

The existing "psych clearance" model is problematic in many ways:

An administrative burden and a source of last-minute logistical headaches for practices
A "rubber stamp" process with questionable rigor, rather than a meaningful therapeutic experience
A trigger for awkward conversations where patients feel judged or perceive the question, "Are you calling me crazy?"
Not actionable or helpful in truly optimizing patient outcomes

Treating chronic pain without adequately addressing psychiatric and behavioral components often leads to:

Suboptimal pain control
Opioid overuse
Higher disability rates
Lower patient satisfaction & retention
Poorer overall quality of life for patients

America faces immense pressure from a national mental healthcare shortage, an unprecedented opioid addiction epidemic, and heightened behavioral health needs post-COVID. Many individuals with chronic pain and co-occurring mental health symptoms (like depression and anxiety) do not receive adequate mental health treatment, with research indicating that only 44% of such individuals receive treatment perceived as sufficient. Referral completion rates for outpatient mental health are also very low, often around 10%.

What the Data Reveals

A comprehensive analysis of 19,129 neuromodulation candidates over a three-year period highlights the prevalence of unaddressed mental health challenges:

Depression: 40.1% had mild or no depression (PHQ-9 <10), but 34.8% had moderately severe or severe depression (PHQ-9 15+).
Catastrophization: 25.3% scored as heavy catastrophizers.
Suicidal Ideation: 7.5% reported past/present suicidal ideation.
Psychotropic Medication Use: A significant 82.7% self-reported being on psychotropic medications.

In a separate study, high preoperative PHQ-9 scores correlate strongly with post-surgical pain, disability, and narcotics use. This evidence underscores the critical need for a more integrated and proactive approach to mental health in pain management.

Nurocoach's Integrated Approach: Healing Mind and Body Together

Nurocoach is committed to transforming chronic pain management by holistically integrating mental health into your pain practice, moving "Beyond the Psych Clearance" while reducing administrative burdens on your staff.

Our mission is to redefine surgical psychological evaluations by illuminating the roots and impacts of chronic illness, co-creating a truly integrative healing journey for every patient, and acknowledging the profound connection between the mind and body.

Partnering with Nurocoach will improve patient outcomes while also reducing the amount of care coordination invested in some of your most challenging patients– specifically, high catastrophizers, untreated depression/anxiety, and those at-risk for addiction.

Our Unique Nurocoach Workflow & Patient Journey

Our approach embeds mental health early and often, starting from the new patient intake. Here’s what you and your patients can expect:

