1. Are You Ready to Assess For Distress? Lee Tremback, MA, LCSW, OSW-C Oncology Social Worker Eastern Connecticut Cancer Institute John A. DeQuattro Cancer Center Manchester, CT

2. National Comprehensive Cancer Network Psychosocial Care Guideline Panel Formed in 1997 Goals: ◦ 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

3. National Comprehensive Cancer Network Psychosocial Care Guideline Panel 28 Panel Members: ◦ 15 female, 13 male ◦ 16 psychiatrists/psychologists ◦ 4 oncology physicians ◦ 4 nurses ◦ 2 social workers ◦ 1 chaplain ◦ 1 patient advocate

4. 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.

6. Institute of Medicine 2007 Report Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Recommendations: ◦ 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

7. NCCN 2012 Standards of Care Distress 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.

8. NCCN 2012 Standards of Care (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.

9. NCCN 2012 Standards of 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

10. American College of Surgeons (ACoS) Commission on Cancer (CoC) Cancer Program Standards 2012: Ensuring Patient-Centered Care Must be in place by 2015 Standard 3.2: Psychosocial Distress Screening

11. Psychosocial Distress Screening S 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.

12. 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.

14. Where to start? Gradual Implementation: ◦ 1 st Radiation Oncology (private practice) ◦ 2 nd Medical Oncology (private practice) ◦ 3 rd Ambulatory Medical Unit (hospital-based) ◦ 4 th Inpatient Units

15. What is the cutoff score? No right or wrong answer Can always change later We chose 5

16. Definition of Pivotal Medical Visit: Radiation Oncology – teaching visit during 1 st /2 nd treatments. Medical Oncology – during 1 st chemo visit AMU – during 1 st chemo visit Inpatient – if diagnosed during hospital stay and getting chemo

17. Standardized, validated instrument After 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

21. Write your policy Emphasize 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

22. Assessment & Referral If 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.

23. Documentation Screening, 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.”

24. Reporting to Cancer Committee Determine data collection process Design 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?

25. Are You Ready to Assess For Distress?