Implementing psychosocial care into routine practice: making it easy
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1. This document discusses implementing a clinical pathway for screening and managing anxiety and depression in cancer patients. It outlines barriers to implementation and strategies to address them. 2. A key barrier is that screening alone does not improve outcomes; a clear clinical pathway and institutional support are needed. The pathway was developed through stakeholder consultation and specifies screening, assessment, referral, and treatment steps. 3. Barriers to implementing the pathway include lack of resources, responsibility issues, staff and patient reluctance. The proposed study will test intensive versus basic strategies to promote pathway uptake, including online training, automated screening/referral systems, and patient/staff educational resources. The goal is to improve psychosocial outcomes for cancer patients.
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Implementing psychosocial care into routine practice: making it easy
- 1. 1
- 2. Implementing psychosocial care into routine practice: Making it easy into routine practice: Making it easy Prof Phyllis Butow School of Psychology & Chair, Psycho-Oncology Co-operative Research Group (PoCoG) 2
- 3. 3 Prevalence of distress Mehnert A et al. JCO 2014; 32: 3540-3551 • Prevalence of distress in cancer patients is HIGH • Recent definitive study in Germany of in- and out-patients • Stratified proportional sampling - appropriate representation of all tumour types • 4020 patients (68% response rate) • Patients scoring above 9 on PHQ interviewed with CIDI-O
- 4. 4-week prevalence of mental disorder Disorder Prevalence (%) 95% CI (%) Mental disorder 32 29 - 34 Anxiety 12 10 - 13 Mood disorder 7 6 -8 Adjustment disorder 11 10 -12 4 Mehnert A et al. JCO 2014; 32: 3540-3551
- 5. Efficacy of interventions › We know interventions are effective › Recent meta-analysis: 198 studies - 22,238 patients › Significant small-to-medium effects for individual and group psychotherapy and psycho-education - Larger effects if high distress patients recruited › Effects sustained, in part, in the medium (< 6 months) and long term (> 6 months) 5 Faller H et al. JCO 2013; 31(6):782-93
- 6. Guidelines in psychosocial care 6
- 7. Screening and management Screening patients with cancer for anxiety and depression is widely recommended internationally Early detection and treatment: Reduces patient suffering and the likelihood of developing a major mood disorder Improves quality of life Reduces health service utilisation 7 • Howell etal (2010), Canadian Association of Psychosocial Oncology: Toronto, • NCCN, Clinical Practice Guidelines in Oncology. Distress Management Version 2. • Andersen (2014) Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults With Cancer: ASCO Guideline Adaptation. • Howell et al (2011) Current Oncology,
- 8. What happens in practice? 8
- 9. PoCoG review of screening for distress in Australia and Internationally › Review of the literature › Structured interviews with: - Key stakeholders from US, Canada, Netherlands, UK and Australia - Clinicians, Representatives of Health Departments and Cancer Councils Commissioned by Cancer Australia 9
- 10. Actual practice… Screening not routinely conducted in Australia Emotional symptoms commonly undetected, severity under-estimated Reasons for not screening? Lack of confidence, insufficient training Time pressures Lack of psychosocial staff and referral guidance - what to do if someone is identified through screening? 10 Mitchell et al., Psych-oncology , 2008; Absolom etal., Psycho-oncology 2011
- 11. Screening not the complete answer 11 Distress screening rates in Canada, 2008-2012 Despite this, psychosocial outcomes not improved Howell D et al, Pall and Supp Care 2014
- 12. › US and UK data show many oncology health professionals - Do not value screening data - Do not respond to it › Patient referral remains adhoc 12 Jacobson P et al, 2007 Mitchell A et al, 2012; 2011 Screening data is not used
- 13. › Synthesis of data from 40 years of screening in the primary care setting shows that: › Screening alone does not improve patient outcomes › A clear clinical pathway, with institutional commitment, is required › Mitchell A et al, 2011 13 Screening not the complete answer
- 14. PoCoG Clinical Pathway for Anxiety and Depression PoCoG developed an evidence-based clinical pathway for identifying and managing anxiety and depression in cancer patients Development guided by: existing empirical evidence wide stakeholder consultation in-depth clinician interviews a delphi process with 87 multidisciplinary stakeholders Shaw J, Price M et al. Supportive Care in Cancer 2015 14