Enrollment & Consent: The process begins when your practice provides a Nurocoach flyer with a registration QR code and sends us a referral fax. Our team contacts the patient, guiding them to our preMR system to input demographic, psychiatric, and insurance information, alongside completing standardized forms on mood, pain management, lifestyle, and treatment expectations (approximately 60 questions, including PHQ/DASS/LOTR/PCS). Patients also provide consent for Chronic Care Management (CCM) or Principal Care Management (PCM) services.
Comprehensive Assessment & Clinical Interview: Nurocoach pre-verifies patient coverage and creates an AMD patient profile. A mental health professional then conducts a thorough clinical interview, typically 1-3 hours in a single telehealth appointment. This session delves into medical, pain, family, and psychological history, assessing:
- Psychosocial History: Reviewing elements that could negatively impact well-being from the procedure.
- Coping Skills: Exploring how pain and stress are managed.
- Expectations: Determining if goals for pain relief are realistic, as SCS rarely eliminates pain.
- Emotional Readiness: Confirming adaptability to an implanted device and participation in follow-up care.
- Support Systems: Ensuring social support and willingness to engage in recommended treatments.
- Validated Measures: We use tools like LOT-R, PHQ-9, DASS-21, PCS, Sleep Assessment, GAD-7, and potentially NIDA Quick Screen and ACEs for early and ongoing risk stratification.
Collaborative Care Plan Development: Based on assessments, a Nurocare™ personalized plan is developed. This includes not only pain treatment (medications, injections, PT, neuromodulation) but also psychiatric treatment (SSRIs/SNRIs, sleep hygiene, therapy referrals) and behavioral interventions (CBT, mindfulness, opioid risk monitoring) to manage risk and optimize outcomes.
Risk Scoring Framework: Data from assessments and interviews is translated into a color-coded framework for clear clinical communication and guided next steps.
- Green: Patients with low scores (e.g., PHQ-9 <10), no serious trauma, or who are already effectively managing their mental health. They may not need extensive intervention. An attestation can be issued quickly.
  - Data suggests that this is likely to be 20-25% of the total patient population.
- Yellow: Patients with moderate scores across the board, or a high indicator on one scale without other significant concerns (e.g., PHQ-9 >12 without other serious issues). Targeted interventions are recommended, and increased access to mental health is likely to improve the patient experience within the practice. However they may not be required for the patient to achieve positive outcomes. These patients are likely to benefit greatly from collaborative care and interventions such as RTM, pain support groups, and individual counseling.
  - This cohort represents another 30-35% of the total patient population.
- Orange: Patients with multiple indicators for concern, including any past suicidal ideation. This group is considered the "sweet spot" for significant impact through ongoing therapy, medication, or both. A PHQ-9 score of 20+ or a PHQ-9 of 15+, combined with a high catastrophization score (PCS 30+) automatically categorizes a patient as "orange".
  - Generally, we would expect this group to represent 35-45% of the total patient population.
- Red: Patients with multiple deep concerns or untreated suicidal ideation, addiction, mania, or unstable, undiagnosed mood disorders. These cases require immediate, and potentially in-person, treatment.
  - This is a small percentage of patients, hopefully only 3-5%.
Ongoing Care Management: A care coordinator or nurse tracks progress using tools like PHQ-9, LOT-R, and DASS-21, maintaining regular contact with the patient between office visits via phone or patient portal. Nurocoach consults monthly or quarterly with the pain physician regarding medication changes or mental health escalation, providing a visual representation of scores for depression, anxiety, sleep, and stress for progress reporting.

Technology Integration: Nurocoach leverages preMR for initial data, AdvancedMD (AMD) for patient profiles and assessment templates, and Freed AI for documenting telehealth patient interactions, reducing note-taking time. We also utilize secure, EHR-integrated, and mobile-friendly two-way messaging and self-report portals for ongoing input and feedback.

Rethinking the Role of Psychological Evaluation in Pain Care

For years, the pre-procedure psychological evaluation—often reduced to a “psych clearance”—has been required for interventions like spinal cord stimulation (SCS), but too often undervalued. At Nurocoach, we take this step further, integrating mental health into pain management in a way that addresses the gaps of the traditional model.

Transforming Patient Outcomes

Our integrated approach delivers measurable benefits that extend beyond traditional pain metrics:

Enhanced Function & Quality of Life: By addressing depression, anxiety, coping skills, and other behavioral health factors, patients often experience improved daily functioning, greater emotional well-being, and reduced reliance on opioids. Integrating psychological care into pain management has been shown to enhance quality of life and promote long-term recovery.
Optimized Treatment Success: Psychological factors such as depression, anxiety, catastrophizing, and unrealistic expectations are frequently associated with less favorable outcomes after interventions like spinal cord stimulation (SCS). Evidence-based guidelines recommend pre-procedure psychological screening and expectation-setting to improve patient readiness and treatment success. Nurocoach helps patients strengthen coping strategies and align expectations, supporting more effective pain management and better overall outcomes.
Realistic Expectations: We help patients set healthy, realistic goals for pain relief. Advanced treatments like spinal cord stimulation (SCS) can reduce pain and improve function, but they rarely eliminate symptoms entirely. By preparing patients with this understanding, we reduce disappointment and support better adjustment to implanted devices and follow-up care.
Ongoing Support:Our commitment doesn’t end with surgical clearance. We provide long-term support through digital check-ins, symptom tracking, self-management tools, and access to integrated care networks. This continuous guidance helps patients recover more fully and thrive well beyond the procedure.
Smarter, Safer Care: Involving mental health early can prevent unnecessary emergency visits, imaging, and procedures. By addressing psychiatric needs up front, we help patients receive the right care at the right time—reducing risks, lowering costs, and improving outcomes.

