Journal of the National Cancer Institute Advance Access originally published online on January 29, 2008
JNCI Journal of the National Cancer Institute 2008 100(3):167-168; doi:10.1093/jnci/djn005
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
© Oxford University Press 2008.
NEWS |
Institute of Medicine Says Psychosocial Care Possible in Any Oncology Practice in U.S.
All cancer care providers should ensure that patients receive needed psychosocial services, according to a new standard of care proposed by the Institute of Medicine (IOM). Perhaps most surprising: The IOM concludes that the resources already exist for every provider, large or small, to meet this standard.
The IOM's proposed standard calls on clinicians to provide screening for psychosocial needs, link patients with services, coordinate and monitor the care received, and follow up (see sidebar). "We believe that it is possible for every provider to meet this standard in some way," said Ruth McCorkle, R.N., Ph.D., of Yale University School of Nursing in New Haven, Conn., a member of the committee.
Lack of resources has been cited as a barrier to including psychosocial services in most cancer care. But the IOM challenges this rationale. "One of the things that struck us in doing this was the very wide range of services that are already available," said Nancy Adler, Ph.D., chair of the IOM panel and vice chair of the psychiatry department at the University of California, San Francisco. "What we saw as the biggest lack is how to hook patients up with these services," she said.
The IOM defines psychosocial services broadly, including not only those that address emotional problems, such as depression, that can accompany a major illness but also "life challenges" that prevent good health care. Examples include the inability to pay for care, lack of transportation to medical appointments, and difficulty with daily activities such as bathing or preparing meals. The report lists more than 100 national groups that offer free or low-cost psychosocial services ranging from information and education to financial assistance, counseling, and emotional and logistical support.
|
"At first, [providing psychosocial services] looked like a large hill to climb—time, expense, the need to create a program," said panel member Lee Schwartzberg, M.D., medical director of the West Clinic in Memphis. "But in fact you don’t have to create a program. We were happily surprised to find this."
The report does not speak only to clinicians. It also includes recommendations for advocacy groups, federal agencies, insurance companies and other payers, and national policy and professional groups. But providers get the most ink. "We focused on what happens when patients are being seen," Adler said. "That's where it has to happen."
Practical Details
The report offers detailed discussions of ways to integrate psychosocial services into any clinic, including descriptions of the processes and resources at the practice level. In addition to the lists of national organizations, there is detailed information on reimbursement mechanisms and psychosocial screening tools. Case studies feature community practices of different sizes that already meet the proposed standard of care.
The committee decided to go into such detail because many providers do not address psychosocial issues, despite evidence that psychosocial interventions can be of benefit. For instance, a survey of the 18 large cancer centers that belong to the National Comprehensive Cancer Network found that only three offered psychosocial screening, despite network guidelines recommending screening. In another survey, 33% of members of the American Society of Clinical Oncology said that they do not routinely screen cancer patients for distress.
One barrier is simply lack of awareness that psychosocial issues are truly integral to cancer care and can be addressed as part of routine care. "It's a question of prioritizing," Schwartzberg said. "A lot of practices may pay attention to psychosocial issues on an ad hoc basis. It would be more efficient to do it in a more systematic way."
The IOM identified three different models for providing psychosocial interventions systematically, depending on a clinic's size and resources. The most comprehensive provides on-site services, with social workers and mental health professionals integrated into the practice. A second model uses local resources to provide needed services. And the third, for practices in more rural settings where community resources may not be available on site, depends on referrals to remote resources, such as national cancer information services and online support groups.
One practical issue that the IOM recommendations do not address is staffing. That should not be overlooked, said Kimberly Lawson, current president of the Association of Oncology Social Workers. "There is likely a strong case to be made for the cost efficiencies imparted by dedicated psychosocial staff such as oncology social workers," she said.
Some large practices, like the West Clinic, do have on-site oncology social workers and psychologists. In others, such as the Kansas City Cancer Center, nurses or nurse practitioners manage psychosocial services—including screening, referral, coordination, and follow-up—as part of their routine duties.
"It has to be somebody's job," said Diane Blum, executive director of CancerCare, a large patient advocacy and support organization in New York City. "One barrier to integrating psychosocial services into a practice could be identifying who will do it."
"My own view is that efficiencies can be gained by using people that every practice has," Schwartzberg said. "Nurses, front desk staff—all can play some role. What is needed is not so much new initiatives as an increase in emphasis."
Key Ingredients
Panel members stressed that good psychosocial care requires good communication. "Everything is based on, depends on, good patient–provider communication," Adler said. The report calls on advocacy groups to educate patients to ask for care that meets the IOM standard.
The IOM also has recommendations for those outside the clinic. For example, it urges group purchasers of health care and health plans to support psychosocial care; national cancer organizations to incorporate good psychosocial care into their standards and policies; and medical education groups to identify needed skills in this area.
Recommendations for more research highlight the need for better screening and need-assessment tools and better approaches to link patients with services and coordinate care. The report urges the National Cancer Institute to monitor progress toward improved delivery of psychosocial services and report its findings at least biannually.
Data collection is a priority, agreed Robert Croyle, Ph.D., the National Cancer Institute's director for cancer control and population sciences. "We are considering how best to collect data on the national level on the quality of psychosocial services," he said. One possibility is to piggyback on current national surveys of cancer patients.
Croyle emphasized the need for more research on what psychosocial interventions are effective. Recent research on quality of care has tended to be descriptive, he said. These studies have established that psychosocial interventions can make a difference in cancer patients’ quality of life. Now, studies that test different strategies and compare different models of psychosocial care are a priority.
"We need more information at the most practical level on key ingredients," Croyle said. "That will be the next generation of studies."
IOM Proposes Standard of Care for Psychosocial Services
Citing evidence that unmet psychosocial needs compromise the effectiveness of cancer care, a new Institute of Medicine report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, proposes a standard of psychosocial care. The proposed standard is based on studies showing that cancer patients are at increased risk for emotional suffering, diminished adherence to treatment, impaired work and social functioning, and additional threats to their health. The report also cites evidence of the effectiveness of interventions to relieve emotional distress in chronic illness and to help patients adopt behaviors that help them manage their symptoms.
The IOM's proposed standard states that all cancer care should ensure the provision of appropriate psychosocial health services by
- facilitating effective communication between patients and providers;
- identifying each patient's psychosocial health needs;
- designing and implementing a plan that links the patient with needed services, coordinates biomedical and psychosocial care, and engages and supports patients in managing their illness and health; and
- systematically following up on, reevaluating, and adjusting care plans.
—Caroline McNeil
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||