NCCN goes further to state that quality psychosocial care includes systematic f/u and re-evaluation.
Commission on Cancer standards used for accreditation
Revised/updated every 3 years
Need for shared vocabulary, shared vision, clear communicationDiverse voices helps development (e.g., not all clinicians work alike)Radical changes in workflow demands senior leaders favor and drive itClinic workflow evolves constantly and a system needs to accommodate the need for rapid alterations
Psychosocial Distress Management
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 />
Agenda<br />Guidelines for psychosocial distress screening<br />Barriers to screening<br />Pilot project at Lurie Comprehensive Cancer Center<br />Lessons learned<br />
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 />
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 />
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 />
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 />
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 />
Are you able to walk from one room to another?
Are you able to stand without losing your balance for 1 minute?
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. www.nihpromis.org.<br />PROMIS<br />Patient-Reported Outcome Measurement Information System<br />
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 />
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 />
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 />
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 />
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 />
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 />
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 />
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 />
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 />