Models of Care in Pediatric Psycho-Oncology APA Div 54 Hem/Onc/BMT SIG World Congress of...
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Transcript of Models of Care in Pediatric Psycho-Oncology APA Div 54 Hem/Onc/BMT SIG World Congress of...
Models of Care in Pediatric Psycho-Oncology
APA Div 54 Hem/Onc/BMT SIGWorld Congress of Psycho-Oncology
July 31, 2015
No conflict of interest
Hem/Onc/BMT SIG
• Formed in 2013• 184 members• Mission:
– Collaborate with organizations with a similar focus and current Society of Pediatric Psychology (SPP) SIGs that often overlap with the Hem/Onc/BMT population
– Provide networking opportunities within SPP for members who have a clinical and/or research interest in Hem/Onc/BMT
– Provide a forum for discussion and sharing of information and ideas regarding clinical and research practices across institutions
SIG Leadership
• Co-Chairs– Jenny Hoag, PhD, Medical College of Wisconsin– Kristin Bingen, PhD, Medical College of Wisconsin
• Hematology Leadership– Cecelia Valrie, PhD, East Carolina University– Matt Myrvik, PhD, Medical College of Wisconsin
• Student/Trainee Representatives– Aimee Hildenbrand, MS, Drexel University– Jeff Karst, PhD, Medical College of Wisconsin– Joy Kawamura, MS, University of Washington
Models of Care in PediatricPsycho-Oncology
• The Psychosocial Services Program of The Children’s Hospital of Philadelphia (CHOP) Cancer Center: Translating Research into Practice – Lamia Barakat, PhD, CHOP
• Needs-Based Psychosocial Care – Amii C. Steele, PhD, Levine Children’s Hospital
• Promoting Positive Adjustment for Sibling Donors of Bone Marrow: A Psychosocial Model of Care at a Single Institution – Nupur Gupta, PsyD, Children’s National Health System
• Model of Care at Nationwide Children’s Hospital (NCH) – Tammi Young-Saleme, PhD, NCH
• Standard of Psychosocial Care for Pediatric BMT/HSCT Admissions – Kris Kullgren, PhD, C.S. Mott Children’s Hospital
Chair – Jenny Hoag, PhD Discussant – Kristin Bingen, PhDMedical College of Wisconsin
Learning Objectives
• Identify at least one model of psychosocial care delivery
• Identify at least one strategy to develop and evaluate a psychosocial program
The Psychosocial Services Program ofThe Children’s Hospital of Philadelphia
(CHOP) Cancer Center:Translating Research into Practice
Lamia P. Barakat, PhD, Elizabeth Britton, LCSW, Kathryn David, LCSW, Anne Reilly, MD,
Stephanie Rogerwick, MA, Jeneane Sullivan, RN, MSN, and Lisa Schwartz, PhD
World Congress of Psychosocial OncologyAPOS/IPOS
July 31, 2015
The CHOP Cancer Center 550 new patients per year (excluding 2nd opinions)
22,880 outpatient visits per year 50 bed inpatient unit (11 stem cell transplant beds)
16,381 inpatient days per year Patients followed off treatment and into survivorship through
early to mid-20s Approx. 1,000 patients followed in Survivorship Program
Associated programs: Psychosocial Services Program
Adolescent and Young Adult Program Survivorship Program
Fertility Preservation Pediatric Advanced Care Team Pediatric Proton Therapy Patient/Family Education
Clinical/Treatment• Persistent and/or escalating distress• High risk factors• Few resources• Intensive application of health care and psychosocial resources
Targeted• Acute distress• Risk factors present• Moderate resources• Enhanced education and support, more frequent follow-up
© 2005, Center for Pediatric Traumatic Stress (CPTS), The Children’s Hospital of Philadelphia
Universal• Distressed but resilient• Few risk factors present• Sufficient resources• Education/support
Pediatric Psychosocial Preventative Health Model (PPPHM)
Services Guided by PPPHM “Universal” services aim to strengthen resources, address expected
distress, and promote resilience Social work and child life services Psychoeducation programs (face-to-face, online/written, audio, video) Patient Navigation
“Targeted” programs are provided for patients and their families who are at risk for or demonstrating difficulties Interventions for procedure-related distress (child life) Creative arts therapies (art and music) Spiritual care Education liaison and Neuropsychological Assessment
“Clinical” interventions--for patients and families with severe distress, pain and/or pre-existing vulnerabilities Care coordination Psychology consultation and intervention Psychiatry consultation (C/L service)
Universal Services
Social Work (9 by service and in outpatient settings) Initial assessment of psychosocial needs Linkage to community and financial resources Negotiation of practical issues related to cancer treatment Bridge to school reentry Coordination of psychosocial care
Child Life (9 child life specialists, 1 activity coordinator) Patient education about diagnosis and treatment Developmentally appropriate play and activities Sibling support
