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11/30/2011
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Cancer Program Standards 2012
Continuum of Care Services:
Psychosocial Distress Screening
Lynne I. Wagner, Ph.D.
Associate Professor,
Department of Medical Social Sciences
Northwestern University,
Feinberg School of Medicine
Chicago, IL
Psychosocial Distress Screening
• Purpose
– To provide participants from CoC-accredited cancer
programs, or those seeking accreditation, with
information about the definition and requirements,
documentation, and compliance expectations for
Standard 3.2 Psychosocial Distress screening
– To provide a general primer on the psychosocial
distress screening concept and spotlight a case study
demonstrating the use of empirically validated tools
and technology to assess and triage
Psychosocial Distress Screening
• Learning Objectives
– Understand the rationale, requirements, and
compliance expectations for the CoC Standard 3.2
Psychosocial Distress Screening
– Illustrate the key concepts of psychosocial distress
screening including available resources and training
programs
– Demonstrate, through a case study, how a cancer
programs has planned, implemented and evaluated a
psychosocial distress screening program
– Identify resources to tailor implementation of distress
screening program
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Psychosocial Distress Screening
Phase in 2015
• Standard 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
Psychosocial Distress Screening
• Process Requirements
– Timing of Screening: Patients with cancer are offered
screening for distress a minimum of 1 time per patient
at a pivotal medical visit to be determined by the
program.
– Method: The mode of administration (such as patient
questionnaire, clinician-administered questionnaire) is
determined by the program
Psychosocial Distress Screening
• Process Requirements (cont…)
– Tools: Facilities select the tool to be administered to
screen for current distress. Preference is given to
standardized, validated instruments with established
clinical cutoffs.
– Assessment and Referral: As recommended in the 2007
IOM report, if there is clinical evidence of moderate or
severe distress, the patient’s 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.
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Psychosocial Distress Screening
• Process Requirements (cont…)
– Documentation: Screening, referral or provision of
care, and follow-up are documented in the patient
medical record to facilitate integrated, high-quality
care.
Psychosocial Distress Screening
• Documentation
– The program completes the Survey Application
Record (SAR)
– The program provides cancer committee minutes
along with other sources that document the methods
implemented to monitor and evaluate psychosocial
distress screening.
Psychosocial Distress Screening
• On-Site Survey
– Surveyor discusses the psychosocial distress
screening process with the cancer committee
• Rating
– 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.
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Defining Distress
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.
NCCN Distress Management Guidelines version 1.2011
Why is Screening for Distress Important for
Provision of Quality Oncology Care?
• Distress is prevalent
• Unmet psychosocial needs compromise quality
of life and may interfere with cancer outcomes
– Institute of Medicine, 2007
• Distress not recognized in routine oncology care
• Addressing distress improves quality of life
• Increasing attention to distress screening as a
component of quality oncology care
Distress is Prevalent
• Distress is common in general population
-46.4% will meet DSM-IV criteria for lifetime episode
-Over 25% meet DSM-IV criteria in current year
Kessler & Wang Ann Rev Public Health 2008
• Elevated risk of distress among adults with cancer
-29-43% rate of distress among sample of 4,500 adults
with seven common types of cancer
Zabora et al. Psych-Onc 2001
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Distress is Prevalent
• Cancer survivors demonstrate elevated rates of
distress -National Health Interview Survey data on 4636
survivors of adult cancers 5 years or more post-
treatment and 122, 220 controls
-Cancer survivors significantly more likely to
experience distress (OR 1.4)
Hoffman et al. Arch Intern Med 2009
• Cancer survivors (n=398) demonstrated impairment
relative to comparison group (n= 796) with declining
mental health after cancer diagnosis Costanza et al. Health Psychology 2009
Consequences of Distress
• Impairs QOL
• Decreased employment functioning
