PCQN QI Collaborative Screening for Spiritual Needs & Anxiety Screening & Improvement January 16, 2017
Agenda Spiritual screening data Structure for anxiety QI collaborative Anxiety data Strategy exchange summary Discussion: How? Who? Facilitators and barriers? Next steps 1/17/2017 2
Percent Screened for Spiritual Needs: Monthly Trends 1/17/2017 3
Percent Screened for Spiritual Needs: Member Comparison Chart 1/17/2017 4
Percent Screened for Spiritual Needs: Monthly Trends 80% 70% 60% 50% 40% 30% 20% PCQN Spiritual Screen Collaborative 10% 0% 1/17/2017 5
Percent screened:7/25/16 01/09/16 (numbers represent # of patients screened) 100% 90% 80% 70% 60% 130 143 249 171 381 92 203 158 33 325 50% 146 249 40% 30% 20% 50 117 10% 0% 1/17/2017 6
Sustaining the Process Design the process to fit into a natural work flow Put ownership in a group Ensure data is readily accessible & visible
Anxiety: Screening & Improvement 1/17/2017 8
QI Collaborative Commitments Open to learning / willingness to experiment Share experiences Join as many calls as you can
Background Why Anxiety? PCQN Conference: 70% of cancer patients have symptoms of anxiety Many cancer patients develop PTSD-like symptoms Anxiety closely associated with pain 1/17/2017 10
QI Framework Amend your plan(s) Brainstorm opportunities for improve. Examine baseline data Set a SMART goal Make your plan specific (who, what, when) Report back to the group Keep track of your progress Try out your plan(s)
Goals of Anxiety QI Initiative Primary: Increase % of pts screened for anxiety (at first visit and during overall admission) Increase % of pts with improved anxiety from 1 st to last assessment Secondary: Identify & implement best practices for screening pts for anxiety Improve our understanding of how to address anxiety with our patients
PCQN Anxiety Data - Inpatient 1/1/2016 12/31/2016 64.5% of patients were screened for anxiety at time of first symptom assessment
PCQN Anxiety Data - Inpatient 1/1/2016 12/31/2016 68.7% of patients were screened for anxiety during course of consultation.
PCQN Anxiety Data - Inpatient 1/1/2016 12/31/2016 67.7% of patients improved from 1 st to 2 nd assessment. 83.3% of patients improved from 1 st to last assessment
PCQN Data: Anxiety improvement Young people are less likely to improve Men & women equally likely to improve No significant differences by diagnosis Pain improvement is a/w anxiety improvement Anxiety improvement is a/w POLST completion Anxiety improvement a/w discharge to hospice Anxiety improvement is a/w shorter hospital LOS 1/17/2017 16
PCQN Report Variables (Trend, MC) Anxiety symptom assess first visit Anxiety symptom assess entire consult Symptom improvement anxiety
Summary of Strategy Exchange How do you typically screen for/assess anxiety in patients? Ask patient directly (0-10; 0-3 scale), use related words, or intuit from story Use validated instrument (e.g. NCCN distress thermometer) Ask family member / caregiver Incorporate into questions about psychosocial concerns Suggestions from Dr. Scott Irwin: Do you worry a lot? Are you often fearful? Do you feel anxious, nervous, or on edge? Would your friends or family say that you are a worrier? How s your sleep? Screening tools: HADS, GAD-7, PCQ-4 1/17/2017 18
Summary of Strategy Exchange What challenges have you encountered: Time What questions? How & who? Difficult to rate Seems obvious and/or suggestive to talk about Team discomfort / lack of training or tools Patient or family discomfort Cultural differences Difficult with intubated pts and patients w/ dementia 1/17/2017 19
Summary of Strategy Exchange What strategies have been helpful? Normalizing Asking open ended questions; Using words other than anxiety (e.g. worry, nervous) Use all members of the PC team Involve family Disconnect w/ technology Just do it! 1/17/2017 20
Summary of Strategy Exchange Treatments & Techniques: Listening, allowing patients to tell their story Normalizing, providing education to patient and family Giving patients sense of control (environmental, shared decision making, ACP) Spiritual or social work support Multimodal, integrative therapies Medications 1/17/2017 21
Management Supportive counseling Relaxation techniques Pharmacotherapy Combinations are best Slide from: Dr. Scott Irwin
Management: Supportive Counseling Weave into routine care Include family when possible Identify pt & family strengths, coping strategies Improve understanding of situation Educate about modifiable factors Create a different perspective Slide from: Dr. Scott Irwin
Management: Complimentary Therapies Guided Imagery Muscle relaxation Hypnosis Meditation Massage Aromatherapy Healing touch Energy therapy Biofeedback Exercise (if possible) Bright light exposure Avoid caffeine, alcohol Treat insomnia Slide from: Dr. Scott Irwin Payne DK, Massie MJ. Anxiety in palliative care. In: Breitbart W, ed. Handbook of Psychiatry in Palliative Medicine. New York, NY: Oxford University Press; 2000:435 Carter C, Holloway R, Schwenk TL. Patient Care. November 15,1994:36 52.
Management Medications Benzodiazepines SSRIs Gabapentin (100 mg q1hr) Trazodone (25-50 mg q1hr) Buspirone
Discussion of Screening 1. How can we best screen for anxiety? Not consistent Physicians mostly ask about anxiety directly Multi-question tool may not be realistic inpt Is it kosher to have family input? Different patients may relate to different screening questions; analogies to spiritual screening here Value of asking directly, though word choice may vary (anxiety, worried, concerned, stressed, nervous, on edge, sleep/keeps them awake at night) Just talk about it, perceived barriers > real barriers?, pts may be receptive Helpful to involve family when patients are non-verbal, signs of anxiety Pick up on non-verbal queues and reflect on it 1/17/2017 26
Discussion of Screening 2. Who should screen for anxiety and when? Bedside nurses, social work Every encounter Different members of the team may get different responses 3. What will facilitate practice improvement for your team? How will you overcome barriers? 1/17/2017 27
Discussion of Screening 3. What will facilitate practice improvement for your team? How will you overcome barriers? Discussion w entire team Anxiety screening needs to be paired with ability to intervene Keep track of this data 1/17/2017 28
Next Steps 1/17/2017 29
STEP 1: Plan Examine baseline data and current process Set a SMART improvement goal: Specific Measureable Achievable Relevant Time-Bound Make a plan for 1 st step(s) to achieve this goal
Thank you! See you on the next QI collaborative call: February 14 at 12:00pm PST Kara Bischoff: kara.bischoff@ucsf.edu Angela Marks: angela.marks@ucsf.edu Rachel Stone: rachel.stone2@ucsf.edu 1/17/2017 31