Post on 05-Jan-2016
description
Shirley Otis-Green, MSW, ACSW, LCSW, OSW-C
Founder & ConsultantCollaborativeCaring
Shirley@CollaborativeCaring.net
Enhancing the Social Work Role in Enhancing the Social Work Role in Family Conferencing: Integrating Family Conferencing: Integrating Screening into Evidence-Informed Screening into Evidence-Informed PracticePractice
Presentation GoalsTo Discuss & Explore…
Systemic Perspective as Related to Oncology Care: An Invitation for Inter-Professional Collaboration
Strategies to Enhance Social Work Expertise & Leadership in Family Conferencing
Role of Screening & Assessment in Providing Evidence-Informed & Culturally-Congruent Care
Shared Perspective… What’s in the best
interests of the patients and
families that we serve?
What is Distress Screening? Distress: “A multifactoral unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope with cancer, its physical symptoms and its treatment.”
National Comprehensive Cancer Network, 1999
An essential element of quality cancer care 30-40% prevalence of clinically significant levels of distress across adult outpatients1-3
1Trask P, Paterson A, Riba M, et al, 2002; 2Jacobsen PB, Donovan KA, Trask PC, et al, 2005; 3Zabora et al., 2001
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33% experience adjustment disorders & other
psychological challenges:Need Screening,
Assessment, Referral& Counseling2
72% encounter serious problems and barriers related to the social, practical, psychological,
informational, spiritual aspects of illness and treatment:Need Screening, Assessment, Navigation,
Referral & Counseling3
100% need on-going education, information and guidance:Need Screening, Service Navigation
& Coordinated Patient & Family Education Services *
1IOM, 2008 2Zabora, et al., 20033Loscalzo & Clark, 20074Zabora, et al., 2001
Psychiatric or mental health disorders1
5 -10%
Distress varies by cancer site4
Need Referral& Counseling1
Claim the Domain: Create A Culture For Screening, Assessment & Family Conferencing
“Get our psychosocial house in order” (Loscalzo, 2011)
Standardize your message: Integrate your message into disease-directed care
Over-communicate about⁻ The value; positive outcomes⁻ Improved processes and systems – fewer
disruptions in clinical services and flow(administrators HATE disruption and lack of
predictability)
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Keeping, Tracking, Using DataTo document the extent of patient/family
challengesTo provide your institution with data for
enhancing care (Quality Improvement/Quality Assurance)To inform development and implementation of
practice, institutional programs, and policiesTo demonstrate impact and raise profile of
oncology social work Make a case for additional staffing, based on
“home-based” data7
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Data Analysis ~ Example 1. Count how many patients check an item in the problem checklist (e.g. “Dealing with partner”).
2. Divide the number of patients who checked an item by the total number who completed DTs.
3. The result is the RATE or PERCENTAGE of patients challenged by the item.
4. Alternatively, add the number of checks within a category (e.g., Family Problems) for each patient.
5. Divide this number by the total number of DTs.
6. This number is the Average number of problems reported by patients seen in your unit.
What are your questions, concerns, challenges around distress screening? How have you addressed these challenges? Instrument selection? Implementation? Turf Battles? Social Work’s Competing Priorities? Other Obligations? Unclear Responsibility? Accountability? Limited Resources?
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Screen to InterveneNormalizes need for help and supportEstablishes social worker’s professional roleIncreases knowledge research base on
psychosocial impacts of cancerEfficacy of psychosocial support for cancer
patients is well-established [Faller, et al., (2013), Journal of Clinical Oncology; Jacobsen, et al., (2008), CA: A Cancer Journal for Clinicians; Gottlieb & Wachala, (2007), Psycho-Oncology; Cwikel, Behar, & Zabora, (1997), Journal of Psychosocial Oncology, 1997; Meyer & Mark (1995), Health Psychology]
Evidence-Based Medicine (EBM)Why do we do what we do when we do for whom we do? (Too often because
that’s they way it’s always been done).Evidence-based medicine is the conscientious, explicit, & judicious use of the
best current evidence in making decisions about the care of individual patients. (Sackett, et al., 1996; 1971)
Five Steps of Evidence-Informed Care1. Ask focused questions: Convert uncertainty into
answerable questions 2. Systematically retrieve the best evidence with
which to answer the questions3. Critically appraise evidence for its validity,
clinical relevance & applicability 4. Make a decision: Apply the results of this
appraisal in your practice 5. Evaluating performance: Auditing evidence-
based decisions
(http://www.cebm.net/index.aspx?o=1914)
Goal: Evidence-Informed PracticeCritical thinking is keyCuriosity regarding outcomesCommitment to explore options &
compare outcomesIntentionality in selecting
interventionsProfessionalism requires contribution
to build a strong evidence base
Tie Theory to Evidence to Bring Research to Practice ~Teams are intricate Systems with their
own dynamics and lifespan They exist within the larger healthcare
system and interact with and respond to the dynamics of the larger system
Family Systems Theory:Changing anything…changes everything!
Example: Communication with Families Facing Life-Threatening Illness: A Research-Based Model for Family Conferences (Fineberg, et al,(2011), Journal of Palliative Medicine) Virginia Satir
What are some of the major challenges encountered with family conferences? Lack of space to accommodate familyDifficulty establishing preconference meeting
with the health care providersDifficulty establishing “off-hour” meetings
(weekends, outside 9am-5pm)Difficulty communicating with family due to
language barriers, lack of a translatorLack of clear “team” to facilitate family
meetings
Key Elements of a Highly Functioning Team Consensual Goals (clarity of purpose)Tendency to “default” on the side of trust
vs. mistrust (“don’t assume the worst about others”)
Willingness to “roll up one’s sleeves and do what needs to be done” (functional “nimbleness” & “role flexibility”)
Perspective of “we’re all in this together” (shared credit & shared responsibility)
Conscious playing off people’s strengths and supporting other’s weaknesses (without focus on fault finding or blaming)
Informal dept. survey (2007) of what makes a team work…
Goal: Enhanced Team Functioning
Most health care professionals receive predominantly discipline-specific training yet are expected to translate this into effective team functioning…(perhaps, not surprisingly this becomes a challenge!)