Hospital School Program and School Reentry Program (3 teachers and 1 education liaison) Patient Resource Navigation (1 MSW) Patient/Family Education (1 NP plus psychosocial team)
At diagnosis (Oncology Home Management class, Cellie Cancer Coping Kit) Webinars AYA Podcasts
Oncology Home Management Class for the newly diagnosed patient/family
Developed through partnership with Oncology Nursing and Psychosocial Services Team. Based on the following assumptions: Medical information families receive at the time of diagnosis affects disease
management and family functioning Importance of collaboration to provide comprehensive education and care Education’s goal is to prepare family for discharge, transition home and
outpatient visitsClass structure Each class is taught by an Oncology RN and member of the Psychosocial Team Class is tailored to each family and is required of families prior to discharge Provides background medical information: Blood counts, review of
chemotherapy, management of side effects, fever guidelines, contact information, reasons to call, etc.
Provides psychosocial support and information: Explanation of psychosocial team and resources, assess understanding of medical content, anticipatory guidance and emotional support, communication with community about diagnosis
Family receives useful resources in class (thermometer, magnets, pillboxes)Program initiated in March 2014 / 325 classes taught as of July 2015
Oncology Home Management Class Evaluation
Patient/family feedback received through evaluations completed after class indicate that:
Families value the class Families feel empowered to care for their child at home and to access psychosocial resources
Example quotes from parents and providers: Parent: “Staff were knowledgeable and so kind. It was so helpful to be able to get away into the
classroom and really focus on what it means to take our son home and what we need to know. The staff and class made it less scary and were very supportive.”
Parent: “Very patient staff. Answered various questions. Confirmed a lot of information I had no knowledge of or wasn’t clear about. This class if very beneficial and I pray it continues for everyone.”
Nurse: “Teaching class brings it back to the old style of nursing, where you really spent time with a family teaching them and bonding with them.”
SW: “It’s so helpful to spend this dedicated time with families to provide support and gain insight to make sure all of their needs are being met.”
Psychosocial Screening Psychosocial screening is recommended as standard of care across disciplines At diagnosis
Social work assessment Psychosocial Assessment Tool (PAT2.0) via research
Off treatment Brief patient and parent reports on PAT2.0, distress thermometer, PedsQL and
neurocognitive screener Screening is acceptable and feasible in our setting
Red flags defined and information reported to social worker for follow-up Findings (Pierce et al., in preparation):
Distress at diagnosis is high due to emotional adjustment to diagnosis, financial stressors, and coordination of family needs
Off treatment distress remains high due to ongoing stressors and focus cancer treatment for prolonged period, and distress is associated with patient HRQL
Patient Resource Navigator(funded by American Cancer Society)
Maintains database of and functions as primary liaison to childhood cancer foundations and resources
Provides informational support to social workers and direct support to families (primarily off treatment)
Conducts Caregiver Café in clinic 4 times/month Oversees distribution of gift cards and holiday
gifts for families Organizes resource tables and presentations at
Cancer Center events and regional patient/family conferences
Serves approximately 150 families directly and another 100 families indirectly per year
Targeted Programs
Supportive counseling (social work) Interventions to reduce procedure-related distress and
therapeutic play (child life) Art Therapy (2) and Music Therapy (2)
Individual therapy Group therapy – for patients and for parents
Inpatient and Outpatient Support Groups—associated with child activities and stand alone
Spiritual Care (1 Chaplain) Education Liaison (1 MSW) Neuropsychological Assessment (2 Pediatric
Neuropsychologists)
Implementing evidence-based treatments SCCIP-ND for newly diagnosed families (Lutz Stehl et al., 2009)
Social workers and other members of psychosocial team received training One session model used to structure inpatient support group for parents of
newly diagnosed patients Evaluation of acceptability and feasibility of implementation by social
workers to guide initial interactions/supportive counseling is underway through award from APOSW
CogmedRM for children with brain tumors (Hardy et al., 2003)
