American American College College of of Surgeons 2013 Content 2014 Content cannot be be reproduced or or repurposed without written permission of of the the American College College of Surgeons. of Surgeons. The Role of the Psychosocial Services Coordinator in Distress Screening Teresa L. Deshields, Ph.D. Siteman Cancer Center The Psychosocial Services Coordinator Who? Mental health professional trained in the psychosocial aspects of cancer care Oncology social worker (OSW C preferred) Clinical psychologist Other mental health professional 2 The Psychosocial Services Coordinator What? Works collaboratively with established departments and community organizations Goal: to provide, improve, and expand the range of psychosocial services 3
4 Accreditation 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. Accreditation Standard 3.2 Psychosocial Distress Screening Purpose: to develop a process to incorporate the screening of distress into standard care to provide patients identified with distress with resources and/or referral for psychosocial needs. 5 Accreditation Standard 3.2 The Psychosocial Services Coordinator is required to: oversee distress screening report to the cancer committee annually 6
7 Process Requirements for Distress Screening Timing of screening Method Tools Assessment and referral Documentation Timing of Screening Screening frequency: minimum of 1 time/patient at a pivotal medical visit determined by the program. Preference for times of greatest risk for distress: time of diagnosis transitions during treatment (such as from chemotherapy to radiation therapy) transitions off treatment 8 Timing of Screening Pivotal medical visits : Diagnosis Presurgical and postsurgical visits First visit with medical oncologist to discuss chemotherapy Routine visit with radiation oncologist Post chemotherapy follow up visit 9
10 Method of Screening Method to be determined by the program Tools for Screening Program selects tool. Preference for Standardized, validated instruments Established clinical cutoffs when possible 11 For moderate or severe distress, the oncology team is to identify and examine the psychological, behavioral and social problems of patients that interfere with their ability to participate fully in their health care and manage their illness and its consequences. 12
13 Evaluation to: confirm physical, psychological, social, spiritual, and financial support needs indicate the need to link patients with psychosocial services offered on site or by referral Documentation Documentation in the medical record: Screening Referral or provision of care Follow up 14 How to Make It Happen 15
16 Getting Started Educating your cancer committee Pulling together a team to do the work Choosing your methodology Rolling out distress screening Educating the Cancer Committee Generate buy in: cancer committee, key administrators, clinicians Start early, provide updates Determine who will make this happen/ push through stuck points 17 Choosing Your Methodology Vulnerable Timepoints Finding suspicious symptom During diagnostic workup Finding out diagnosis Awaiting treatment Change in treatment End of treatment Discharge from hospital Medical follow up/ surveillance Transition to survivorship Treatment failure Recurrence, progression Advanced cancer End of life 18
19 Choosing Your Methodology Timing Pivotal medical visit Benefits: responsive to clinically sensitive timepoints for the patient, systematic Costs: will inflate your rate of distressed patients, may restrict your population of patients screened Every patient, every visit Benefits: systematic, can see changes over time, doesn t assume pivotal is the same for all Costs: more labor/ cost intensive,?patient annoyance? Choosing Your Methodology Patient reported Benefits: component of patient centered care, validates patients reporting problems/ distress Costs: slows down the clinic flow, must be scored/ interpreted Clinician reported Benefit: can be part of review of systems, may facilitate documentation and/or referral Costs: missed distress, time intensive, social desirability effects with patients 20 Choosing Your Methodology Paper and pencil Benefits: less costly, can happen anywhere Costs: following the paper, need to score/ interpret, doesn t facilitate documentation (in patient chart, for COC) Electronic Benefits: automatic scoring, may facilitate documentation, potential for automated referrals Costs: financial cost, patient interface with technology (independence in completing, access to equipment) 21
22 Tools Considerations Multifactorial nature of distress Single focus measures not sufficient Psychometrically valid tool Validated with cancer patients Patient burden Brief, easy to understand Clinic burden Brief, easy to communicate Ease of scoring/ interpretation Tools Options Distress Thermometer Usually used with problem list Most used, researched tool Easy to score Patient Health Questionnaire 4 Focused on depression, anxiety; total score reflects distress Very brief General Health Questionnaire 12 Brief Symptom Inventory 18 Others 23 National Comprehensive Cancer Network Distress Thermometer Please tell me the number (0-10) that best describes how much distress you have been experiencing in the past week including today. Extreme distress No distress 24
25 National Comprehensive Cancer Network Problem List (38 items) Issues: Who will identify distressed patients How to alert medical team to positive screens Who will interact with distressed patients What to do with distressed patients 26 Who will identify distressed patients? Depends on methodology selected If paper and pencil, someone must score If electronic, someone must flag result 27
28 How to alert medical team to positive screens? Field in electronic medical record Verbal alert from person doing screening Flag on chart What to do with distressed patients? Consider range of contributing problems (not all psychological) Identify resources to address various problem areas (do this first!) Resource can be internal or external How to make an effective referral 29 Who will interact with distressed patients? To discuss positive screening results with patient To assess patient s acuity To triage, determine appropriate referral 30
31 Documentation Issues: Who will document? What to document? Instrument used, screening result, and clinical interpretation of screening Response to positive screen, including any referrals made and plan for follow up Patient s acceptance or refusal of referral(s) Lessons Learned at Siteman Linking screening with vitals assessment is feasible Patients willing to respond verbally Limited problems with extended conversation, clinic delays Anticipatory anxiety means elevated scores in new patients Follow up/ triage done by medical team fits with usual practice 32 Common Obstacles Lack of buy in at institution No collaborators to develop institutional plan Difficulty selecting screening tool Lack of agreement re: timing of screening Concern re: patients acceptance of process Problems with documentation 33
34 QUESTIONS?