- 15. PoCoG pathway › Process of stakeholder involvement designed to ensure engagement › Gaining multi-disciplinary perspectives designed to ensure the pathway is acceptable to all groups › Pathway designed to provide clear and detailed guidance 15
- 16. Methods Conducted a two-round, on-line Delphi study Round 1: 39 statements across 6 domains Scoring: Statements rated 1 (strongly disagree) to 5 (strongly agree) Free text comments to justify response Consensus defined as 80% or more of respondents rating the item within two points on the scale In round 2, participants re-rated statements that failed to gain consensus in light of the overall group responses 16
- 17. Participants Participants: 87 clinically active members of PoCoG from a range of disciplines: Medical and radiation oncologists, nurses, psychologists, social workers, palliative care physicians, psychiatrists, GPs and cancer surgeons Rural/regional and metropolitan regions across all states Range of practice settings Public/private Tertiary referral centres, regional hospitals Outpatient/community services 17
- 18. Results – key findings Screening Broad agreement Pathways should be tailored for local implementation based on local resources as well as patient characteristics Screening should be routinely implemented and formalised Designated staff member should be responsible No consensus on specific methods of screening Two step process Edmonton Symptom Assessment System (ESAS) Who is most appropriate to conduct screening 18
- 19. Results – key findings Assessment and Referral Broad agreement Further assessment to clarify the nature and severity of anxiety/depression Need to accommodate patient treatment preferences Need for patient education to maximise uptake of services No consensus on: Whether screening and subsequent assessment should be carried out simultaneously by the same staff member or sequentially 19
- 20. Results – key findings Stepped Care Clinical Pathway Broad agreement Stepped care model for managing anxiety/depression is appropriate No consensus on: Whether practical and spiritual issues should be included in the pathway Inclusion of treatment time frames 20
- 21. Results-key findings Monitoring and Care Coordination Broad agreement Responsibility for coordination of care will depend on local staffing, resources, patient factors and preferences Ongoing monitoring and follow up: Lower levels of distress: nurses, oncologists and GPs responsible Higher levels: specialised mental health professionals take on responsibility No consensus on: Who should be responsible for coordination of care for anxiety/depression 21
- 22. Conclusions Our results confirmed: Overall support for the clinical pathway Support for routine formal screening of anxiety/depression in oncology Support for stepped-care model of treatment and review Need for flexibility in pathway implementation Lack of consensus on specific screening methods and roles for management and co-ordination of care 22
- 23. The Pathway: Is flexible and tailored to each site Incorporates screening, referral and management recommendations Provides timing for follow up Suggests roles and responsibilities Utilises a stepped care model 5 steps from minimal to severe anxiety/depression Patients receive least intensive intervention likely to be effective More intensive interventions reserved for patients who do not benefit from simpler first line treatments
- 25. 25
- 26. Can we get this clinical pathway into routine practice? 26
- 27. Lack of research into “The gap” › Despite an increase in intervention studies, there is a serious lack of implementation / dissemination studies › <6% of studies aim to close gap between evidence and clinical practice › Bryant J, Boyes A, Jones K, et al: Examining and addressing evidence- practice gaps in cancer care: a systematic review. Implement Sci 9:5908-9, 2014 27
- 29. Barriers analysis - How can we implement the pathway? - Qualitative interviews: - Expert opinion elicited via audio-recorded semi-structured interviews - 12 multi-disciplinary clinicians - Transcribed, coded and analysed - Rankin N, Butow P et al. BMC Health Services Research, 2014
- 30. Resources › Lack of time, staff, resources, facilities › No agreement on screening tools & cut off scores Responsibility › Who screens? Assesses? Refers? › Ethical responsibility of detecting distress Staff barriers
- 31. Enabling implementation Engagement “…Engagement with psychosocial services and the nursing staff as a starting point is really important because ... at the end of the day they’re going to implement it.” Education and training “(You) have to … offer training to the oncologists and nursing staff in terms of basic psycho-education and... have some simple resources that could be provided to patients.” 31