Two research protocols for patients with brain tumors post-radiation therapy Received small infrastructure grant to offer CogmedRM as part of clinical
care and now developing model to identify eligible patients and deliver the intervention
Altered Book Making Art Therapy Group (Cobb & Negash, 2010) Offered via weekly inpatient group for parents of recently relapsed patients
Neuropsychological Assessment and associated Quality Improvement
Initiatives
150 neuropsychological assessments per year Clinical assessments (billed) Proton Protocol (billed) COG ALTE and other consortium studies
Satisfaction with assessment QI: families uniformly found the evaluation and feedback helpful
Educational needs of patients and survivors QI (Hocking et al., in
progress): Significant ongoing concerns regarding academic achievement and
social functioning Patients with brain tumors and patients with solid tumors most at risk
for ongoing educational challenges Support needed for negotiating with schools on accommodations and
obtaining school evaluations, 504 plans and IEPs
Clinical Interventions
Patient Care Coordination Through partnership of social work and pediatric psychology
with patient care teams; screening aims to identify those at risk and prompts care coordination prior to safety events
Psychiatry Consultation (through C/L service) Psychology consultation and intervention by referral:
1.5 FTE (across 5 pediatric psychologists) (bill using health and behavior codes)
Referred when behavioral health concerns become acute and/or interfere with treatment
Evaluation and management of risk for harm/suicidality Development of behavior plans Referral to community psychologists/psychiatrists as
appropriate
Psychology Quality Improvement Initiatives 200 consultations per year completed by pediatric psychologists
Approx. 60% followed for intervention Progress Note QI
Consultation note and Progress note are templated in EPIC Operationalized progress toward treatment goals Added Global Assessment of Functioning rating Drop-down menus facilitate reference to commonly used treatment goals
and associated evidence-based interventions Adolescent and Young Adult Needs Assessment (Barakat et al., in press)
Most common challenges included treatments and associated physical changes, barriers to pursuit of academic/vocational goals, and social isolation
For preferred program focus, AYA ranked highest increasing strength and endurance/reintegration into sports and dealing with physical changes resulting from treatment
Preferred modalities for program delivery were one-on-one/in person and online through message boards/Facebook
Next Steps Universal Services
PFE AYA education at diagnosis Families moving off treatment
AYA space in new ambulatory care center Relaxation recordings for caregivers and AYA VitalHearts training for staff support
Targeted Programs Executive Function Clinic Education Liaison – new position for Master’s special education teacher Stem Cell Transplant Protocol (to mirror Proton Protocol) Maternal Problem-solving Training (Bright IDEAS)
Clinical Interventions Psychology Consultation QI to assess value of psychology services via provider
satisfaction with: Time to consultation Communication from the pediatric psychologist Contribution of pediatric psychology consultation to plan of care
Needs-Based Psychosocial Care
Amii C Steele, PhDLevine Children’s Hospital at Carolinas Medical
CenterCharlotte, NC
Levine Children’s Hospital
• Southeast United States • Charlotte, North Carolina
– Population: 2.5 million • Carolinas Medical Center
(864 beds)• 234 bed children’s hospital• 24 bed inpatient
Hematology, Oncology, & BMT
• 147 new Oncology patients in 2014• 348 Sickle Cell patients in 2014• 9 Physicians• Insurance
– Commercial 48 %– Government 52 %
Psychosocial Services
• Inpatient/Outpatient– 1 FTE Pediatric Psychologist– 3 FTE Licensed Clinical Social Workers (Onc/BMT)– 1 Child Life Specialist
• Inpatient – 1 FTE Child Life Specialist – .5 FTE Child Life Assistant– 1 FTE Chaplain – 1 FTE School Teacher – Child and Adolescent Psychiatry – Pediatric Palliative Care
Psychosocial Care
Social Work & Child Life
All Oncology Patients
Psychology Consult
Elevated Distress ScorePhysician ConcernParental Request
Psychiatry Consult
Evaluation for Medication Physician Concern(Inpatient Only)
Psychological Services
Promote coping/adjustment to medical illness or injury
Cognitive and Behavioral Strategies
Improve treatment adherence and compliance
Non-pharmacologic Pain Management
Relaxation and Biofeedback techniques
End of Life and Bereavement support and therapy
Psychological Assessment
Consults
• Primary referrals:
– Depressed Mood
– Anxiety
– Difficulties Coping with Medical Illness
– Family Coping Difficulties
