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Psychosocial Distress Management


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Nan Rothrock, PhD

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Psychosocial Distress Management

  1. 1. Psychosocial Distress Management at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University<br />Nan Rothrock, PhD<br />Department of Medical Social Sciences<br />Northwestern University<br />
  2. 2. Agenda<br />Guidelines for psychosocial distress screening<br />Barriers to screening<br />Pilot project at Lurie Comprehensive Cancer Center<br />Lessons learned<br />
  3. 3. Distress<br />A multifactorial unpleasant emotional experience of a psychological cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis. <br />National Comprehensive Cancer Network. NCCN Distress Management Guidelines version 1. 2011.<br />
  4. 4. Increasing Attention on Screening for Psychosocial Distress in Cancer<br />Institute of Medicine’s Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs (2007)<br />Importance of distress screening <br />Importance of addressing psychosocial health in quality cancer care<br />NCCN <br />“Distress should be recognized, monitored, documented, and treated promptly at all stages of the disease and in all settings”<br />National Comprehensive Cancer Network. NCCN Distress Management Guidelines version 1. 2011.<br />
  5. 5. Commission on Cancer<br />American College of Surgeons (ACoS) Commission on Cancer (CoC) 2012 Cancer Program Standards<br />“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”<br />Oversight by psychosocial representative on cancer committee<br />
  6. 6. CoC Requirements<br />Minimum frequency – once per pivotal medical visit (eg, diagnosis, transitions in treatment, transitions off treatment)<br />Mode of assessment determined by program<br />Preference for standardized, validated tools with established clinical cutoffs<br />
  7. 7. CoC Requirement (cont.)<br />Moderate/severe distress<br />“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”<br />After identifying needs, link to appropriate psychosocial services on site or by referral<br />Documentation in medical record (screening, referral/provision of care, follow-up)<br />IOM Report. 2007.<br />
  8. 8. HOW?<br />
  9. 9. Barriers<br />How do I measure distress?<br />How do I know what level of distress warrants follow-up? <br />How do I get that information to someone <br />who can do something about it?<br />
  10. 10. Measurement<br />MANY distress measures (Distress Thermometer, Hospital Anxiety and Depression Scale [HADS], Patient Health Questionnaire [PHQ]-9, etc)<br />
  11. 11. Single-Item Distress Thermometer<br />Quick, easy, but not always sufficient<br />Butt Z, et al. J Pain Symptom Manage. 2007; 35:20-30.<br />
  12. 12. Measurement<br />Ideal measure: brief, precise, covers relevant issues in cancer<br />How can you be brief AND comprehensive?<br />Computer Adaptive Tests (CATs)!<br />
  13. 13. <br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br />Item<br />1<br />Item<br />2<br />Item<br />3<br />Item<br />4<br />Item<br />5<br />Item<br />6<br />Item<br />7<br />Item<br />8<br />Item<br />9<br />Item<br />n<br />100<br />50<br />0<br />Physical Functioning Item Bank<br /><ul><li>Are you able to run 5 miles?
  14. 14. Are you able to run or jog for 2 miles?
  15. 15. Are you able to walk a block on flat ground?
  16. 16. Are you able to walk from one room to another?
  17. 17. Are you able to stand without losing your balance for 1 minute?
  18. 18. Are you able to get in and out of bed?</li></li></ul><li>NIH-funded initiative to develop item banks for patient-reported outcomes (eg, fatigue, depression, pain, sexual function, perceived cognitive function)<br />Use across chronic conditions<br />Can be administered as CATs or short forms<br />Scores can be linked to other existing measures<br />Online software (Assessment Center) can administer CATs to patients securely<br />National Institutes of Health.<br />PROMIS<br />Patient-Reported Outcome Measurement Information System<br />
  19. 19. Cutpoints<br />Established cutpoints (within normal limits, mild, moderate, severe)<br />Based on panels of clinical experts<br />Severe category warrants messaging at Lurie<br />
  20. 20. Getting the Right Info to the Right People<br />Integration into electronic health record<br /> - More comprehensive system<br />Messaging to appropriate clinician (oncologist vs social worker)<br /> - Improve daily workflow and time management<br />
  21. 21. Distress Screening at Lurie<br />Patients access Epic MyChart (patient portal)<br />Seamlessly navigated to Assessment Center<br />Patient fills out measures on Assessment Center<br />Scores pushed into Epic under Other Orders<br />In-basket message when results are in Severe category or patient identifies need<br />
  22. 22. Measures<br />PROMIS CATs<br />Depression<br />Anxiety<br />Fatigue<br />Pain interference<br />Physical function<br />Discipline-Specific<br />Social work needs<br />Informational needs<br />Nutritional status<br />Modified Patient-Generated Subjective Global Assessment (PG-SGA)<br />~ 40 questions<br />
  23. 23. In-Clinic Assessment<br />
  24. 24. Sample Depression Question<br />
  25. 25. Sample Social Work Needs Question<br />
  26. 26. Screening Triage Algorithm<br />
  27. 27. Provider Messaging: Symptom Reports<br />Message provides total score, range, and patient’s answers<br />The following items contributed to a score of Severe <br />In the past 7 days:<br />“I felt worried.” – Often<br />“I felt frightened.” – Sometimes<br />
  28. 28.<br />Psychosocial Resources<br />
  29. 29. Pilot Tests<br />Phase 1: Pilot administration via iPad<br />Phase 2: Administer via home-based assessment and iPad with improved usability<br />Phase 3: Administer per clinical practice<br />
  30. 30. Phase 1: Usability of iPad Assessment<br />12 Gynecologic oncology patients<br />Median age = 61.5 (range, 34-73)<br />Administration approximately 10 minutes (range, 8-16 minutes)<br />20% required assistance<br />12/12 patients would complete at every MDV<br />Sample feedback: Font too small<br />
  31. 31. Phase 2: Real-Time Workflow in Clinic<br />N = 11<br />Median age = 54 (range, 35-76)<br />Mean 1.6 minute to distribute iPad and check-in patient<br />Administration 10.7 minutes (range, 6-22 minutes)<br />64% complete in waiting room; 27% finish in exam room<br />18% required tech assistance (Internet connection)<br />
  32. 32. Patient Feedback<br />
  33. 33. Patient Feedback<br />
  34. 34. Patient Feedback<br />
  35. 35. Patient Feedback<br />
  36. 36. Clinic Staff Feedback<br />
  37. 37. What Have We Learned?<br />
  38. 38. Lessons Learned<br />Integration of software systems takes longer than you think it should<br />Clinicians, patients, operations staff, and software vendors have competing urgencies requiring prioritization<br />Each group has own language and culture<br />And not all members of a group are alike<br />Patients are not as scared of technology as some may think<br />Logistic issues are critical and should be considered at the outset of an initiative<br />
  39. 39. NextSteps<br />Implementation in clinic for all new patients receiving treatment at center (not 2nd opinions)<br />Set up schedule for follow-up assessments (eg, monthly)<br />Later -> customized assessment per provider (eg, incorporate neuropathy-specific measure for taxanes)<br />
  40. 40. Thank You!<br />Acknowledgments <br />Funding provided by the Lurie Comprehensive Cancer Center<br />Resources:<br /><br /><br /><br />David Cella<br />Lynne Wagner<br />Laura Abraham<br />Kile King<br />Richard Gershon<br />Julian Schink<br />Darren Kaiser<br />RohiniBahl<br />I. Syed<br />Steven Rosen<br />Mary Jo Graden<br />Virginia Nothnagel<br />Mary O’Connor<br />Shalini Patel<br />Michael Bass<br />