Strategic Benefits for Referring Physicians and Practices

Nurocoach streamlines operations and enhances patient care, providing tangible benefits to your practice:

Holistic Risk Visibility: Gain deeper insights into patients’ psychological readiness, expectations, and risk factors that standard evaluations often overlook.
Reduced Burden of Challenging Patients: Our model helps identify and address patients’ emotional and behavioral barriers, easing strain on staff and improving patient satisfaction scores.
Collaborative Care Planning:We support the development of integrated treatment plans that address both pain and psychiatric comorbidities. Plans may include medical interventions (pharmacotherapy, interventional procedures, physical therapy, neuromodulation), psychiatric management (SSRIs/SNRIs, sleep optimization, psychotherapy referrals), and behavioral approaches (CBT, mindfulness, opioid risk assessment and monitoring). This multidisciplinary model ensures alignment across specialties and optimizes patient outcomes.
Enhanced Credibility: By proactively addressing mental health, referring physicians demonstrate a higher standard of integrated care and avoid the appearance of “rubber-stamp” or "green light" for clearances.
Optimized Resource Allocation: Our structured patient segmentation (Green, Yellow, Orange, Red) ensures resources are prioritized effectively, so high-need patients receive the right level of follow-up and support.

New & Recurring Revenue Streams:

For practices, integrating Nurocoach's services can generate recurring monthly revenue, even between patient visits, through appropriate billing codes:

Principal Care Management (PCM): If the primary focus is chronic pain alone, the pain physician can bill G3002 (initial 30 minutes per calendar month) and G3003 (each additional 15 minutes). While Nurocoach psychiatrists' input strengthens the care plan, they don't bill PCM codes directly.
Chronic Care Management (CCM): When both chronic pain and a psychiatric disorder are actively managed in a care plan, CCM codes are a strong fit.

99490: For at least 20 minutes of clinical staff time monthly .
99491: For at least 30 minutes of physician/qualified provider time monthly.
99487: For complex CCM, requiring at least 60 minutes per month for two or more chronic conditions with a care plan of moderate to high complexity .
99489: For each additional 30 minutes of complex CCM (national average reimbursement: $70.52).
The time spent by a care coordinator or nurse tracking patient progress and managing care counts toward CCM/PCM billable time.
Nurocoach psychiatrists: Can bill their own E/M or psychotherapy codes (e.g., 99213, 90792) for direct patient encounters.

Nurocoach accepts most major insurance plans and is committed to aligning with the top insurance plans accepted by your practice, ensuring mirrored plan coverage and financial accessibility for patients. This collaborative model, supported by robust technology and a dedicated team, ensures patients receive comprehensive support while practices achieve clinical excellence and operational efficiency.

Why does timing matter?

Integrating Mental Health Assessments from the Outset of Pain Patient Intake

The conventional approach of conducting a mental health assessment only when a neuromodulation clearance is required presents significant limitations for both patients and pain practices. This model often positions mental health evaluations as a mere administrative checkbox, rather than a crucial therapeutic step. Patients frequently perceive these clearances as judgmental, fearing they suggest they are "crazy," which can lead to defensiveness and a lack of openness.

Instead, there is a compelling case for pain practices to integrate mental health assessments at the very outset of new patient intake, regardless of whether a procedure requiring clearance is immediately on the horizon. This proactive, holistic approach can significantly enhance patient outcomes, optimize practice resources, and foster invaluable collaborations with mental health providers.