65%4%
17%
9%4%
Psychologist Time Spent in Activity
InterventionAssessmentSupervisionProgram Devel-opmentResearch
A Typical Day
Tips for Success
• Funding• Support
– Billing – Administrative
• Equipment: assessment measures• Frills• Education
How Pediatric Psychology Services Differ From Traditional Psychotherapy
Source: Casciani, 2004
Promoting Positive Adjustment for Sibling Donors of Bone Marrow:
A Psychosocial Model of Care at a Single Institution
Nupur Gupta, PsyD; Steven J. Hardy, PhD; Amanda L. Thompson, PhD
BACKGROUND
Children’s National Health System• Large Mid-Atlantic urban hospital in Washington, DC
Center for Cancer and Blood Disorders (CCBD)• 300 newly diagnosed patients seen annually• 30 inpatient beds
Division of Blood and Marrow Transplantation• ~ 65 bone marrow transplants conducted annually
• ~ 40 allogeneic bone marrow transplants
PSYCHOSOCIAL TEAM
• Psychology: 2 attendings, 2 postdoctoral fellows, 2 graduate student externs
- Routine for all newly diagnosed patients with cancer
- Hematology and BMT patients by consult only
• Social Work: 9 total across disease teams (1 dedicated to BMT)
- All patients within CCBD receive social work support
• Child Life: 2 Specialists (1 inpatient, 1 outpatient)- Routine for all newly diagnosed patients with cancer and those receiving a BMT- Hematology patients by consult only
PSYCHOSOCIAL TEAM
Additional team members and services available to all patients and families:
• Art Therapy: 4 Art Therapists• Pastoral Care: 4 Chaplains• Education: 1 Educational Specialist• Music Therapy: 1 Music Therapist• Yoga Therapy: 1 Yoga Therapist• Patient Navigator: 1 Navigator/Teen Room
Coordinator
PSYCHOSOCIAL CARE of SIBLING DONORS
• New model of care developed by psychology in collaboration with BMT team members
• Expansion of psychology services to include assessment and monitoring prior to transplant through three months post
RATIONALE
• Limited literature on psychosocial functioning and care of sibling donors of pediatric bone marrow
• Past findings suggest that sibling donors can be adversely affected by their experience
RATIONALE
• Common concerns:
– Feelings of coercion or exclusion– Anticipatory fears– Feelings of isolation– Depressive symptoms, anxiety, low self-esteem– Feelings of anger and blame, particularly when
transplantation is unsuccessful
RATIONALE
Ethical Assumptions
Ethical Considerations
How to buffer against
psychological risks
How to help siblings feel more involved
How to reduce
feelings of
responsibility
Not a major medical risk to donor
Parents provide
ultimate consent
Better to save a family member’s life
Ethical care of sibling donors requires us to reevaluate our assumptions about donation and consider their needs more closely. Goals for current model of care:
• Increase sibling involvement in decision-making conversations
• Increase developmentally appropriate psychoeducation
• Encourage siblings to ask questions and discuss their experience
• Ensure siblings feel well-supported• Early identification of risk factors or
concerns to be addressed and monitored throughout
MODEL of CARE
Pre-Transplant
• In addition to full pre-transplant work-up conducted by donor physician and transplant social worker, psychology meets with sibling donors to:
– Assess siblings’ understanding of transplant, attitudes toward donation, impact of patient’s illness, current psychological functioning
– Provide psychoeducation and recommendations for promoting sibling well-being
• Psychology visit is billed under patient’s account as part of the transplant work-up
MODEL of CARE
1 and 3 Months Post-Transplant
• Psychology speaks with sibling donors in-person or over the phone to:
– Assess any new or ongoing concerns regarding the donation and transplant process, current coping, psychological functioning, program evaluation
– Provide brief interventions, recommendations for ongoing support, and additional resources as needed
• Not currently being billed
IMPLEMENTATION
Concerns identified at pre-transplant
Limited Awareness
Limited Understanding
Limited SupportAnxiety and
Transplant-Related Worries
IMPLEMENTATION
Reported benefits of model of care
ValidationReassurance
and Clarification
Helpful Recommendations
Decrease in Anxiety
Symptoms
IMPLEMENTATION
Data Tracking for Future Statistical Analyses
• Demographic Information• Transplant-Related Information • Transplant Evaluation Findings/Themes
IMPLICATIONS• Increase attention to the rights and needs of sibling
donors, in line with calls from the National Marrow Donor Program and American Academy of Pediatrics
• Enhance and standardize ethical care of sibling donors
Model of Care at Nationwide Children’s Hospital
Tammi Young-Saleme, Ph.D., Jennifer Hansen-Moore, Ph.D, ABPP, Stacy Flowers, Psy.D.