• Decreased medical adherence
• Increased medical costs
• Increased health risk behaviors
• Decreased health protection behaviors
Distress Undetected in Oncology Settings
• Physicians substantially underestimate oncology
patients’ psychosocial distress Fallowfield et al. 2001
Keller et al. 2004
Merckaert et al. 2005
• Only 53% of NCCN institutions routinely screen for
distress
Jacobsen & Ransom 2007
• Patients willing to discuss distress only if MD initiates,
however MDs defer to patients to raise concerns
Detmar et al JCO 2000
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Increasing Attention on Screening for
Psychosocial Distress in Cancer
• Institute of Medicine’s Cancer Care for the Whole Patient:
Meeting Psychosocial Health Needs (2007)
– Importance of distress screening
– Importance of addressing psychosocial health in
quality cancer care
• NCCN
• “Distress should be recognized, monitored,
documented, and treated promptly at all stages of the
disease and in all settings”
• American Society of Clinical Oncology Quality Oncology
Practice Initiative
– One of 25 “core” quality indicators
NCCN Distress Management Guidelines version 1.2011
www.qopi.asco.org
Distress Screening: Empirical Support
• 585 patients with breast cancer and 549 patients
with lung cancer randomized to:
(1) minimal screening
(2) full screening
(3) screening plus triage
• Screening conducted online
• High level of distress at baseline
• Triage condition significantly lower distress at 3
months compared to minimal screening
Carlson et. al 2010
Distress Screening: Process Requirements
• Timing of Screening
• Method of Screening
• Screening Tools
• Assessment and referral
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Timing of Screening
• ACoS Standard
Timing of Screening: Patients with cancer are offered
screening for distress a minimum of 1 time per patient at a
pivotal medical visit to be determined by the program
Assess prior to second medical visit
• Time of transition during cancer care
associated with increased risk for distress:
diagnosis, start of treatment, transition to a
new treatment modality, end of treatment,
at recurrence, at surveillance visits
Screening Methods
Method Pros Cons Examples
Clinician-
administered
questions
-Incorporate with ROS
-Immediate interpretation
and triage
-Time intensive
-Patient may not
disclose sensitive
personal information
Routine pain
assessment
Patient
questionnaire:
Paper based
-Can be completed at
patient convenience, eg.
while waiting for appts
-Provides more privacy
than face-to-face
questions
-Requires real-time
review of responses for
completeness of
responses, elevated
distress
-Requires patient
literacy skills
Patient intake
questionnaire
Patient
questionnaire:
Electronic
assessment
-Integration with electronic
health record possible
-Automated scoring and
interpretation
-Automated triage
possible
-Requires patient to
have Internet access or
in-clinic access
-Programming for EHR
integration costly
See case
example from
RHLCCC
Distress Screening Tools
• NCCN Distress Thermometer
• PHQ-9
• PHQ-2
• Hospital Anxiety and Depression Scale
• Brief Symptom Inventory – 18
• Beck Depression Inventory
Instrument
length
Sensitivity,
specificity
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Single Item Distress Thermometer
• Quick, easy, but not always sufficient
Screening Cut-off = 5
Sensitivity Specificity
Anxiety .85 .78
Depression .63 .69
Butt et al. JPSM 2007; 35:20-30
Case Example:
RHLCCC Screening Initiative
• Right tools: Brief, validated, clinically useful
• Right technology: Electronic assessment and
triage to manage volume
• Right team: Robust inter-disciplinary
psychosocial team to manage referrals
Bringing advances in measurement science
and technology to the clinical forefront
Screening Initiative: Tools and Technology
• Patient Reported Outcomes Measurement
Information System (PROMIS)
• NIH-funded network to develop PROs
• www.nihPROMIS.org
– Brief, precise measures of cancer-related
symptoms through computer adaptive testing
• Assessment Center provides platform for online
administration of PROMIS measures
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Tools: Domains to be Assessed
PROMIS Computer
Adaptive Testing:
• Depression
• Anxiety
• Fatigue
• Pain
• Physical function
TOTAL LENGTH: ~ 40 items
Discipline-Specific
Measures:
• Social work needs
• Informational needs
• Nutritional status
– Modified Patient-
Generated Subjective
Global Assessment
(PG-SGA)
Sample Depression Question
Physical Functioning Item Bank
Item
1
Item
2
Item
3
Item
4
Item
5
Item
6
Item
7
Item
8
Item
9
Item
n
100 50 0
•Are you able to run five miles?
