Meeting Psychosocial Needs of Women with Breast Cancer (2004) / Chapter Skim
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7 Barriers to Appropriate Use of Psychosocial Services
7 Barriers to Appropriate Use of Psychosocial Services
Pages 165-198
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From page 165... ...
Among the barriers imposed by providers anti systems of care are: patient-provicler miscommunication, failure to implement clinical practice guiclelines, inexperience with assessment for psychosocial distress anti rapicI screening tools, poor coorclination anti fragmentation of complex care, a lack of provider familiarity with community resources, anti limitecI systems of quality assurance anti accountability. This chapter reviews available evidence regarding these harriers to receipt of appropriate psychosocial care.
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From page 166... ...
The test of equity of access involves first determining whether there are systematic differences in use ancI outcomes among groups in United States society anti, if there are, the reasons for these differences (IOM, 19931. Some of the factors that have been investigated as possibly affecting access to mental health services inclucle: · Health insurance coverage ancI type of coverage; · Cost, inclucling health insurance ancI out-of-pocket costs; · Attributes of the health care clelivery system (e.g., geographic clistribution of cancer care facilities, lack of service coordination; separation of meclical ancI behavioral (mental)
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From page 167... ...
The diagnosis of cancer can, in itself, leacI to a loss of health insurance coverage or to higher insurance premiums. In 1992, 7 percent of cancer survivors who were insured prior to their diagnosis reported that their health TABLE 7-1 Estimates of Health Insurance Coverage Among Women with Breast Cancer (diagnoses and deaths)
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From page 168... ...
provide free services or financial assistance to inclivicluals with cancer who lack the means to pay for their care. These programs ancI services cannot substitute for adequate insurance coverage for cancer care, but they can ease the financial burclen for small numbers of inclivicluals in neecI.
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From page 169... ...
Increasingly, mental health services are being proviclecI by managed behavioral health organizations, which are estimated to cover approximately 200 million Americans (IOM, 1997; Goff, 20021. Often mental health ser
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From page 170... ...
Managed care may also serve as a barrier to appropriate psychosocial services when mental health providers who are trained in psycho-oncology and management of distress in patients with cancer are not available within the behavioral health plan's service network. Concerns have been raised that mental health providers in networks often do not have expertise in psycho-oncology (Wellisch, IOM workshop, October 20021.
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From page 171... ...
Some evidence suggests that, in the general population, the use of mental health care increases after managed behavioral health care is implementecI in private insurance plans (Goiciman et al., 19981. This is, in part clue to shifts from in-hospital to outpatient mental health care.
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From page 172... ...
Reimbursement of the treatment of psychosocial services for women with breast cancer through public ancI private insurers may be facilitatecI by the clevelopment of six reimbursement cocles for psychological services to patients with physical health diagnoses (APA, unciatecI memo; http:// www.apa.org/practice/cpt_2002.htmI, accessed April 17, 2003)
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From page 173... ...
There is limitecI information on the extent to which women's breast care is coorclinatecI ancI organized to facilitate the identification ancI management of psychosocial distress. One important stucly in this area founcI breast cancer care sites in New York City to lack comprehensive systems to ensure care coordination
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From page 174... ...
As part of their stucly of institutional approaches to coordinate care for women with early-stage breast cancer, Bickell anti colleagues completecI inclepth semi-structurecI interviews at six hospitals with providers of breast cancer care anti their support staff. Systematic use of patient support programs, such as patient educators anti navigators, were perceived to be valuable in coordinating care.
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From page 175... ...
of care are being supported by the Robert Wood lohnson Foundation. The most extensive effort to improve psychosocial care at a population level has been in Australia where a National Breast Cancer Center has undertaken review of evidence-based research for psychosocial interventions and developed the findings into recommendations and clinical practice guidelines.
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From page 176... ...
Attributes of Health-Care Providers A lack of awareness on the part of breast cancer care providers of psychosocial neecis anti available resources, problems in patient-provicler communication, anti the absence of clear direction on how to distinguish "normal" anti expected distress from significant distress that shouicI be referred
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From page 177... ...
Problems in Patient-Provicler Communication A basic psychosocial support for women with breast cancer is their relationship to physicians who provide them with full information, who are willing to answer questions and show respect for the "human" side of illness. Psychosocial distress among patients may not be addressed in practice because of problems in patient-provider communication, and efforts are under way to improve oncologists' communication skills (Baile et al., 1999; Fallowfield et al., 2001; Schapira, 2003)
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From page 178... ...
Adoption of Clinical Practice Guidelines Efforts to improve the provision of psychosocial services for women with breast cancer have recently focused on implementing clinical practice guiclelines. Clinical practice guiclelines are "systematically clevelopecI statements to assist practitioner anti patient decisions about appropriate health care for specific clinical circumstances" (IOM, 19901.
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From page 179... ...
The NCCN guicleline has been enclorsecI by several organizations: American Psychosocial Oncology Society; Oncology Nursing Society; American Society of Oncology Social Work; Professional Chaplains' Organization; American College of Surgeons, Commission on Stanciarcis for Cancer Care; anti the American Community Cancer Centers (HollancI et al., 20011. Guiclelines clevelopecI in countries such as Australia, Canacia, anti ScotlancI have attempted to incorporate the management of psychosocial concerns into their cancer-relatecI clinical practice guiclelines (Table 7-21.
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From page 180... ...
NCON (1999~. On Clinical Practice Guiclelines for the Care anti Treatment of Breast Cancer (Canaclian Meclical Association, 19981.