50
• Located in Columbus, Ohio
• Ranks 7th in U.S. News and World Report for Cancer Specialty
• NCH Inpatient Beds on Main Campus - 464
NCH Hem/Onc/BMT Stats
• Hem/Onc/BMT Ambulatory Clinic– BMT Clinic – 6 rooms – Infusion Clinic / Day Hospital – 14
rooms – Hem/Onc Clinic – 14 rooms – Apheresis – 4 bays
• Hem/onc/BMT Inpatient– 42 rooms/beds
• 12 BMT only rooms/beds• 1 MIBG room• 1 comfort care room• 28 regular rooms/beds
• 180 new oncology diagnosis per year
• 60 BMT per year
Early Days at NCH
• Psychosocial Staffing was sparse, inconsistent, and not integrated
• Average 165 new patients each year
Social Worker1 FTE
Inpatient Child life
1 FTE
Psychology crisis
consults
Present Day Psychosocial StaffingStaff FTESocial Workers 5.0
Psychology 3.0
Child Life 3.0
Pastoral Care 1.0
Music Therapy 1.0
Therapeutic Rec 2.0
Massage Therapy 3.0
Art Therapy 1.0
Educational Program Liaisons 2.0
Columbus Public School Teachers 2.0
Genetics Counselors 1.5
Community Events Coordinator 1.0
Grand Total 25.5
How did we grow?
• Education• Stepwise and strategically• Patient experience emphasized• National Standards of practice and policy • Partnership with Leadership• Emphasis on Quality• Collaboration with Foundation
55
Unique aspects of NCH Psychosocial Program
• Director of Psychosocial Services• Matrix reporting • Comprehensive and Preventative Model of Care
– Each patient and family is seen by a consistent care team including a Psychologist at diagnosis
• Integration/alignment of psychosocial service providers into healthcare teams • Continuity of Care
– Consistency in providers across inpatient and outpatient • Collaboration with Palliative Care Team and Home Based Hospice• Training Programs (social work, psychology, child life, pastoral care) • Strong partnership with NCH Foundation to ensure funding stream • Collaboration with community partners to maximize support of patients and
families outside of NCH
56
Model of Care at Diagnosis
• Psychology – Assessment of family risk and resiliency factors
• Social Work – Assessment of financial and resource Needs
• Child Life – Assessment of child’s risk for negative psychological outcomes due to hospitalization
• Pastoral care– Assessment of Spiritual needs
• Educational liaison– Assessment of educational needs
• Therapeutic Recreation– Assessment of baseline peer and social interactions
• Massage Therapy– Assessment of anxiety to utilize massage for promoting pain relief, healing and
relaxation
Continuity of Care
During on going treatment Contacts at each admission Medical Clinic visits Outpatient services available
At the End of treatment Coming off therapy transition meetings
Survivorship Involvement in Long term survivorship program
End of Life Hospice care/palliative care
Growth of Service Metrics
• 2,894 inpatient psychosocial consults in 2010
• 5,975 inpatient psychosocial consults in 2014
• 34,417 patient encounters from the psychosocial team in 2014
59
Program Improvements
• Psychosocial Coordination of Care Task Force• AYA Program• Bereavement Program• Nursing and MD Fellowship Education/Training• Care for the Caregiver• Sibling Donor Advocacy Program for BMT• Psychosocial Screening for patients and families who will undergo MIBG at
NCH
60
Quality Improvement Engagement
– Psychosocial Bundle Compliance– Cure Me Cancer Index– End of Treatment Care Meetings
61
MassageTherapy
MusicTherapy
Adolescents/Young AdultsEducational & Social Events
Inpatient Parent Dinners
BluejacketsFashion
Show
Art
Therapy
KidsKickingCancer
CentralOhio NHF Sports
Rehab
PediatricPsychology
Individual
Family
Sibling Support
PastoralCare
Grief & Bereavement
SocialWork
Counseling
Disease Education