Inter-Professional/Transdisciplinary Care: Integrative, holistic, innovative, hospice/anthropology concept.Implies a revolution of the medical hierarchy.Collaboration/communication/compassion amongst
team members based upon team-training.
Transformation in Palliative Care: Traditional Multi-Disciplinary Practice
(Typically a “reactive” physician-led model with ad hoc membership using a consultative format)
Interdisciplinary Team(More “proactive” model; theoretically recognizes contributions of all, but typically MD-RN based and
physician-led)
Transdisciplinary Team(Shared team vision; recognized role-overlap;
integrated responsibilities, training, leadership & decision-making)
- Dale Larson, (1993), The Helper’s Journey, Research Press.
1. What is Medically AppropriateBased on current medical
information what current and future medical interventions does the team believe will improve and which will worsen or provide no benefit the patient’s current condition in terms of function/quality/time
(Adapted from: EPERC Fast Facts ~ Medical College of Wisconsin, 2006)
10 Steps of the Family Conference
Pre-Meeting with Patient/Family: To Ensure Culturally Congruent Decision-MakingConducted by: Social Worker? Chaplain?
Nurse?Obtain history & assess the patient and
family’s needs & understanding of the situation – what are their goals, priorities, hopes, fears, cultural & spiritual concerns?
Determine: Who makes decisions in the family?Who else should be included in the discussions
(in person, via SKYPE, etc)? Scheduling preferences?Determine if “full disclosure” is desired?
Culture/Spirituality Provides the Lens
Through Which We View
Our Experiences
2. Pre-Meeting PlanningCoordinate medical opinions
between consultants and primary MD
Obtain patient/family psychosocial data
Review Advance Care Planning DocumentsIs patient decisionalIs there a power of attorney
Review medical history/treatment options/prognostic information
3. EnvironmentChoose a proper
environmentQuiet, comfortable,
chairs in a circleInvite participants
to sit downCheck your
appearance, turn off pagers,
4. IntroductionsIdentify legal decision maker or family
designated decision makerIntroduce self and have others introduce
themselves and relationship to patientReview your goals; ask family if these
are the same or different than their goalsEstablish ground rules
Everyone can talk, but only one at a timeNo interruptions
Build RapportBuild a relationship
Ask the family to tell you something about the patient;
“I know about the patient’s illness but I was wondering if you could tell me something about her as a person, her hobbies or interests?”
5. What does the patient know?Make no assumptions; Find out what
the patient/family already knowsWhat do you understand about your condition?What have the doctors told you?How do you feel things are going with your
treatment?
Chronic Illness: tell me how things have been going for the past 3-6 mos. what changes have you noticed?
6. Medical ReviewPhysician presents medical information succinctlyPresent the Big PictureCurrent condition;
Expected CourseSpeak slowly,
deliberately, clearlyNo medical jargon
Semantics Matter…Avoid depersonalizing labels:
“The breast in room 603;” “The DNR in ICU”
Lack of common language to discuss illness, planning and options:Artificial Nutrition and Hydration vs.
providing food and waterDo not or withhold vs. allow (DNR vs. AND)Avoid: “Do everything” or “there is nothing
more we can do”
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7. Reactions, QuestionsAllow silence, give patient/family time to
react and ask questionsAcknowledge and validate reactions prior
to any further discussionInvite questions
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“For most patients, two fundamental facts ensure that the transition to death will remain difficult.
First is the widespread and deeply held desire
not to be dead.
Second is medicine’s inability to predict the future … to give patients a precise and reliable prognosis…
When death is the alternative, many patients who have only a small amount of hope will pay a high price to continue the struggle.”
(Finucane, T.E. 1999)(Finucane, T.E. 1999)
8. Review Care OptionsAllow for pushback from patient and familyConsider that recommendations for treatment
might be on a trial basisCheck again for clarity and consensusAsk for more questionsConfirm plan of care: Goal is to identify Shared
Goals of Care that are tailored for this particular patient/family at this particular point in time
Consider all options and repercussions of these options and provide recommendations based upon mutual understanding of situation.
9. Confirm Plan of CareBased on the decision what do they
want/need in the time remainingConfirm Goals- so what you are saying isEstablish a Plan
Decide on steps to achieve plansUsually involves discussion of CPR, ICU,
artificial nutrition/hydration, home hospice
If test or treatment won’t meet goals it’s best not to start it
Confirm plan & summarize to ensure that everyone shares understanding of plan
10. ConclusionSummarize areas of consensus and
any disagreementsCaution against unexpected outcomesProvide continuityDocument in the medical record &
provide summary documents to familyWho was present, what was decided, next steps
Discuss results with other concerned healthcare professionals not present
Implications for Your Institution?
SummaryA Commitment to Excellence is Needed if We
are to Transform the Delivery of Care toThose We Serve
Importance of Screening & Assessment in Determining Evidence-Informed Interventions
Family Conferencing Offers Leadership & Advocacy Opportunities for Oncology Social Workers
Our Skills in Understanding Systems can be Useful to Enhance Team Dynamics and Improve Family Functioning