Model Pathways for Distress Management

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Model Pathways for Distress Management

Author(s): Lauren Rynar, Ph.D.
Editor(s): Teresa Deshields Ph.D.

Introduction:

The American College of Surgeons Commission on Cancer (COC) Standard 5.2 requires accredited cancer centers to implement a procedure for psychosocial distress screening (DS) and referral for psychosocial care.⁵ While the standard includes DS policy requirements, it does not offer specific guidance on different models and best practices. Therefore, a variety of distress management (DM) models have been suggested and implemented across cancer centers.

Models of DM refer to differences in the systems of distress screening, assessment, triage, and intervention that are utilized by a cancer center. Recommended models of DM involve the use of patient-reported outcomes to identify cancer-related distress and link distressed patients to supportive services. Models of DM often vary based on staffing and the level of coordination and integration between supportive care providers and medical providers. Choosing a DM model requires consideration of patient needs and cancer center resources.

The Components of Distress Management

Understanding each component of CoC Standard 5.2 can help to identify or design the DM model that is most appropriate for a particular cancer center based on both patient population and provider availability6. Components of Standard 5.2 (timing, method, assessment and referral, documentation) and considerations for staffing and integration are presented here. Different models for each component are reviewed in Table 3, moving from least involved/integrated (Model 1) to most involved/integrated (Model 3).

1. Timing of Screening

Cancer centers must determine a schedule of screening. While Standard 5.2 only requires screening to be performed at a single timepoint during a patient’s cancer treatment, most literature supports the effectiveness of DS at multiple time points.

2. Method of Screening

At least three factors must be considered when establishing a method of DS⁷:

- What tool is administered? DM teams must consider which tool(s) to utilize to screen for distress.
  - Many tools exist to screen for distress (see section 2).
  - Ideally, selected tools will be standardized, validated measures with established clinical cutoffs with previous use in individuals with cancer.
  - At least one domain of distress must be evaluated, but ideally more than one is included.
- Who administers DS? DS may be clinician-administered or patient-administered, or some combination of the two.
- In what format is DS administered? DS may be administered via paper-and-pencil or electronic questionnaires.
  - Further, depending on the technology and electronic medical record (EMR) resources of a particular institution, DS may be integrated with the EMR and allow for automatic notifications to care providers.
  - Electronic fformat of DS may also allow for remote completion of a screening tool, e.g., via an e-check-in process, which can further expedite and streamline response to screening.

3. Assessment and Referral

There must be a systematic process for reviewing results of DS to identify patients presenting with clinically significant distress and needing additional follow-up, including further assessment and referral. Specifically, if we know a patient is distressed, how do we determine what care they need, and how do we link them to that resource(s)?

4. Documentation

The DM model must be documented in a clear institutional policy. The screening results must be documented in the patients’ medical records.

There are a couple of additional issues relevant to the process of distress management.

Integration

Integration refers to the extent to which behavioral health and other healthcare providers collaborate based on physical proximity, use of the EMR, communication, and culture. DM models, and in particular the component of assessment and referral, will vary greatly based on the level of integration that is possible among providers.

Staffing

Cancer center staffing often dictates the other components of the overall DM model. For example, availability of medical assistants and nursing staff can guide decisions on patient- versus provider-administered distress screening. Similarly, availability of behavioral health providers may guide referral processes.

Table 3. Models for Addressing the Components of Distress Management

Component of DM	Model 1 (least involved/integrated)	Model 2	Model 3 (most involved/integrated)
Timing	Start of care Pivotal points in care Remission Recurrence Progression New treatment modality Completion of treatment	Timed Initial Visit Timed intervals	Every visit Exceptions for particular settings, e.g.: Weekly in radiation oncology Start of new treatments in infusion
Method of screening	Clinician administered screening	Patient administered screening	Electronic administration
Assessment	Unidimensional distress screening instrument	Emphasis on select patient-centered needs (e.g., depression, physical symptoms)	Multidimensional screening measure or combination of measures, e.g., general multidimensional screening followed by additional assessment tailored to identified needs
Referral	Oncologist manages all aspects of screening and referral	Identified non-mental health staff support oncologist in reviewing screening and triaging to needed services	Specified staff follow-up on screening, perform further assessment, and triage to needed services
Integration/ Collaboration	Coordinated: Basic collaboration at a distance, e.g., supportive services and medical services operate in separate systems	Co-located: Collaboration on-site, at least some system sharing, in-person communication possible	Integrated: Shared concept of team care Shared culture System and facility sharing, consistent communication
Staffing	Physician champions Nurses/medical assistants Administrative leadership (all supportive services external)	Physician champions Nurses/medical assistants Administrative leadership Information technology experts Social workers (some supportive services internal)	Physician champions Nurses/medical assistants Psychologist/Psychiatrist Information technology experts Administrative leadership Social workers Chaplains (most or all supportive services internal)

Click here to view table as PDF

Best Practices

It is well established that actual practice across cancer care settings is widely discrepant from guideline recommendations, which may be attributable to a variety of causes, including: a) lack of clarity regarding best practice and b) mismatch between desired DM model and available resources. To address this discrepancy, the NCCN Guidelines has moved from guideline “recommendations” to more explicit guidance on how to apply DM models to address psychosocial needs and psychiatric presentations3. Regardless of the chosen model, its success requires multilevel change at the system, institution, provider, and patient level16.

Review of this chapter may help to guide key choices in determining a DM model. Ultimately, the choices a cancer committee makes regarding DM will be dependent on cancer center resources. Some particularly important considerations, which may be less dependent on level of staffing include:

• Measure selection,

• Format selection, e.g., paper versus electronic,

• Screening timing, and

• Process for reviewing results and making referrals.

Bottom Line

Strategic consideration of different models of distress screening and distress management procedures supports concise, consistent, and sustainable implementation of institutional protocols. Investing in end-game resources, (e.g., on-site supportive services, methodology to monitor and track patient outcomes) should guide the selection of specific components for a site’s DM model to ensure sufficient resources to meet identified demand.

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