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Cancer Center Administrators ForumMarch 31, 2015

Jeanine StilesChief Administrative Officer

Associate Director for Administration

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“The medical system that saved my life wasn’t able to help me not want to take my life… I have developed a deep love and reverence for the oncologists and nurses, and I believe that these people really do understand that, in some ways, it never ends for us. But I also believe that collectively the system of care failed to prepare me for the mental health crisis that I would experience.”

“There’s no excuse for that.”

Lost in Transition After Cancer

“While an increasing number of cancer treatment centers have begun offering post-treatment care plans and support groups to help patients navigate these challenges, many patients continue to fall through the cracks. “Sometimes we do a good job of preparing people for this, but often we don’t,” Dr. Oeffinger said. “We need to do a better job.”

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Suleika Jaouad

Cancer Survivor

Building Supportive Oncology/Psycho-Oncology Programs

“We like to think of the end of cancer treatment as the closing of a chapter, but what most people don’t realize is that the emotional struggle continues long after,” Dr. Kevin C. Oeffinger, a primary care physician and director of Memorial Sloan Kettering Cancer Center’s adult long-term follow-up program, told me recently over the phone. “Feelings of post-treatment depression and anxiety are amazingly normal. I would go so far as to say that if you don’t have them it’s a surprise.”

Full story New York Times: Lost in Transition After Cancer:

http://mobile.nytimes.com/blogs/well/2015/03/16/lost-in-transition-after-cancer

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Commission on Cancer New Standards for ACoS Accreditation

• Patient Navigation Process - 3.1• Distress Screening - 3.2• Survivorship Care Plan - 3.3

It’s the Right Thing to do for Patient Centered Care

The importance of identifying and addressing supportive care needs of cancer patients is widely recognized as a core component of high-quality cancer care. The IOM asserts that “...health care systems that are involved in cancer care should explicitly incorporate attention to psychosocial needs into their policies, practices and standards (Adler).” Despite this, supportive care needs of cancer patients too often go undetected and untreated. The IOM concludes that cancer care delivery systems in the US are in crisis.

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UCDCCC – Other NCI Designated Cancer Centers

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UCDCCC Staff Satisfaction

Access to care

Meeting needs

Staff Support

Overall

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% of Staff Satisfied or Very Satisfied

GO

AL

• Overall staff satisfaction rate was 29%

• Staff satisfaction rate goal is 90%

• Dissatisfaction was highest around issues of patient access to supportive care.

Staff Satisfaction Survey

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It takes a Team

Julie Giannini, RN

Angie Usher, LCSW

Jena Cooreman, LCSW Jeanine Stiles, CAO

Nathan Fairman, MD

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City Of Hope Training3 day workshop

The Journey

Matthew J. Loscalzo, L.C.S.W. Executive Director, Supportive Care Medicine Administrative Director, Sheri & Les Biller Patient and Family Resource Center Liliane Elkins Professor in Supportive Care Programs, Endowed Professor Professor, Population Sciences

Lots of Homework to do…..

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Department of Psychiatry/Hematology-Oncology/ Primary Care/Public Health Sciences

– Support of a Psychiatric Clinic within the Cancer Center– Joint recruitment of Psycho/Oncologist – current recruitment– Buy in from Medical Oncologist– Partnerships with primary care MD’s for Survivors Clinic– Education vehicle for primary care MD’s – Outcomes Research in concert with Public Health Sciences

Internal Partnerships

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Distress Screening Pilot • A 6-month, IRB approved, distress screening pilot study of

358 Cancer Center patients was completed in February 2014.

• Screening Tool: National Comprehensive Cancer Network Distress Thermometer and adapted problem checklist

• Process: – Patients rate their current level of distress on a scale from 0 to 10– Causes of distress assessed using 39-item problem checklist– Patients scoring 5 or above referred to social services for

assessment

Making the Case

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Results of Screening Pilot

40%

22%

38%

Reported Distress Levels n=358

0-2 minimal distress

3-4 moderate distress

5-10 high to severe distress

Practi

cal P

roblem

s

Family

Pro

blems

Emotio

nal Pro

blems

Physical

Problem

s

0%

20%

40%

60%

80%

100%

60%

35%

82% 82%

Frequency of Reported Problemsfor patients with high to severe distress

n = 136

Problem Area

% r

epor

tin

g a

pro

ble

m

38% of patients reported high to severe levels of distress 30% were referred to social services

38% of patients reported high to severe levels of distress 30% were referred to social services

Current staffing (1.75 FTE) meets approximately 10.5% of the need for psychosocial services among highly distressed new patients.