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From page 181... ...
Australian National Health and Specific psychosocial Extensive experience with Medical Research Council, guideline on breast cancer. adoption of psychosocial Psychosocial Clinical Practice guidelines into breast Guidelines: Information, Support, cancer care.
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From page 182... ...
The National Guicleline Clearinghouse, a repository of eviclence-basecI clinical practice guiclelines maintained by the Agency for Healthcare Research anti Quality, the American Meclical Association, anti the American Association of Health Plans inclucles 94 mental clisorcler-relatecI guiclelines, but none is specific to cancer (http://www.guicleline.gov/inclex.asp, accessed lanuary 23, 20031. The only cancer-specific psychosocial guiclelines are those from NCCN, Australia, Canacia, anti ScotiancI.
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From page 183... ...
Although bone marrow transplantation is not recommenclecI for women with acivancecI breast cancer, these guiclelines have facilitatecI the use of psychosocial services among those for whom the intervention is appropriate. Icleally, clinical practice guiclelines not only give providers the guidance they neecI to cleliver interventions, they also lay out a plan for the integration of services into the clelivery of care.
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From page 184... ...
Oncology providers remain an integral part of the process insofar as they continue the evaluative ancI treatment process at subsequent appointments. The roles of mental health, social work, anti pastoral care providers in assessing neecI ancI providing psychosocial services are clelineatecI in Table 7-3.
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From page 186... ...
. While many clinical trials support the value of psychosocial interventions, there have been no studies demonstrating that systematic screening of women with breast cancer for psychosocial distress has lee!
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From page 187... ...
. Despite the lack of evidence for the benefits of screening for psychosocial distress in the cancer context, there is wiclespreacI agreement that clinicians shouicI at least be screening their patients for depression which is a prevalent, treatable, condition in the general population, ancI of higher prevalence among inclivicluals with chronic illness such as cancer.
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From page 188... ...
In a stucly of the effect of counseling by a nurse specialist on recovery among breast cancer patients following mastectomy concluctecI in the late 1970s, the nurse's regular monitoring of women's progress facilitatecI the recognition ancI subsequent referral of threequarters of women who neeclecI psychiatric help (Maguire et al., 19801. DISTRESS LADDER: MANAGEMENT BY STANDARDS & PRACTICE GUIDELINES ~ ~NP GO: / P j~ _5 DISTRESS Scale (0-1 0)
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From page 189... ...
Accountability There is no one system to assure the quality of cancer care, but several programs in place couicI potentially serve to improve access to psychosocial services. As clescribecI in Chapter 6, there are two sets of stanciarcis that aciciress cancer-relatecI quality of care, those of the American College of Surgeons' (ACoS)
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From page 190... ...
· Physical Appearance By 2015, the negative impact of cancer oh physical appearance and body image will be substantially reduced in ~7~5~o~f~t~h~o~s~e~aff~e~ct~e~d~c~a~n~ce~r~s~u~wi~v~o~rs~ SOCIAL ASPECTS OF QUALITY OF LIFE · Social Support By 2005, the number of cancer survivors, their families, and caregivers who participate in appropriate ACS patient support programs or are referred to other community programs will increase by at least 50~. · By 2005, 60% of survivors, their families, and caregivers will be aware of and have knowledge about American Cancer Society quality of life education and support Services.
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From page 191... ...
Other cancer advocacy organizations have promoted an awareness of psychosocial services as a part of quality cancer care. The National Breast Cancer Coalition (NBCC)
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From page 192... ...
Poncho 10 The provision of psychosocial services must be safeguarded and promoted. Persons diagnosed with cancer shogid receive psychosocial assessments at critical junctures along the continuum of cancer care to determine availability of needed support and their ability ~t~o~s~e~e~k~i~n~fo~rm~at~i~o~n~a~n~d~to~a~d~v~o~cate~o~n~the~i~r~owh~be~ha~f~.~ ~c~/d 1~1 Psychosocial research Is Integral to comprehensive cancer care and, as such, psychosocial outcome measures should be Included In all future clinical trials.
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From page 193... ...
Lack of access to health care is a general societal problem in America. An estimated 8 percent of women with breast cancer lack health insurance coverage, anti many more have inadequate health insurance coverage for even basic health care needs.
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From page 194... ...
Health-care providers can serve as barriers to appropriate psychosocial care if they fail to acknowlecige such issues in the course of providing cancer care or if they clo not refer patients to available services. Implementing clinical practice guiclelines that incorporate assessment ancI treatment of psychosocial distress is a promising strategy to overcome many of these barriers.
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From page 195... ...
3. The NCI, the American Cancer Society (ACSJ, and professional organizations (e.g., American Society of Clinical Oncology, American College of Surgeons, American Association of Colleges of Nursing, American Psychosocial Oncology Society, American Society of Social Work, American Society for Therapeutic Radiology and Oncology, Oncology Nursing SocietyJ need to partner with advocacy groups (e.g., National Breast Cancer Coalition, National Alliance of Breast Cancer Organizations,Wellness Community, NCCSJ to focus attention on psychosocial needs of patients and resources that provide psychosocial services in local communities and nationally.
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From page 196... ...
1999. Update: NCCN practice guidelines for the management of psychosocial distress.
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From page 197... ...
1999. NCCN practice guidelines for the management of psychosocial distress.
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From page 198... ...
2001. Ensuring quality cancer care by the use of clinical practice guidelines and critical pathways.
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