Matthew J. Loscalzo, L.C.S.W., APOS Fellow Liliane Elkins Professor in Supportive Care Programs Administrative Director, Sheri & Les Biller Patient

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1 Matthew J. Loscalzo, L.C.S.W., APOS Fellow Liliane Elkins Professor in Supportive Care Programs Administrative Director, Sheri & Les Biller Patient and Family Resource Center Executive Director, Department of Supportive Care Medicine Professor, Department of Population Sciences City of Hope

2 Grant/Research Support: NIH Other financial/material interest: Receive royalties for SupportScreen Other financial/material interest: Spouse is a Consultant for PUMA

3 You control the entire process Screening experience: Demonstrated feasibility Increases efficiency of clinic operations Enhances the patient experience Identifies initial focus of the patient Maximizes face-time with physician and team Given existing technologies, screening now transcends mere problem identification Each setting has to decide, as a team, who they want to be Patient-centered care cannot exist without patient input and team integration Biopsychosocial screening can be the connective tissue of the health system

4 Efficiency Allocation of Limited Resources More patients in less time The Costs of Patient Distre$$ Quality of Care Patient Satisfaction Monetizing Follow-up Care Institutional Risk Regulatory Compliance Patient Safety Meeting new standards and guidelines Evolving Guidelines from Medicare and Commercial Payers

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6 Patient-Centered Care Control Predictability Connection Meaning

7 An unpleasant emotional experience of a psychological, social and/or spiritual nature which extends on a continuum from normal feelings of vulnerability, sadness and fears to disabling problems such as depression, anxiety, panic, social isolation and spiritual crisis. Adapted, NCCN

8 47% of cancer inpatients in 3 comprehensive cancer centers had a DSM III psychiatric diagnosis (Derogatis, et al. 1983) But 66% of these had adjustment disorders Approximately 1/3 of all cancer outpatients experience high levels of distress (Zabora, 1998) Emotional distress is associated with: Decreased adherence to treatment (Ayres, et al., 1994) Relapse and survival (Andersen, et al., 2008, McCorkle et al., 2000) Higher medical costs, greater burden on the medical system (Allison, et al., 1995) Lower quality of life

9 Approximately 1/3 of all cancer patients experience high levels of distress* Emotional distress is associated with: Decreased adherence to treatment ** Relapse and survival*** Higher medical costs, greater burden on the medical system **** Distress is more than emotional symptoms***** * Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S: The prevalence of psychological distress by cancer site. Psychooncology: 10:19-28, ** Ayres A, Hoon PW, Franzoni JB, et al. Influence of mood and adjustment to cancer on compliance with chemotherapy among breast cancer patients. J Psychosom Res 1994; 38: *** Spiegel D. Psychosocial aspects of breast cancer treatment Semin Oncol 1997;24:S1-36-S1-47. ****Allison TG, Williams DE, Miller TD, et al. Medical and economic costs of psychological distress in patients with coronary artery disease. Mayo Clin Proc 1995;70: ***** NCCN: Distress: Treatment Guidelines for Patients, ed II. National Comprehensive Cancer Network and the American Cancer Society, 2005.

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11 Increase death and disease burden Social isolation is comparable to smoking & cholesterol risk 66% higher risk of dying within 6 yrs in socially isolated women with breast cancer (Kroenke, 2006) 8% of families having a member with cancer delayed or did not receive care because of cost Reduces patient adherence to treatment: By depression and anxiety Impairs concentration and memory Weakens motivation Leads to poor coping and unhealthy behaviors smoking, medication misuse, unhealthy eating

12 A brief method for prospectively identifying and triaging cancer patients at risk for illness-related biopsychosocial complications that undermine the ability to fully benefit from medical care, the efficiency of the clinical encounter, satisfaction and safety.

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14 Gives patients a voice and an opportunity to partner with their health care team Overcomes patients reluctance to ask for help Allows patients to share vulnerabilities Discovers if patients need verbal skills to ask for help Helps patients accept problems and overcome stigma Introduces patients to the availability of screening services

15 Whole patient-centered care brings in the biopsychosocial model1 Greater openness by health care professionals about psychosocial problems Higher expectations of patients and families New guidelines and standards American Society of Clinical Oncology (ASCO)2 American College of Surgeons (ACoS) Commission on Cancer (2012) 3 1. Institute of Medicine: Cancer Care For The Whole Patient: Meeting Psychosocial Health Needs. Washington, DC, National Academies Press; Neuss M, Gilmore T, Kadlubek P. Tools for Measuring and Improving the Quality of Oncology Care: The Quality Oncology Practice Initiative (QOPI ) and the QOPI Certification Program. J Oncol. 2001;25(10): American College of Surgeons Commission on Cancer: Cancer Program Standards 2012: Ensuring Patient- Centered Care.

16 Quality Oncology Practice Initiative (QOPI) Standardized procedures for measuring and reporting quality of outpatient medical oncology care; sponsored by ASCO 1 National Quality Forum and ACoS Oncology Quality Indicators May be used for public reporting, payment incentives, or quality improvement 2 1. Neuss M, Gilmore T, Kadlubek P. Tools for Measuring and Improving the Quality of Oncology Care: The Quality Oncology Practice Initiative (QOPI ) and the QOPI Certification Program. J Oncol. 2011;25(10): American College of Surgeons Commission on Cancer: Cancer Program Standards 2012: Ensuring Patient-Centered Care.

