Purpose: A diagnosis of cancer, its treatment, and surveillance are fraught with distress. Despite recommendations from The National Comprehensive Cancer Network (NCCN) 2013 Guidelines, many cancer centers struggle to implement distress screening and to identify “appropriate intervals” for screening. A grant from the VA Office of Academic Affairs supported the development of a Center of Excellence (CoE) specialty cancer care clinic for breast, melanoma, and lymphoma, at a large academic VAMC to deliver patient-centered care and train learners in interprofessional practice. The CoE team has made distress screening a priority for this clinic.
Methods: Veterans are screened at every visit in the CoE clinic to determine the incidence, trends, and components of distress and provide same-day intervention for those scoring > 4 on the Distress Thermometer (DT). The distress screening has been rolled out to the lung cancer clinic and ear, nose, and throat (ENT) cancer clinics. Veterans are screened at check in. A nurse reviews the screenings prior to the veteran entering the exam room. Veterans with distress scores > 4 are offered same-day appointments with the appropriate provider(s) accompanied by student learners. The social worker assesses practical and family concerns; the psychologist addresses veterans’ emotional concerns; physical problems are handled by the nurse practitioner or medical oncologist. Veterans commonly need intervention from all of the providers. Trainees observe the interventions with the veterans, as each discipline addresses the distress. The distress screening process in the Lung Cancer Clinic and ENT clinic is different, as the psychologist and social work staff are not always present in these clinics throughout the day. The veterans who scored > 4 are offered a same-day visit or they can choose to have a follow-up telephone call from a social worker or psychologist.
Results: During the first 15 months of the CoE cancer clinic, 192 of 525 screenings (37%) yielded scores > 4, consistent with previous research (Holland & Alici, 2010). Of the veterans who had moderate to severe distress > 4, 65 (34%) had practical problem concerns and 44 (23%) cited family problems. The remaining components of distress revealed 136 (71%) emotional problems, 16 (9%) spiritual needs, and 176 (92%) physical. Some veterans had problems in multiple domains. The lung cancer clinic has completed 169 screens over the past 5 months, 96 (31%) were scores of > 4. Of these veterans, 32 (19%) uncovered practical problems, 15 uncovered (10%) family problems, and 64 (40%) were distressed due to emotional concerns. The largest sources of distress were physical problems; 120 (74%) of participating veterans uncovered physical issues. The ENT clinic has just begun screening the veterans for distress. The projected date for data analysis for the ENT clinic is August 2014.
Conclusions: VA grant funding supported an oncology team and its trainees to work together in an interprofessional specialty clinic. The team found that same-day intervention for veterans scoring > 4 is feasible, because the nurse can immediately alert the appropriate provider(s). One of the goals of the CoE clinic is to demonstrate sustainability of the intervention across the VA ’s cancer care program. The distress screening has been implemented successfully in the lung cancer and ENT clinics with minimal disruption to the flow of these established clinics. There are plans to implement this process in all cancer care clinics at the medical center.
