1. Jean B. Sellers, RN, MSN Administrative Clinical Director Lineberger Comprehensive Cancer Center Nov. 11, 2015 Continuum of Care Standard: Psychosocial Distress Screening

2. Psychosocial Distress Screening “Today, it is not possible to deliver good-quality cancer care without using existing approaches, tools, and resources to address patients’ psychosocial health needs.” “It is not sufficient simply to have effective services; interventions to identify patients with psychosocial health needs and to link them to appropriate services are needed as well.”

3. Guidelines NCCN Guidelines Recommends that all patients be routinely screened to identify the level and source of their distress. Distress should be recognized, monitored and documented and treated promptly at all stages of the disease. IOM Report (2007) Cancer Care for the Whole Pt: Meeting Psychosocial Health Needs Emphasized the importance of screening patients for distress and psychosocial health needs as a critical first step of whole patient care.

4. What is Distress? Multifaceted unpleasant emotional experience of psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope with cancer, it’s physical symptoms, and it’s treatment.” NCCN Guidelines for Clinical Practice 3.2012

5. According to NCI’s Adjustment to Cancer: Anxiety and Distress (PDQ®) prevalence rates for significant levels of distress in patients with cancer range from 22% to 58%

6. Definition Challenges Multi-dimensional Varying course May resolve without treatment How to measure it? What to measure? How to triage patients with limited resources?

7. Research studies show… patients are not likely to initiate a conversation with the physician about distress physician’s often defer to the patients to raise any concerns about distress- related topics My clinic time is so limited… I’m not crazy. I want my doctor to pay attention to my cancer treatment If the stress of this is too much they will tell me

8. Additional Findings Anxiety, rather than depression is more likely to be a problem in cancer survivors and their spouses Mitchell, A, et al. Lancet Oncol 2013 14(8):721-32 Fear of Recurrence was reported as top concern and highest unmet need in both cancer pts and survivors Simard,S. J. Cancer Surv 2013, 7(3):300-22

9. 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 provision of psychosocial care.”

10. Accreditation The purpose of this standard is to develop a process to incorporate the screening of distress into the standard care of oncology patients and provide patients identified with distress resources and/or referral for psychosocial needs. CoC

11. Psychosocial Distress Screening Components Timing-At least once per patient at a pivotal medical visit Method-Questionnaire, physician administered questionnaire, or other method Tools-Prefer standardized, validated instruments with established clinical cutoffs Assessment and Referral Documentation

12. Psychosocial distress screening is a brief method for prospectively identifying and triaging cancer patients at risk for illness- related psychosocial complications that undermine their ability to fully benefit from medical care, the efficiency of the clinical encounter, satisfaction and safety Psychosocial Distress Screening

13. Needs & Resource Assessment Leader Identified patient population Current resources in place a. Internal/external b. Rehab, Behavioral Health c. Support groups, nutrition d. Community (YMCA, public library)

14. Cancer Center Assessment What are you looking for? How to incorporate the information into workflow and records? How often are you going to administer? What are the cut-offs? How is information shared? Triage Elevated scores (suicide) When do we re-assess?

15. Role of Navigator Primary purpose and target of navigation program What experience do navigators have? Is navigation going to have a formal or informal role in screening? Process of communication

16. Timing of Screening: Patients with cancer are offered screening for distress a minimum of one time per patient at a pivotal medical visit to be determined by the program. CoC Process Requirements:

17. Pivotal Medical Visits Time of Diagnosis Pre-surgical & Post-surgical First Chemo; First Radiation Post Treatment Recurrence or Progression Treatment Failure End of Life

18. CoC Process Requirements: Methods: The mode of administration (such as a self-administered questionnaire, clinician-administered questionnaire) is determined by the program.

19. Tools: Facilities select the tool to be administered to screen for current distress. Preference is given to standardized, validated instruments with established clinical cutoffs. CoC Process Requirements

20. TOOLS

22. Title Items Time (min) Constructs Measured Brief Symptom Inventory (BSI-18) 183–5Somatization, depression, anxiety, general distress CancerSupportSource SM 255-10 Distress Thermometer (DT) & Problem List 1,5 (varies) 2–3Distress and problems related to the distress Edmonton Symptom Assessment System 92-3Symptoms Hospital Anxiety and Depression Scale (HADS) 145–10Symptoms of clinical depression and anxiety PHQ-9 95-10Anxiety and depression Psychological Distress Inventory 135-10Psychological functioning (incl. coping) Psychosocial Screen for Cancer (PSSCAN) 2110-15General Distress SupportScreen 53 Psychosocial needs Zung Self-Rating Depression Scale 205–10Symptoms of depression