- 32. Enabling implementation Evidence-based, and will make their life easier “Widespread education that highlights both the importance of psychosocial assessment, as well as the efficacy of intervention(s) “... how it reduces clinician time by identifying and intervening with psychological distress in a timely manner.. and .. prevents unnecessary admissions and presentations, as well as improving quality of life and satisfaction with care “…how this improves the clinical life for the coal-face oncologist. And how it improves the quality of life of patients and their carers” 32
- 33. Patient barriers Patient reluctance › Stigma of mental health care › Feel embarrassed they are not coping › Don’t want to burden cancer care team › Feel they are not bad enough to warrant care, have enough support at home “For a lot of people, it’ll be the first time they’ve ever spoken to someone about distress, so it’s not a simple step” “There’s a great resistance with some people... there’s one gentleman … who is just refusing point blank to see anybody, yet his wife is telling me that he’s spending most of his time in tears at home....” 33
- 35. Enabling intervention › Patient resources - Booklets and internet sites that normalise psychological morbidity and care › Staff training in making an effective referral - Role-play, online resources 35
- 36. System barriers and solutions Culture of health services “there needs to be explicit support from the institution that spending time on these issues is time well spent. That it’s valued and supported, people are given time to do it, and that it is a priority...so that everybody’s engaged in this being an important service initiative…” Change management “It needs to be system level intervention where these things are …integrated, in routine documentation, in IT systems and in quality review.” 36
- 37. Enabling implementation Adoption into health policy at state and local level “ I think one of the things that might help you, though... the funding they get for cancer services from the NSW health department ... there’s key KPIs that they have to meet… And if something like this was built into the memorandum of understanding ... it means that... at local district level you’ve got senior buy in to say ‘this is an expectation of our cancer services” 37
- 38. CINSW Translational Program Grant OVERALL AIMS • Facilitate the integration of the clinical pathway for anxiety and depression in cancer patients into routine care • Develop and evaluate implementation strategies to promote uptake of pathways in the Australian health context.
- 39. Chief Investigators Associate Investigators › Prof Phyllis Butow › Prof Gavin Andrews › Prof Afaf Girgis › Prof Brian Kelly › Prof Tom Hack › A/Prof Josephine Clayton › Dr Melanie Price › A/Prof Philip Beale › Prof Rosalie Viney › Dr Laura Kirsten + Consumer advisory group › Dr Joanne Shaw › Dr Haryana Dhillon › Dr Joseph Coll › Dr Peter Grimison › Prof Tim Shaw › Dr Nicole Rankin › Dr Michael Murphy › Dr Jill Newby › Mr John Stubbs › Dr Frances Orr › Dr Toni Lindsay Wide expertise
- 40. Clinical partners › Four Cancer Institute NSW Translational Cancer Research Centres (TCRCs) - Sydney Catalyst - Centre for Oncology Education and Research Translation - Sydney Vital - Sydney West - - TCRCs are networks of clinical and research teams - Will encourage buy-in and engagement - Will champion the work
- 41. How will we address barriers? Target Barrier Strategy Administration / Leaders Lack of support • Appoint clinical and administrative champions • Involve TCRCs • CINSW backing General Oncology staff Lack of team ownership Involve key staff from all disciplines in tailoring the pathway to their context Lack of education re why and how Online educational resources with role-play demos and cases: • Empathic communication • How to screen • How to make a referral (Especially if patient reluctant) Available on EVI-Q and at point of contact, with annual reminders to review 41
- 43. Target Barrier Strategy General Oncology staff Lack of time Automated system which: • Cues patient to complete online assessment at baseline and follow-up • Provides graph of scores over time • Sends email to staff when patient is over cut-off, for further assessment • Provides links to referral template • Emails referral to pre-specified staff • Is linked to electronic records if possible (eg MOSAIQ) Psychosocial staff Lack of time Develop online cognitive-behavioural therapy to which mild to moderate cases can be referred • Keeps staff informed of progress • Staff cued if further intervention needed Encourage wider referral options 43 How will we address barriers?
- 45. Target Barrier Strategy Patients • Stigma • Reluctance to burden staff Patient written and online resources: • Explain anxiety and depression • Normalise • Note part of routine care • Provide a lay version of the pathway Train staff to screen and refer well 45 How will we address barriers?
