Models of Care in Pediatric Psycho-Oncology

APA Div 54 Hem/Onc/BMT SIGWorld Congress of Psycho-Oncology

July 31, 2015

No conflict of interest

Hem/Onc/BMT SIG

• Formed in 2013• 184 members• Mission:

– Collaborate with organizations with a similar focus and current Society of Pediatric Psychology (SPP) SIGs that often overlap with the Hem/Onc/BMT population

– Provide networking opportunities within SPP for members who have a clinical and/or research interest in Hem/Onc/BMT

– Provide a forum for discussion and sharing of information and ideas regarding clinical and research practices across institutions

SIG Leadership

• Co-Chairs– Jenny Hoag, PhD, Medical College of Wisconsin– Kristin Bingen, PhD, Medical College of Wisconsin

• Hematology Leadership– Cecelia Valrie, PhD, East Carolina University– Matt Myrvik, PhD, Medical College of Wisconsin

• Student/Trainee Representatives– Aimee Hildenbrand, MS, Drexel University– Jeff Karst, PhD, Medical College of Wisconsin– Joy Kawamura, MS, University of Washington

Models of Care in PediatricPsycho-Oncology

• The Psychosocial Services Program of The Children’s Hospital of Philadelphia (CHOP) Cancer Center: Translating Research into Practice – Lamia Barakat, PhD, CHOP

• Needs-Based Psychosocial Care – Amii C. Steele, PhD, Levine Children’s Hospital

• Promoting Positive Adjustment for Sibling Donors of Bone Marrow: A Psychosocial Model of Care at a Single Institution – Nupur Gupta, PsyD, Children’s National Health System

• Model of Care at Nationwide Children’s Hospital (NCH) – Tammi Young-Saleme, PhD, NCH

• Standard of Psychosocial Care for Pediatric BMT/HSCT Admissions – Kris Kullgren, PhD, C.S. Mott Children’s Hospital

Chair – Jenny Hoag, PhD Discussant – Kristin Bingen, PhDMedical College of Wisconsin

Learning Objectives

• Identify at least one model of psychosocial care delivery

• Identify at least one strategy to develop and evaluate a psychosocial program

The Psychosocial Services Program ofThe Children’s Hospital of Philadelphia

(CHOP) Cancer Center:Translating Research into Practice

Lamia P. Barakat, PhD, Elizabeth Britton, LCSW, Kathryn David, LCSW, Anne Reilly, MD,

Stephanie Rogerwick, MA, Jeneane Sullivan, RN, MSN, and Lisa Schwartz, PhD

World Congress of Psychosocial OncologyAPOS/IPOS

July 31, 2015

The CHOP Cancer Center 550 new patients per year (excluding 2nd opinions)

22,880 outpatient visits per year 50 bed inpatient unit (11 stem cell transplant beds)

16,381 inpatient days per year Patients followed off treatment and into survivorship through

early to mid-20s Approx. 1,000 patients followed in Survivorship Program

Associated programs: Psychosocial Services Program

Adolescent and Young Adult Program Survivorship Program

Fertility Preservation Pediatric Advanced Care Team Pediatric Proton Therapy Patient/Family Education

Clinical/Treatment• Persistent and/or escalating distress• High risk factors• Few resources• Intensive application of health care and psychosocial resources

Targeted• Acute distress• Risk factors present• Moderate resources• Enhanced education and support, more frequent follow-up

© 2005, Center for Pediatric Traumatic Stress (CPTS), The Children’s Hospital of Philadelphia

Universal• Distressed but resilient• Few risk factors present• Sufficient resources• Education/support

Pediatric Psychosocial Preventative Health Model (PPPHM)

Services Guided by PPPHM “Universal” services aim to strengthen resources, address expected

distress, and promote resilience Social work and child life services Psychoeducation programs (face-to-face, online/written, audio, video) Patient Navigation

“Targeted” programs are provided for patients and their families who are at risk for or demonstrating difficulties Interventions for procedure-related distress (child life) Creative arts therapies (art and music) Spiritual care Education liaison and Neuropsychological Assessment

“Clinical” interventions--for patients and families with severe distress, pain and/or pre-existing vulnerabilities Care coordination Psychology consultation and intervention Psychiatry consultation (C/L service)

Universal Services

Social Work (9 by service and in outpatient settings) Initial assessment of psychosocial needs Linkage to community and financial resources Negotiation of practical issues related to cancer treatment Bridge to school reentry Coordination of psychosocial care

Child Life (9 child life specialists, 1 activity coordinator) Patient education about diagnosis and treatment Developmentally appropriate play and activities Sibling support

Hospital School Program and School Reentry Program (3 teachers and 1 education liaison) Patient Resource Navigation (1 MSW) Patient/Family Education (1 NP plus psychosocial team)

At diagnosis (Oncology Home Management class, Cellie Cancer Coping Kit) Webinars AYA Podcasts

Oncology Home Management Class for the newly diagnosed patient/family

Developed through partnership with Oncology Nursing and Psychosocial Services Team. Based on the following assumptions: Medical information families receive at the time of diagnosis affects disease

management and family functioning Importance of collaboration to provide comprehensive education and care Education’s goal is to prepare family for discharge, transition home and

outpatient visitsClass structure Each class is taught by an Oncology RN and member of the Psychosocial Team Class is tailored to each family and is required of families prior to discharge Provides background medical information: Blood counts, review of

chemotherapy, management of side effects, fever guidelines, contact information, reasons to call, etc.

