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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.