Are You Ready
to Assess For Distress?
Lee Tremback, MA, LCSW, OSW-C
Oncology Social Worker
Eastern Connecticut Cancer Institute
John A. DeQuattro Cancer Center
Manchester, CT
National Comprehensive Cancer Network
Psychosocial Care Guideline Panel
Formed in 1997
 Goals:

◦ Identify patients needing psychosocial help
◦ Address barriers to psychosocial care caused
by stigma of psychological/psychiatric
problems
◦ Develop ways for patients to obtain
psychosocial resources
National Comprehensive Cancer Network
Psychosocial Care Guideline Panel

28 Panel Members:
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15 female, 13 male
16 psychiatrists/psychologists
4 oncology physicians
4 nurses
2 social workers
1 chaplain
1 patient advocate
Definition of Distress:
A multifactorial, unpleasant experience of
an emotional, psychological, social, or
spiritual nature that interferes with the
ability to cope with cancer, its physical
symptoms, and its treatment. Distress
extends along a continuum ranging from
normal feelings of vulnerability, sadness,
and fear to disabling conditions such as
clinical depression, anxiety, panic, isolation,
and existential or spiritual crisis.
Institute of Medicine 2007 Report
Cancer Care for the Whole Patient: Meeting
Psychosocial Health Needs
 Recommendations:

◦ Screen for distress and psychosocial needs
◦ Make a treatment plan to address these needs
and implement it
◦ Refer to services as needed for psychosocial
care
◦ Reevaluate with plan adjustment as
appropriate
NCCN 2012 Standards of Care
Distress should be recognized, monitored,
documented & treated promptly at all stages of
disease & in all settings.
 Screening should identify the level & nature of
the distress.
 All patients should be screened to ascertain
their levels of distress at the initial visit, at
appropriate intervals & as clinically indicated,
especially with changes in disease status.
 Distress should be assessed & managed
according to clinical practice guidelines.

NCCN 2012 Standards of Care
(cont’d)
Interdisciplinary committees implement
standards for distress management.
 Educational & training programs developed for
health care professionals & certified chaplains
 Licensed mental health professionals & chaplains
readily available .
 Insurance contracts include reimbursement for
mental health services.

NCCN 2012 Standards of Care
(cont’d)
Patients, families should be informed that
management of distress is an integral part
of total medical care; provided with info
about psychosocial services
 Quality of distress management programs
should be included in CQI.
 Clinical measurements should include
assessment of the psychosocial domain

American College of Surgeons (ACoS)
Commission on Cancer (CoC)
Cancer Program Standards 2012: Ensuring
Patient-Centered Care
 Must be in place by 2015
 Standard 3.2: Psychosocial Distress
Screening

Psychosocial Distress Screening

S 3.2:The cancer committee develops and
implements a process to integrate and
monitor on-site psychosocial distress
screening and referral for the provision of
psychosocial care.
Compliance requires:
Screen patients at least once during the
cancer patient’s course of treatment; this
screening should occur during a pivotal
medical visit.
 Patients are screened using a
standardized, validated instrument with
established clinical cutoffs.
 Cancer programs are not penalized for
developing their own instrument and
constructing their own cutoff scores.

Where to start?
Gradual Implementation:
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1st Radiation Oncology (private practice)
2nd Medical Oncology (private practice)
3rd Ambulatory Medical Unit (hospital-based)
4th Inpatient Units
What is the cutoff score?
No right or wrong answer
 Can always change later
 We chose 5

Definition of Pivotal Medical Visit:
Radiation Oncology – teaching visit
during 1st/2nd treatments.
 Medical Oncology – during 1st chemo visit
 AMU – during 1st chemo visit
 Inpatient – if diagnosed during hospital
stay and getting chemo

Standardized, validated instrument

After 6 month trial using NCCN
instrument, reviewed our experiences:
◦ Physical problems already assessed by nurses
◦ Didn’t address Advance Directives, personal
care needs, family health issues, etc.
◦ Didn’t like calling them all problems
◦ Needed more thorough assessment of
depression
Write your policy
Emphasize that patients are continually
assessed by the cancer center treatment
team for physical, psychological, social,
financial & spiritual distress
 Include:
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Timing of Screening
Method
Tools
Assessment & Referral
Documentation
Assessment & Referral
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If score is over 5:
◦ Identify & examine the psychological,
behavioral & social problems of patients that
interfere with their ability to participate fully
in their health care and manage their illness
and its consequences.
◦ Confirm the presence of physical,
psychological, social, spiritual, and financial
support needs.
◦ Indicate the need to link patients with
psychosocial services offered on-site or by
referral.
Documentation
Screening, referral or provision of care,
and follow-up are documented in the
medical record.
 “Referral received re: pt had a score of 6
on distress screen due to __________.”
 “Patient provided with info on CHR
energy assistance program.”
 “Will continue to assess patient for
depression.”

Reporting to Cancer Committee
Determine data collection process
 Design quality improvement study

◦ Timeliness of intervention after screening
◦ How many referrals to social worker, chaplain,
behavioral health come from distress
screening?
◦ Are all patients screened at least once?
Are You Ready
to Assess For Distress?