Community
Financial
SchoolProgramSchool Liaison / Reentry
Early Intervention
Inpatient Classroom/SmartboardMedical
TeamChildLife
Bravery Beads
Lavender Ribbons Coping Kits
Gabe’s My Heart Chemo Duck
FamilyAdvisoryCouncil
Flashesof
Hope
SurvivorshipCelebration
Sickle Cell Peer Mentoring
Sickle Cell Scholarship DinnerSickle Cell
Transition to OSU
Sickle CellCommunity Health Fairs
Sickle Cell Minority HealthMonth Family Education Day
HemophiliaAnnual Dinner
InfusionWeekend
NHF Partnership Events
vWD Retreats
Wildlights at the Zoo
F.A.M.O.H.I.O
FHF CampVolunteers
Woods Foundation Jewelry Making
Sam BishFoundation Parties
Family Appreciation Day
HemophiliaWalk
CampBold Eagle
Kids n Kamp
A Kid Again
Nellie’s Catwalk
Makea Wish
Special Wish
Therapeutic Recreation
ClinicalTherapies
Physical TherapyOccupational Therapy
Standard of Psychosocial Care for Pediatric BMT/HSCT Admissions
Kris Kullgren, PhDChristina Limke, PsyD
Taylor Mosley
University of Michigan/CS Mott Children’s Hospital
• Opened December 2011• 12-story inpatient wing and a 9-story
outpatient wing• 348 beds
BMT at UM/Mott Children’s Hospital
• 32 bed hematology/oncology unit• 120 new cancer diagnoses/year• 40-50 BMTs/HSCTs per year
– leukemia, lymphoma, immunodeficiencies, bone marrow failure syndromes, lymphoproliferative diseases, neutrophil disorders, neuroblastoma, Wilm's tumor, brain tumors, retinoblastoma, sickle cell disease, thalassemia, inborn errors of metabolism
BMT Psychology Consultation Liaison (CL)
• BMT is part of our general psychology CL service• Between October 2011 and November 2014
– 1017 new consults total– 30% hematology/oncology– 15% BMT
• 152 BMT consults
Onc/BMT Psychosocial TeamStandard Orders
• Psychologist (1)– Trainees (practicum,
intern, fellow)• Social worker (4) • Child life (6)
By referral
• Music therapy • Pet therapy • Art therapy• Med buddies • School
– Teacher– Educational specialist
• Psychiatry• Spiritual care
Model of Care• Social work—outpatient pre-transplant evaluation
– Relocation, caretaker plan, finances, school plans, insurance, lodging, mental health history, adherence
• Psychology—inpatient pre-transplant evaluation – Health/mental health history, hospitalization experience, social
support, expectations for transplant, coping skills, adherence history
• Determine follow-up intervention based on need• Attend family centered bedside rounds weekly• Billing/finance
– See everyone– Bill psych CPT or H&B as appropriate (no pre-auths)
Program Evaluation: Our Process
• Clinical database for QI • Track every new consult order
Program Evaluation: Our Patients• Gender: 45% female• Age: 12.6 years
– range 2 months – 31 years• Ethnicity: 79% Caucasian, 9% African-
American• Payor: 34% Medicaid• Length of stay: 1-96 days
– mean = 26.5 days, (SD = 15.8 days)• Mortality: 3.3% died during admission
Program Evaluation: Our Service• Provider: 32% seen by trainee• Referral question:
– 76% transplant evaluation– 10% coping/adjustment
• Contacts: mean = 3.3, mode = 1, max = 16• Units (15 mins) of care: mean = 6.3 (6.4)• Repeat consults: 35% seen at prior
admissions
Program Evaluation: Our Service
• Disposition: 22.4% referred to outpatient therapy
Primary Intervention
Problem-fo-cused copingAssessment onlyGeneral supportCBTRelaxation
24%
19%18%
15%
8%
Intervention Target
ChildParentFamily61%13%
26%
Challenges
• Staffing– Trainees increase accessibility
• Misses when unable to see• Time commitment for rounds
– Unable to bill• Only service that we provide this level of care• Outpatient therapy resources
Lessons Learned
