2007-09-17_ipso-psycho-oncology by xiangpeng


									                                    A strategic approach to psycho-oncology in Australia
                                    September 2007

  New South Wales

                                            Dr Nicole Rankin                         Ms Louise Whitaker                             Dr Catherine Mason                               Prof. James Bishop        Ms Sue Sinclair
                                       Psycho-oncology Co-operative Research Group      Cancer Institute NSW                    Sydney West Cancer Network, Westmead Hospital           Cancer Institute NSW    Cancer Institute NSW

BACKGROUND                                                                                                     RESULTS

T   his poster describes a strategic approach to improve the integration of psychosocial
    support within cancer services in New South Wales (NSW), Australia, to achieve quality
cancer care for cancer patients, their families and carers.
                                                                                                               Phase 1: Review of Psycho-oncology services.
                                                                                                               • Participants: A total of 70 oncology health professionals from 26 cancer services in NSW participated in the Review. The sample was designed to include
                                                                                                                 well established and less well established services and key results are likely to be broadly representative for the State.
The Cancer Institute NSW is Australia’s first government-funded state based cancer control                      • Psycho-oncology staffing and programs: All services had access to specialist oncology nurses, 65% had social workers and 42% had psychologists. Most
organisation. To improve quality of life and clinical outcomes for cancer patients, the                          services provided programs including assistance for rural and remote patients, financial advice and pastoral care. Fewer services offered interventions
Cancer Institute NSW has dedicated $3.5 million over three years in developing a strategic,                      such as individual or family–based therapy or group programs.
state-wide approach to the delivery of psycho-oncology services.
                                                                                                               • Service provision: Participating psycho-oncology staff reported that 42% of services were adequate or better and 58% were limited (27%) or very limited
This approach was enhanced through the creation of the Patient Support Sub-Committee,                            (31%). For the latter group, services were limited and offered only to those patients in crisis situations.
consisting of NSW representatives with expertise in psycho-oncology across the disciplines                     • Team structure: Eight sites (31%) had dedicated psycho-oncology staff but they did not work together as a cohesive team. Seven sites (27%) had staff
of psychiatry, psychology, social work, health service delivery, medical oncology, academic                      providing psychosocial care but were not solely dedicated to cancer. Three sites (12%) had a psycho-oncology team structure that provided specialist
research and consumers.                                                                                          programs and interventions. Two sites (8%) had psycho-oncology staff integrated within a broader tumour-specific or an allied health cancer-specific team.
It is intended that all cancer services be able to provide a comprehensive approach to                           The remaining three sites (12%) reported having no psychosocial support specifically available to cancer patients.
psychosocial care through:                                                                                     • Screening for patient distress: No sites were screening all patients who entered their service. There was a noted lack of agreement of participants from
                                                                                                                 within sites about the processes to screen patients for distress. At 10 sites patients were identified as potentially distressed at a multidisciplinary team
• The provision of patient-centred care;
                                                                                                                 or other patient planning meeting, and a clinician or psychosocial staff would subsequently offer the patient a psychosocial assessment, consultation or
• The provision of education and training for oncology health professionals in communica-                        referral. At 11 sites, screening strategies were in place or were being developed, but were not available to all patients. Participants at other sites were
  tion and counselling skills and the identification of patients for referral to psycho-oncology                  unsure if any screening strategies were in place.
                                                                                                               • Commonly identified challenges identified by such staff included provision of an optimal level of services and sufficiently skilled staff, inadequate data to
• Collaboration with other oncology professionals and participating in a multidisciplinary                       demonstrate psycho-oncology service effectiveness and, at times, insufficient space to allow privacy for patient consultations.
• Implementation and development of psycho-oncology policies, protocols and procedures;                        Phase 2: New clinical positions
  and,                                                                                                         A total of 28 new positions were created across 8 AHS in NSW. Of these,
• The collection of data and evaluation and reporting on the psycho-oncology service.                          • 17 were in social work; 10 in psychology and 1 in psychiatry.
                                                                                                               • 13 were located in metropolitan cancer services, 14 in regional/rural areas, with 1 position in remote areas.
                                                                                                               • In many instances, these staff positions were the first ever dedicated roles for psycho-oncology. This required staff to establish new structures for
Phase 1: Review of Psycho-oncology services.                                                                     delivering psycho-oncology services and creating new systems to work in a multidisciplinary approach to psychosocial care.