•Are you able to run or jog for two miles?
•Are you able to walk a block on flat ground?
•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?
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RHLCCC Social Work Needs Assessment
Work Flow: Assessment and Messaging
New patients receive instructions to activate EHR
patient communication portal (Epic MyChart)
Patients access Epic MyChart
MyChart links seamlessly with Assessment
Center within organization firewall
Patient completes assessment through
Assessment Center (at home or in-clinic)
Provider messages and triage managed through
Epic health record integration
In-Clinic Assessment Provided via iPad
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Depression,
Anxiety
1) MD, RN message when sx
moderate/severe (70th %ile)
2) Psychology, Social work
copied to initiate consult
Practical,
financial
concerns
Social worker sent
message with list of needs
expressed by patient to
initiate consult
Screening Triage Algorithm
Electronic Health Record Integration:
Automated Triage
Patients with severe depression, anxiety or
reporting social work needs automatically triaged
to SW pool through in-basket message
Electronic Health Record Integration
Items administered, responses, T-score and
descriptor of range populated
in EHR
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RHLCCC Screening: Patient Feedback
1 2
7
0
2
4
6
8
Not at all A little bit Somewhat Very much
Did the survey ask questions about aspects of your health and well-being that are important to you?
4
6
0
1
2
3
4
5
6
7
Not at all A little bit Somewhat Very much
Do you think it's important for your medical team to know your results
from these surveys?
• Median age = 61.5 (range 34-73)
• Administration 10.7 minutes (range 6-22 minutes)
• All patients reported assessment was “easy” or “very
easy”
• Questions too personal? 100% “Not at all”
Case Example:
RHLCCC Screening Initiative
• Right Tools: Brief, validated, clinically useful
• Right Technology: Electronic assessment and
triage to manage volume
• Right Team: Robust inter-disciplinary
psychosocial team to manage referrals
www.AssessmentCenter.net
Bringing advances in measurement science
and technology to the clinical forefront
Implementing Distress Screening Standard
at Your Institution
• Identify psychosocial staff at your institution:
– Social worker, case management, ACS navigator
– Faculty: Psychology, Social work, Health services
• Timing: New pts, trajectory of care, point of transitions
• Methods: Clinician administered, patient questionnaires
• Tools: Select tool and cut-off based on resources for
administration; NCCN DT + PHQ-2
• Assessment and Referral:
– Identify local and national resources for referral
– Provide patients with educational materials, resources
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Distress Management:
Assessment and Referral
• On-site psychosocial team
– Conferences, webinars on building
psychosocial teams
• NCI-funded training programs for oncology
staff
• Referral to psycho-oncology providers
866-APOS-4-HELP
www.apos-society.org
Distress Management:
Assessment and Referral
• Referral to cancer support organizations
– Community-based support groups
– Telephone-based counseling
– Internet-based support groups
– Patient navigation
800-813-HOPE; www.cancercare.org
Psychosocial Distress Screening
Provider Resources
• American Society of Clinical Oncology
www.asco.org
• American Psychosocial Oncology Society
www.apos-society.org
• National Cancer Institute
Physician Data Query (PDQ)
www.cancer.gov
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Questions?
Please visit the CoC’s CAnswer Forum to post
questions on this Webinar.
http://cancerbulletin.facs.org/forums/
Additional resources on the new Standards can be
found at the CoC Best Practices Repository:
http://www.facs.org/cancer/coc/bestpractices.html
Login instructions can be found in the attachment
posted along with the presentation handouts.