• High need population• Diverse age range• Diverse needs• Integration into team works best• High commitment• Good communication with team members• Helpful to meet patients early in admission• Move toward formal screening for triage
Models of Care in Pediatric Psycho-Oncology
Discussant & Co-Chair of APA Div 54 Hem/Onc/BMT SIG
Kristin Bingen, PhDChildren’s Hospital Of Wisconsin/Medical College of WIPediatric Hem/Onc/BMT
Models of Psychosocial Care-Similarities
• Multidisciplinary psychosocial team• Social Work & Child Life services provided to all patients
at diagnosis.• Inpatient & outpatient psychosocial services• Psychosocial assessment/screening• Psychosocial services aimed at promoting patient &
family’s healthy coping/adjustment to cancer across the cancer care continuum
• QI/Program development/evaluation to improve/provide quality care to patients & families
• Billing for Psychology services (health & behavior mental health CPT codes)
Models of Psychosocial Care-Differences
• Different psychosocial assessment/screening methods:– Psychosocial interview &/or questionnaire/survey (PAT2.0, DT, PedsQL)
• Different models of psychosocial care delivery:– Patients are seen by all core members of psychosocial team, including
psychology, at diagnosis VS patients screened for level of distress/psychosocial risk and triaged to appropriate level of intervention (i.e., PPPHM model).
– Consistent psychosocial providers across inpatient & outpatient settings VS different providers/teams for inpatient vs outpatient
• Different QI/Program Evaluation Approaches
• Differences in staffing , trainees and resources
Comparison of Pediatric Onc/BMT Psychosocial Staffing
Cancer Center # of inpatient beds Annual # of new patients/diagnoses
Staffing (1.0 = 1 full-time, .5 = part-time)
Levine Children’s 24 147 Social Work 3.0Child Life 2.0Psychology 1.0
Children’s National 30 300 Social Work 9.0 Child Life 2.0Psychology 2.0
U of Michigan/CS Mott Children’s
32 120 Social Work 4.0Child Life 6.0Psychology 1.0
Nationwide Children’s 42 180 Social Work 5.0Child Life 3.0Psychology 3.0
CHOP 50 550 Social Work 9.0Child Life 9.0Psychology 5.0
Models of Psychosocial Care-Unique Features
• Programs addressing the specific needs of families/vulnerable patient populations:– Sibling Donor Advocacy Programs for BMT– Caregivers– AYA– Patients who will undergo MIBG or proton therapy
• Integration of holistic therapies: expressive therapies, massage, pet therapy, yoga, recreational activities
• Integrated medical & psychosocial education programs (i.e., Oncology Home Management Class, End of Treatment Care Meetings)
Take Home Message…
• Despite differences in delivery of psychosocial care, all pediatric oncology programs universally provide:– Psychosocial screening to determine need for/level of
psychological intervention– Access to psychosocial care– Multidisciplinary psychosocial care, integrated into medical
care
• No matter the size of the cancer center or the number/amount of psychosocial providers or resources, standards of psychosocial care can be achieved.
Program Evaluation
• Are we meeting the standards of psychosocial care?
• Are we providing evidence-based, quality psychosocial care?
• Are we improving patient & family outcomes?
Program Evaluation Approaches• Service Utilization/Access
– Patient demographics– # of psychosocial consults, by discipline– # of patient encounters – Compliance with placing and carrying out psychosocial consults-time to consultation
• Patient/Caregiver Experience and Satisfaction
• Consideration of pre-/post-comparison when implementing a new program or providing psychosocial services to new population
• Psychosocial Outcomes (health-related QOL, psychosocial functioning, distress)
• Health Care Economics
Questions?