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Cancer Survivors’ Focus Group • April 2014 - focus group of cancer survivors was

conducted with the following goals:– Identify common areas of concern among cancer survivors– Use information to guide development of survivorship care

• Most prevalent emergent themes included concerns about:– access to supportive care services, – care coordination between different services– provision of emotional support– Supportive care services felt to be of high quality but

insufficient to meet patient need

Focus Groups

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• Reduced emotional distress and improved quality of life (Faller et. al., 2013)

• Improved patient and family communication and coping skills (Graves, 2003)

• Reduced barriers to patient care• Improved patient investment in and acceptance

of diagnosis, treatment goals and prognosis• Increased access to community supportive

resources

Why Invest – Benefits to Patient

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• Addressing the psychosocial needs of distressed clinic patients in real time allows physician to maintain clinic schedule with minimal disruption

• Assistance in communicating information to patients and families

• Filters distractions from disease-specific care• Easily accessible, dependable compassionate

experts who help patients and support doctors• Address complex psychosocial problems for

which doctors do not have time or training

Why Invest – Benefits to Providers

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• Brings UCDHS into alignment with national standards / guidelines for quality cancer care

• Models several goals of the UCDHS Strategic Plan• Reduces healthcare costs and increases revenues

– Psychotherapeutic interventions correlated to subsequent reduction in health care use. Reductions are more prominent for high utilizers (Lane; Sobel; Crane, et al)

– Cancer patients with mild to significant mood disturbance have increased utilization rates of hospital care and can raise medical costs up to 250% (Carlson & Bultz)

– A meta-analytic review of the impact of psychological interventions on health care utilization, found an average 20% savings resulting from psychological interventions (Chiles, et al)

– Cost of providing therapeutic interventions has been shown to be offset by medical cost savings over time (Lechnyr; Guthrie, et al)

Why Invest – Benefits to Health System

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Supportive Oncology Services: Requested Additional Staffing

Staff 2014 FTE current staff

2015 FTErequest

2016 FTErequest

Total FTErequest

Psychiatrist 0.2 0.4*    

Adult LCSW 1.75 3.0 2.0 5.0

Nurse Practitioner   1.0   1.0

Adult RD 0.6 1.4 2.0 3.4

Pediatric LCSW 0.5 0.5   0.5

Pediatric RD   0.4 0.6 1.0

Child Life Specialist   1.0   1.0

Practical Assistance Coordinator   1.0   1.0

FTE Requested

Proposal Submitted to Health System LeadershipDecember 2014

Total of 13 FTE’s requested

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Survivorship

A report last year by the American Cancer Society, in collaboration with the National Cancer Institute, estimates there are almost 14.5 million cancer survivors alive in the United States today, and that number will grow to almost 19 million by 2024. Although more and more Americans are surviving cancer thanks to early detection programs, new treatment regimens and awareness campaigns, much remains to be learned about the short- and long-term issues faced by survivors. With long-term survival comes a new challenge: how to keep cancer survivors healthy and emotionally stable after treatment ends.

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• Provide patients the environment to address and deal with latent side affect, emotional support, Not lost in Transition

• Develop survivorship care plans – EMR tool.• Allow oncologist to see newly diagnosed• MD champion in survivor issues and side affects• Ability to develop a robust program for outcomes

research• External advisor for survivor issues• External advisor for Health Services Research • Hiring of a dedicated QA RN

Establishing A Survivors Clinic

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YEAR 1:• Design and develop a module in EMR for data capture of distress and nutrition

screening• Design and implement supportive oncology plan of care• Communicate importance of supportive oncology services to patients and family• Create a survivorship clinic to address end-of-treatment needs and assist in

transition to primary care• Develop practical assistance services to quickly and efficiently address concrete

patient needs• Identify psychosocial needs of new patients through distress screening• Identify nutritional needs of new patients through routine screening• Create clear clinical pathways to supportive care services• Provide supportive oncology education to providers and staff• Identify opportunities for community partnerships to improve access to services

and resources

Implementation Plan

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YEAR 2:• Conduct follow-up, reevaluation and adjustment of supportive oncology

plan of care• Expand distress screening to include follow-up screening at pivotal

points of treatment• Expand nutritional screening to include follow-up patients• Continue to increase access to services through internal development

and community partnerships• Introduce psychotherapy services for patients utilizing LCSW staff in lieu

of licensed psychologists • Quality oversight

Implementation Plan

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• A Project to Assure Quality Cancer Care (APAQCC)• UCDCCC has been accepted as a participant to this research project

being conducted by the Association of Oncology Social Work• The purpose of this project is to:

– Improve the psychosocial care received by cancer patients and their families – Provide social workers with tools and skills to implement and monitor

psychosocial care, particularly distress screening, and adhere to standards of care (American College of Surgeons, QOPI)

– Inform Social Work practice and provide data to advocate for resources (e.g., programmatic support, staffing)

• Participants in APAQCC will: – Assess their institution’s capacity for providing psychosocial support services

and compare it to other similar institutions – Use data for quality improvement and enhancement of support service delivery

How We Will Measure Our Impact

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Drinks with Shrinks

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Kentucky Has Nothing Over California