Are You Ready Are You Ready to Assess For Distress?to Assess For Distress?

Lee Tremback, MA, LCSW, OSW-COncology Social WorkerEastern Connecticut Cancer Institute John A. DeQuattro Cancer CenterManchester, CT

National Comprehensive Cancer National Comprehensive Cancer Network Psychosocial Care Network Psychosocial Care Guideline PanelGuideline PanelFormed in 1997Goals:

◦Identify patients needing psychosocial help

◦Address barriers to psychosocial care caused by stigma of psychological/psychiatric problems

◦Develop ways for patients to obtain psychosocial resources

National Comprehensive Cancer National Comprehensive Cancer Network Psychosocial Care Network Psychosocial Care Guideline PanelGuideline Panel28 Panel Members:

◦15 female, 13 male◦16 psychiatrists/psychologists◦4 oncology physicians◦4 nurses◦2 social workers◦1 chaplain◦1 patient advocate

Definition of Distress:Definition of Distress:A multifactorial, unpleasant

experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer, its physical symptoms, and its treatment. Distress extends along a continuum ranging from normal feelings of vulnerability, sadness, and fear to disabling conditions such as clinical depression, anxiety, panic, isolation, and existential or spiritual crisis.

Institute of Medicine 2007 Institute of Medicine 2007 ReportReportCancer Care for the Whole Patient:

Meeting Psychosocial Health NeedsRecommendations:

◦Screen for distress and psychosocial needs

◦Make a treatment plan to address these needs and implement it

◦Refer to services as needed for psychosocial care

◦Reevaluate with plan adjustment as appropriate

NCCN 2012 Standards of NCCN 2012 Standards of CareCareDistress should be recognized, monitored,

documented & treated promptly at all stages of disease & in all settings.

Screening should identify the level & nature of the distress.

All patients should be screened to ascertain their levels of distress at the initial visit, at appropriate intervals & as clinically indicated, especially with changes in disease status.

Distress should be assessed & managed according to clinical practice guidelines.

NCCN 2012 Standards of Care NCCN 2012 Standards of Care (cont’d)(cont’d)Interdisciplinary committees implement

standards for distress management.Educational & training programs

developed for health care professionals & certified chaplains

Licensed mental health professionals & chaplains readily available .

Insurance contracts include reimbursement for mental health services.

NCCN 2012 Standards of NCCN 2012 Standards of Care (cont’d)Care (cont’d)Patients, families should be

informed that management of distress is an integral part of total medical care; provided with info about psychosocial services

Quality of distress management programs should be included in CQI.

Clinical measurements should include assessment of the psychosocial domain

American College of Surgeons American College of Surgeons (ACoS)(ACoS)

Commission on Cancer (CoC) Commission on Cancer (CoC) Cancer Program Standards 2012:

Ensuring Patient-Centered CareMust be in place by 2015Standard 3.2: Psychosocial

Distress Screening

Psychosocial Distress Psychosocial Distress ScreeningScreeningS 3.2: 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.

Compliance requires:Compliance requires:Screen patients at least once during

the cancer patient’s course of treatment; this screening should occur during a pivotal medical visit.

Patients are screened using a standardized, validated instrument with established clinical cutoffs.

Cancer programs are not penalized for developing their own instrument and constructing their own cutoff scores.

Where to start?Where to start?

Gradual Implementation:◦1st Radiation Oncology (private

practice)◦2nd Medical Oncology (private

practice)◦3rd Ambulatory Medical Unit

(hospital-based)◦4th Inpatient Units

What is the cutoff score?What is the cutoff score?No right or wrong

answerCan always change

later We chose 5

Definition of Definition of PivotalPivotal Medical Medical Visit:Visit:Radiation Oncology – teaching

visit during 1st/2nd treatments.Medical Oncology – during 1st

chemo visitAMU – during 1st chemo visitInpatient – if diagnosed during

hospital stay and getting chemo

Standardized, validated Standardized, validated instrumentinstrumentAfter 6 month trial using NCCN

instrument, reviewed our experiences:◦Physical problems already assessed by

nurses◦Didn’t address Advance Directives,

personal care needs, family health issues, etc.

◦Didn’t like calling them all problems◦Needed more thorough assessment of

depression

Write your policyWrite your policyEmphasize that patients are

continually assessed by the cancer center treatment team for physical, psychological, social, financial & spiritual distress

Include:◦Timing of Screening◦Method◦Tools◦Assessment & Referral◦Documentation

Assessment & ReferralAssessment & ReferralIf score is over 5:

◦Identify & examine the psychological, behavioral & social problems of patients that interfere with their ability to participate fully in their health care and manage their illness and its consequences.

◦Confirm the presence of physical, psychological, social, spiritual, and financial support needs.

◦Indicate the need to link patients with psychosocial services offered on-site or by referral.

DocumentationDocumentationScreening, referral or provision of

care, and follow-up are documented in the medical record.

“Referral received re: pt had a score of 6 on distress screen due to __________.”

“Patient provided with info on CHR energy assistance program.”

“Will continue to assess patient for depression.”

Reporting to Cancer Reporting to Cancer CommitteeCommitteeDetermine data collection processDesign quality improvement study

◦Timeliness of intervention after screening

◦How many referrals to social worker, chaplain, behavioral health come from distress screening?

◦Are all patients screened at least once?

Are You Ready Are You Ready to Assess For Distress?to Assess For Distress?