Why Early Mental Health Assessment is Critical:

High Co-occurrence of Mental Health Issues and Chronic Pain: Chronic pain is a multifactorial condition that is highly comorbid with mental health disorders such as depression, anxiety, PTSD, and substance use disorders. Studies indicate that 20-40% of adults with chronic pain experience co-occurring depression and anxiety. U.S. adults living with chronic pain are approximately five times more likely to have clinically significantunremitted anxiety or depression compared to those without chronic pain, comprising the majority (55.5%) of those with these symptoms.
Suboptimal Mental Health Treatment for Chronic Pain Patients: Despite the high prevalence of co-occurrence, chronic pain patients often face systemic disparities in mental health care. Research shows that only 44.4% of U.S. adults with chronic pain and mental health needs receive mental health treatment that screens negative for unremitted anxiety and depression, compared to 71.5% of those with mental health needs alone. Referral completion rates for outpatient mental health are very low, with only about 10% of patients following through. This indicates a significant "treatment gap".
Influence of Psychosocial Factors on Pain Outcomes: Psychosocial factors, including mood, sleep, life stressors, neuroticism, substance use, physical activity, and socioeconomic factors, are powerful predictors of self-reported pain. High preoperative PHQ-9 (depression) scores correlate strongly with worse post-surgical pain, increased disability, and higher narcotic use. Pain catastrophizing, defined as a negative mental set during actual or anticipated pain, leads to higher pain reports and impedes recovery. Conversely, optimism is associated with less pain and can act as a buffer against catastrophizing, especially in individuals with high dispositional pain catastrophizing.
Early Identification for Personalized Care: Introducing mental health assessments at intake provides a comprehensive understanding of a patient's psychological makeup, including their levels of optimism, pessimism, and catastrophizing. This early insight allows for a personalized treatment plan that addresses not only physical pain but also underlying psychological and emotional barriers. This holistic approach ensures that patients are truly ready to process and maximize improvement from medical procedures.
Reducing Administrative Burden and Practice Strain: Current "psych clearance" models are often seen as administrative burdens and lead to last-minute logistical headaches. By integrating mental health early, pain practices can proactively identify at-risk patients and provide a roadmap for their care using structured assessment tools. This reduces stress on staff resources and can potentially lead to fewer emergency department visits and unnecessary procedures by addressing issues before they escalate.
Fostering Patient Engagement and Reducing Stigma: When mental health is introduced as a standard part of the intake process, it helps demystify mental health care and can reduce the stigma patients often feel when mental health is only discussed after all biomedical investigations are exhausted. Physicians, who are often highly trusted by their patients, can emphasize the importance of mental health support as an integral part of their overall care, which significantly increases patient follow-through for counseling.

Opportunities for Collaboration with Mental Health Providers (e.g., Nurocoach):

Collaborating with specialized mental health groups like Nurocoach provides a structured and effective way to implement early, comprehensive mental health assessments and integrate care:

Integrated Psychiatric Support: Nurocoach offers a comprehensive plan of mental health care that goes "beyond the pill," putting counseling at the center alongside medication management, Transcranial Magnetic Stimulation (TMS), sleep and pain management coaching, and nutrition. This integrated approach ensures that patients receive multidisciplinary support, addressing both the biological and psychosocial dimensions of pain.
Standardized and Validated Assessments: Nurocoach utilizes validated measures such as the Revised Life Orientation Test (LOT-R) for optimism, PHQ-9 for depression, DASS-21 for distress, and NIDA for substance use, as well as sleep assessments. These tools provide quantitative data to identify patients' mental health status and potential risks, even allowing for the detection of "heavy catastrophizers" and those with low optimism.
Streamlined Workflow and Communication: Nurocoach integrates mental health intake as part of the new patient process, handling registration, pre-testing, and insurance verification. They provide pre-consult reports with patient test scores and brief histories to referring physicians. This collaboration, including regular clinical provider calls, ensures a coherent, team-oriented approach to patient care.
Addressing Pain Patient Heterogeneity: While biological markers are effective in predicting medical conditions associated with chronic pain, their performance for self-reported pain is limited. Psychosocial factors, however, offer a more reliable prediction of self-reported pain and its bodily distribution and impact. An integrated model acknowledges that both biological pathology and psychosocial factors interact synergistically to influence the development and expression of pain.
Holistic, Front-Loaded Approach: By embracing this holistic, front-loaded approach to mental health assessment, pain practices can more effectively address the complex, multifactorial nature of chronic pain, leading to improved patient outcomes and more efficient use of clinical resources.