In 2004, a purposive sample of cancer services (‘sites’) was selected from across NSW                          Phase 3: Staff progress survey
using a maximum variation sampling technique to ensure a representative spread of major
                                                                                                               • Participants: Twenty-six (of 28) psycho-oncology staff participated in the progress survey, consisting of 15 social workers, 10 psychologists and one
teaching hospitals with dedicated cancer services, different cancer service models in the
provision of surgical, medical and/or radiation oncology services, as well as tumour specific
services, regional and rural hospitals, as well as private hospitals; a community based                        • Establishing the role: Qualitative analysis showed that the role of psycho-oncology staff to be inherently multifaceted and varied, with a focus on service
psycho-oncology model and a pilot tele-health psycho-oncology model. A mix of case                               provision to patients, their families and carers as well as communication with other members of staff. Assessment, intervention, referral, resource
studies and formal interviews, using a structured survey instrument, were conducted in the                       provision, advocacy and education were the most highly reported activities. Other activities included working within a team, providing patients with
first half of 2005 with participants from each site.                                                              opportunities to access support networks and doctors, and developing a better, systematic service.
                                                                                                               • Screening for patient distress: Many respondents indicated that processes for screening patients were in place or being implemented. The responsibility
Phase 2: Implementation of new clinical positions.                                                               to screen patients was shared across a variety of roles including cancer nurse coordinators, psychologists, social workers, nursing staff and reception staff.
The Cancer Institute NSW worked collaboratively with key stakeholders in eight Area                              The number of patients screened varied markedly across services, from as few as ten and up to more than fifty patients screened per month. The most
Health Service (AHS) to identify those cancer services with the greatest need for psycho-                        frequently used screening tools were the NCCN Distress Thermometer (36%) and HADS (20%). A further 16% used another psychometrically valid and
oncology staff positions. Standard position descriptions for clinical psychologists and social                   reliable screening tool, while 32% of respondents did not use any.
worker roles were developed by Institute staff and the Patient Support Sub-Committee                           • Priority areas for short-term service development: The six most commonly reported challenges were streamlining services and referral pathways, raising
to assist the recruitment process. Each AHS was offered the equivalent of two funded                             community awareness, arranging professional supervision, providing support group services, relationship-building, and professional development.
positions (one psychologist and one social worker) and then determined whether to
                                                                                                               Phase 4: Clinical pathway
implement these as full-time or fractionated positions across services. Recruitment of staff
commenced in July with most positions being filled by December 2005.                                            • Pilot workshop outcomes identified broad support for a clinical pathway and distress screening with identified benefits at the patient and professional
Phase 3: Staff progress survey                                                                                 • The next phase of this project involves implementation and evaluation of the modified pathway at selected metropolitan and non-metropolitan sites .
A survey instrument was developed by the Cancer Institute NSW in 2006. A research
company was commissioned to administer the survey, which was sent via email to                                                                                                  IMPLICATIONS FOR CLINICAL PRACTICE
psycho-oncology staff. Prior to survey distribution, introductory information was sent to
participants and the AHS Directors of cancer services. Completed surveys were returned                           The Cancer Institute NSW strategic approach to developing psycho-oncology services in the State has significant implications for clinical practice.
via email, fax or post. Up to three reminder emails or phone calls were made and surveys                         While the four phases described above have overlapped and are not linear in implementation, it is clear that positive improvements have resulted
were returned within four weeks. The survey was completed by end October 2006.                                   within the past three years.
                                                                                                                 Phase 1, the Review of psycho-oncology services, confirmed that psychosocial oncology services in NSW were not well defined structurally and
Phase 4: Clinical pathway development
                                                                                                                 required integration and leadership from within cancer services programs.
A working group of the Patient Support Sub-Committee developed a draft evidence-based
                                                                                                                 Phase 2 saw the greatest single injection of new staff positions in psycho-oncology services in recent years and has significant clinical implications in
clinical pathway for the screening and referral of cancer patients for psychosocial support in
                                                                                                                 increasing the availability of psychosocial staff in cancer services.
early 2006.
                                                                                                                 Results from the progress survey in Phase 3 shows the challenges involved in establishing new services and the role of psycho-oncology staff. These
A consultant was engaged to develop a workshop program to pilot the pathway. Two
                                                                                                                 results point to evidence that screening mechanisms are being implemented with nearly three quarters of respondents using evidence-based tools.
workshops, one urban (Liverpool-Macarthur) and one regional (Albury), were held in June
2007 with health care professionals from a wide variety of specialties. The workshops                            Phase 4 is due for completion in early 2008 which will review the benefits and challenges when introducing a clinical screening tool and the Distress
tested the tools developed for the clinical pathway for the screening and referral of cancer                     Thermometer into the clinical setting.
patients for psychosocial support. These tools included the “the draft Clinical Pathway”,
“Identifying risk factors associated with distress in cancer patients” and the “Distress


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