17 Chemotherapy planning: chart documentation standards (Standard 2.F, 11.D and 13): 2F: Assessment regarding psychosocial concerns and need for support, with action taken when indicated Documentation of psychosocial concerns may include: copy of distress, depression, or anxiety screening form in the chart; patient self-report of distress, depression, or anxiety; or chart documentation regarding patient coping, adjustment, depression, distress, anxiety, emotional status, family support and care-giving, coping style, cultural background, and socioeconomic status 11.D: On each clinical visit or day of treatment during chemotherapy administration, staff: Assess and document psychosocial concerns and need for support; taking action when indicated. Psychosocial assessment do not need to be assessed more than once per week. [i.e. during multi-day treatments]. 13: The practice/institution maintains referral resources for psychosocial and other supportive care services. Neuss, MN. Jacobson JO, Polovich M, Polovich M, et al: 2013 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards Including Standards for the Safe Administration and Management of Oral Chemotherapy. J. Oncol. Pract. 2013; 9:5s-13s.

18 Standard 3.2: Psychosocial Distress Screening The cancer committee develops and implements a process to integrate and monitor on-site psychosocial distress screening and referral for the provision of psychosocial care as the standard for patients with cancer The distress screening MUST be reviewed in person on the day of the identified pivotal medical visit.

19 Efficient and easy-to-use instruments now exist New technologies Positive effect on patient outcomes Improved treatment adherence1 Increased quality of life2 Increased patient satisfaction3 Increased quality of life and length of life4 Funding linked to supportive care 1. Institute of Medicine: Cancer Care For The Whole Patient: Meeting Psychosocial Health Needs. Washington, DC, National Academies Press; Carlson LE, Groff SL, Maciejewski O, et al. Screening for distress in lung and breast cancer outpatients: a randomized controlled trial. J Clin Oncol 2010;28(33): Taenzer P, Bultz BD, Carlson LE, et al. Impact of computerized quality of life screening on physician behaviour and patient satisfaction in lung cancer outpatients. Psycho-oncology. 2000;9: Temel JS, Greeg JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM. 2010;363(8):

20 Automated touch-screen tool designed to enhance patient care through simple to use technology Identifies problem-related distress Facilitates patient, physician and multi-specialist communication Automates personalized referrals and provides tailored patient education materials in real time

21 Touch screen implemented in June ,000 screenings 32,000 patients 70 + physicians 7 out of 11 of outpatient clinics 1% refusal rate Distress screening and questionnaires tailored to specific populations

22 Gives patients a voice and common language to partner with their health care providers Teaches patients about common problems De-stigmatizes requests for help Enhances communication with health care team Raises the expectations of psychosocial services Improves continuity of care Helps ensure timely referral to supportive services Tailored education materials are printed in real time Identifies personal needs Prioritizes immediate needs Streamlines tailored support services Is user-friendly

23 Outpatient Medical Oncology Hematology/HCT Breast Cancer Surgery Couples Clinic Head and Neck Plastics Gynecology Urology Pediatrics Psychiatry Additional Sites ICU (caregivers) Pre-Anesthesia and expanding

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26 Patient-Friendly Interface Item Format

27 Attention Dr. Bertram Yuh, Your patient, XXXXXXXX [MRN: XXXXXX], seen on 6/27/2015 1:07:33 PM, is requesting help from you or a member of your team. MD: Preferred spoken language - SPANISH Racial/ethnic background - LATINO/HISPANIC Patient is experiencing pain at this time Requested information on clinical trials Advance Directive - Yes, but COH does not have a copy Have you had a discussion with your loved ones about who you would want to speak for you (your decision maker) and what your wishes are - Yes, I have discussed with my immediate family PE/RN: Sleeping - MODERATE PROBLEM (EDU materials provided) Controlling my urine or stool - MODERATE PROBLEM (EDU materials provided) Pain - SEVERE PROBLEM (EDU materials provided) MSW: Transportation - MODERATE (MSW info provided) Being unable to take care of myself - MODERATE (MSW info provided) Other: Would you like to receive information about upcoming courses and events at City of Hope? Please type your address below. (This information will not be shared with another entity): XXXXXXXX@GMAIL.COM Survey Title: ACOS SupportScreen - English Survey Language: English If you have any questions or concerns about this screening process please contact Matthew Loscalzo at mloscalzo@coh.org

28 Quickly and efficiently screens all patients as standard of clinical care Presents an organized list of problems Ability to anticipate workload problems Linked ICD-9 codes support enhanced medical charting Takes less time to identify patient problems Identifies patients who are at high risk for disruption of clinic services/treatment and lack of compliance Streamlines triage and referral to appropriate resources Focuses more on their area of expertise Reduces data entry and verification burden Creates data for grants, publications, and programs Easily exported to most commonly used software applications More efficient data interpretation

29 Raises the standard of clinical care Screens every new patient Increases patient satisfaction Identifies and triages patients in real time Increases safety Minimizes disruption of processes and systems Enhances staff efficiency Reduces no-shows Linked ICD-9 codes increase revenue Reduces administrative costs Creates development opportunities Grows competitiveness in the market place Is a differentiator in the scientific community Can be a model for other institutions

30 Screening for distress alone is not adequate Screening is a team endeavor Patients and families are not the barrier Tension between research and patient centered clinical care is an opportunity for collaboration No one instrument can do it all prioritize

31 Integration into the electronic medical record (EMR) Tailored for special populations Web-based screening from home New technologies (cell phone and web-based) Partnerships with health care, technology Real-time linkages to community-based physicians and organizations Automated personalized health messages Research from subjective reports to biomarkers to interventions