24. Assessment and Referral: The oncologist, nurse and social worker are 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. CoC Process Requirements

25. NCCN Clinical Practice Guidelines in Oncology-Distress Management

26. Patients who screen over clinical cut-off should receive an assessment by a physician, nurse, and/or social worker Unrelieved physical symptoms should be treated according to disease-specific or supportive care guidelines Clinical evidence of mild distress should signal the need for the primary oncology team to share relevant patient resources When indicated, referrals should be made to mental health services, social work or counseling services, or pastoral services for further evaluation/intervention/referral JNCCN, Volume 11, number 5.5, May 2013 presented by Jimmie C. Holland, MD Distress Screening and the Integration of Psychosocial Care Into Routine Oncologic Care.

27. SOCIAL WORK INTERVENTIONS Emotional support, supportive therapy, patient and family counseling, teach empowerment skills, relaxation, mindfulness meditation techniques MENTAL HEALTH ASSESSMENT (psychiatrist, psychologist, nurse, advanced practice clinician, or social worker) Behavior and psychological symptoms Psychiatric history Use of medications Pain Fatigue Sleep disturbances Other physical symptoms Cognitive impairment Body image and sexuality Capacity for decision making and physical safety

28. Documentation: Screening, referral or provision of care and follow-up will need to be documented in the patient’s medical record. Complete the SAR Provide cancer committee minutes and other sources documenting development and implementation of a process to integrate, monitor and evaluate distress screening and referral for the provision of psychosocial care. CoC Process Requirements

29. 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. The Psychosocial Services Representative on the cancer committee is required to oversee this activity and report to the cancer care committee annually. S 3.2 Compliance

30. Documentation that the patient’s emotional well-being has been assessed If there is a problem identified, action has been taken Quality Indicators

31. Lessons Learned Volume does not indicate best This is a culture change Engage stakeholders early Be visible; predict there will be problems Share data Link benefits Pilot

32. Choose or create a screening tool(s) and delivery method Establish a threshold/cutoff and use screening results to triage patients for further evaluation and care Distribute resources and information to all patients Document gaps in resources & determine the options for addressing those gaps (S 3.1) Designate the healthcare team available to do a full assessment for those who fall above the threshold/cutoff Assess, intervene & follow-up on those patients in need & document their care and follow-up Psychosocial Service Representative reports to the cancer committee and discuss the screening and care delivery process with surveyor Summary

33. References National Comprehensive Cancer Network; NCCN Clinical Practice guideline in Oncology: Distress Management (version 3.2013). www.nccn.org/professionals/physician_gls/f_guidelines.aspwww.nccn.org/professionals/physician_gls/f_guidelines.asp Lazenby, M., Ercolano, E., Grant, M., Holland, J., Jacobsen, P., & McCorkel, R. (2015). Supporting commission on cancer-mandated psychosocial distress screening with implementation strategies. American Society of Clinical Oncology, Journal of Oncology Practice, 11 (3) 413-420 Wagner, L., Spiegel, D. & Pearman, T. (2013). Using the science of psychosocial care to implement the new American College of Surgeons Commission on Cancer Distress Screening Standard. JNCCN, 11(2)214-221 Clark, P., Bolte, S., Buzaglo, J., Golant, Daratsos, L., Loscaizo, M (2012). From distress guidelines to devleoping models of psychosocial care: current best practices. Journal of Psychosocial Oncology, 30:6, 694-714 Zebrack, B., Kayser, KK., Sundstrom, L., Sarvas, S., Henrickson, C., Acquati, C & Tamas, R. (2015). Psychosocial distress screening implementation in cancer care: an analysis of adherence, responsiveness and acceptability. ASCO, Journal of Clinical Oncology 33(10),1165-1170 Jacobsen, P. & Wagner, L. (2012). A new quality standard: The integration of psychosocial care into routine cancer care. ASCO, Journal of Clinical Oncology, 30,(11), 1154-1159 Torous, J., Shanahan, M., Lin, C., Peck, P., Keshavan, M. & Onnela, J. (2015). Utilizing a personal smartphone custom app to assess the patient health questionnaire-9 (PHQ-9) depressive symptoms in patients with major depressive disorder. JMIT Mental Health, 2(1):e8)