- 46. Research programme › A cluster randomized controlled trial (RCT) to evaluate the cost and efficacy of: - an intensive, tailored implementation strategy - versus - a basic implementation strategy for the anxiety and depression clinical pathway
- 47. All sites › Access to all the health professional, patient and system resources › On-site briefing session on pathway and systems › Posters advertising the program 47
- 48. Intervention sites › Training and ongoing support of local champions › Audit and feedback prior to and midway through the intervention › Face-to-face education regarding the portal and online tools which support the pathway › Facilitated tailoring of the pathway to the local setting › IT support › Other strategies to address the specific barriers and facilitators in each site 48
- 49. The outcome? › We hope: - The clinical pathway will remain in use - Improved knowledge about implementing health practice change - Ultimately, better outcomes for patients 49
- 50. IN SUMMARY › If we are to really improve psychosocial outcomes, we need proven interventions, clinical pathways, › AND › Careful attention to implementation › It is not easy, but it can be done! 50
- 51. Or we could… 51
Editor's Notes
- #8: Screening cancer patients for anxiety and depression is widely recommended internationally because early detection and treatment of anxiety and depression not only reduces patient suffering and reduces the risk of developing a major mood disorder, it also increases cancer treatment adherence and reduces overall health service utilisation
- #11: Despite acknowledging the important of psychosocial care screening cancer patients for anxiety and depression is not routinely conducted in Australia. Furthermore patterns of referral, treatment and follow up once anxiety or depression is identified is also variable across Australian cancer centres. This means that anxiety and depression often go undetected in Australia and even when identified the severity of symptoms can be under estimated. Reasons for lack of screening are multifaceted but relate to lack of training, time pressures in a busy clinic and a lack of referral guidance – what do you do if you identify someone as anxious or depressed?
- #15: To address the gap in service delivery, PoCoG have developed a clinical pathway to standardise psychosocial care. The pathway outlines the best practice steps for the identification and management of anxiety and depression. The pathway incorporates screening, referral and management recommendations, provides timelines for follow up and specifies roles and responsibilities for treatment, monitoring and follow up. The pathway recommends a stepped care approach to treatment. This means that patients receive the least intensive intervention likely to be effective, with more intensive interventions reserved for patients with greater levels of anxiety or depression. Development was guided by review of the existing evidence, stakeholder consultation and in-depth clinician interviews over a number of years.
- #17: To do this we conducted a two round on-line delphi study where participants were asked to review 39 statements across the domains of implementation of the pathway, screening, severity assessment if screening identifies anxiety or depression, the utility of the stepped care model, monitoring and coordination of psychosocial care and roles and responsibilities associated with care delivery.
- #18: Participants in the study were members of PoCoG who were working primarily in oncology and psycho-oncology. We had representation from across Australia from a range of practice settings
- #19: So, looking at each of the domains individually, there was broad agreement for the need for tailoring the pathway based on local staff and availability of resources and patient characteristics, overall support for routine screening, although there was no consensus on whether this screening should involve a two step process of a short screening questionnaire followed by a more detailed questionnaire such as the HADs or clinical assessment and our recommendation for use of the ESAS as a brief screen was also not supported. There was also no agreement regarding whether the cancer nurse coordinator was the best person to conduct the screening, although the reality is that the task is likely to fall to nurses.
- #20: There was also agreement that there was a need to further assess patients identified through screening as being anxious or depressed. There was also a need to engage the patient in this process through education and taking into account their treatment preferences. But no consensus on whether screening and more extensive assessment should be done at the same time by the one person or sequentially to allow for involvement of specialist psycho-oncology services
- #21: There was strong support for the stepped care model including the responsibilities for treatment delivery based on severity of symptoms. Participants were not in agreement about the inclusion of practical and spiritual concerns in the pathway or the inclusion of specific treatment timeframes.
- #22: Participants reported that the monitoring of patients and co-ordination of care needed to be locally determined based on staffing and resources, although there was consensus that at higher levels of anxiety and depression specialist mental health services were required. Because of differences in staff resopurces across sites, there was no consensus regarding who should be responsible for the coordination of care or specific professional roles designated within the pathway, in particular the role the general practitioner should play in patient psychosocail care.
- #26: This flow chart is an example of a single step within the pathway and as you can see includes information about the type of intervention and who should deliver it, when progress needs to be reviewed and by whom, as well as follow up recommendations in both the short and longer term.