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Continuum of Care Standard:
Psychosocial Distress
Screening
Jean B. Sellers, RN, MSN
Administrative Clinical Director
Lineberger Comprehensive Cancer
Center
Nov. 11, 2015
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.”
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.
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
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%
Definition Challenges
•
•
•
•
•
•
Multi-dimensional
Varying course
May resolve without treatment
How to measure it?
What to measure?
How to triage patients with limited
resources?
I want my
doctor to pay
attention to
my cancer
treatment
stress
Research studies show… ofIf the
this is too
much they
will tell me
patients are not
likely to initiate a
conversation
with the
physician about
distress
I’m not
crazy.
physician’s often
defer to the
patients to raise
any concerns
about distressrelated topics
My clinic
time is so
limited…
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
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.”
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
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
Psychosocial Distress Screening
Psychosocial distress screening is a brief
method for prospectively identifying and
triaging cancer patients at risk for illnessrelated psychosocial complications that
undermine their ability to fully benefit from
medical care, the efficiency of the clinical
encounter, satisfaction and safety
Needs & Resource Assessment
• Leader
• Identified patient population
• Current resources in place
a.
b.
c.
d.
Internal/external
Rehab, Behavioral Health
Support groups, nutrition
Community (YMCA, public library)
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?
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
CoC Process Requirements:
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.
Pivotal Medical Visits
•
•
•
•
•
•
•
Time of Diagnosis
Pre-surgical & Post-surgical
First Chemo; First Radiation
Post Treatment
Recurrence or Progression
Treatment Failure
End of Life
CoC Process Requirements:
Methods: The mode of administration
(such as a self-administered
questionnaire, clinician-administered
questionnaire) is determined by the
program.
CoC Process Requirements
Tools: Facilities select the tool to be
administered to screen for current
distress. Preference is given to
standardized, validated instruments with
established clinical cutoffs.
TOOLS
Title
Items
Time
(min)
Brief Symptom Inventory (BSI-18)
18
3–5
CancerSupportSourceSM
25
5-10
Distress Thermometer (DT) & Problem List
1,5
2–3
Distress and problems related to the
distress
Edmonton Symptom Assessment System
9
2-3
Symptoms
Hospital
(HADS)
14
5–10
Symptoms of clinical depression
and anxiety
PHQ-9
9
5-10
Anxiety and depression
Psychological Distress Inventory
13
5-10
Psychological
coping)
Psychosocial Screen for Cancer (PSSCAN)
21
10-15
General Distress
SupportScreen
53
Zung Self-Rating Depression Scale
20
Anxiety
and
Depression
Scale
(varies)
Constructs Measured
Somatization, depression, anxiety,
general distress
functioning
Psychosocial needs
5–10
Symptoms of depression
(incl.
CoC Process Requirements
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.
NCCN Clinical Practice Guidelines in Oncology-Distress Management
• 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
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
CoC Process Requirements
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.
S 3.2 Compliance
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.
Quality Indicators
• Documentation that the patient’s
emotional well-being has been
assessed
• If there is a problem identified, action
has been taken
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
Summary
• 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
References
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National Comprehensive Cancer Network; NCCN Clinical Practice guideline in Oncology: Distress
Management (version 3.2013). www.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)