Provides psychosocial support and information: Explanation of psychosocial team and resources, assess understanding of medical content, anticipatory guidance and emotional support, communication with community about diagnosis

Family receives useful resources in class (thermometer, magnets, pillboxes)Program initiated in March 2014 / 325 classes taught as of July 2015

Oncology Home Management Class Evaluation

Patient/family feedback received through evaluations completed after class indicate that:

Families value the class Families feel empowered to care for their child at home and to access psychosocial resources

Example quotes from parents and providers: Parent: “Staff were knowledgeable and so kind. It was so helpful to be able to get away into the

classroom and really focus on what it means to take our son home and what we need to know. The staff and class made it less scary and were very supportive.”

Parent: “Very patient staff. Answered various questions. Confirmed a lot of information I had no knowledge of or wasn’t clear about. This class if very beneficial and I pray it continues for everyone.”

Nurse: “Teaching class brings it back to the old style of nursing, where you really spent time with a family teaching them and bonding with them.”

SW: “It’s so helpful to spend this dedicated time with families to provide support and gain insight to make sure all of their needs are being met.”

Psychosocial Screening Psychosocial screening is recommended as standard of care across disciplines At diagnosis

Social work assessment Psychosocial Assessment Tool (PAT2.0) via research

Off treatment Brief patient and parent reports on PAT2.0, distress thermometer, PedsQL and

neurocognitive screener Screening is acceptable and feasible in our setting

Red flags defined and information reported to social worker for follow-up Findings (Pierce et al., in preparation):

Distress at diagnosis is high due to emotional adjustment to diagnosis, financial stressors, and coordination of family needs

Off treatment distress remains high due to ongoing stressors and focus cancer treatment for prolonged period, and distress is associated with patient HRQL

Patient Resource Navigator(funded by American Cancer Society)

Maintains database of and functions as primary liaison to childhood cancer foundations and resources

Provides informational support to social workers and direct support to families (primarily off treatment)

Conducts Caregiver Café in clinic 4 times/month Oversees distribution of gift cards and holiday

gifts for families Organizes resource tables and presentations at

Cancer Center events and regional patient/family conferences

Serves approximately 150 families directly and another 100 families indirectly per year

Targeted Programs

Supportive counseling (social work) Interventions to reduce procedure-related distress and

therapeutic play (child life) Art Therapy (2) and Music Therapy (2)

Individual therapy Group therapy – for patients and for parents

Inpatient and Outpatient Support Groups—associated with child activities and stand alone

Spiritual Care (1 Chaplain) Education Liaison (1 MSW) Neuropsychological Assessment (2 Pediatric

Neuropsychologists)

Implementing evidence-based treatments SCCIP-ND for newly diagnosed families (Lutz Stehl et al., 2009)

Social workers and other members of psychosocial team received training One session model used to structure inpatient support group for parents of

newly diagnosed patients Evaluation of acceptability and feasibility of implementation by social

workers to guide initial interactions/supportive counseling is underway through award from APOSW

CogmedRM for children with brain tumors (Hardy et al., 2003)

Two research protocols for patients with brain tumors post-radiation therapy Received small infrastructure grant to offer CogmedRM as part of clinical

care and now developing model to identify eligible patients and deliver the intervention

Altered Book Making Art Therapy Group (Cobb & Negash, 2010) Offered via weekly inpatient group for parents of recently relapsed patients

Neuropsychological Assessment and associated Quality Improvement

Initiatives

150 neuropsychological assessments per year Clinical assessments (billed) Proton Protocol (billed) COG ALTE and other consortium studies

Satisfaction with assessment QI: families uniformly found the evaluation and feedback helpful

Educational needs of patients and survivors QI (Hocking et al., in

progress): Significant ongoing concerns regarding academic achievement and

social functioning Patients with brain tumors and patients with solid tumors most at risk

for ongoing educational challenges Support needed for negotiating with schools on accommodations and

obtaining school evaluations, 504 plans and IEPs

Clinical Interventions

Patient Care Coordination Through partnership of social work and pediatric psychology

with patient care teams; screening aims to identify those at risk and prompts care coordination prior to safety events

Psychiatry Consultation (through C/L service) Psychology consultation and intervention by referral:

1.5 FTE (across 5 pediatric psychologists) (bill using health and behavior codes)

Referred when behavioral health concerns become acute and/or interfere with treatment

Evaluation and management of risk for harm/suicidality Development of behavior plans Referral to community psychologists/psychiatrists as

appropriate

Psychology Quality Improvement Initiatives 200 consultations per year completed by pediatric psychologists

Approx. 60% followed for intervention Progress Note QI

Consultation note and Progress note are templated in EPIC Operationalized progress toward treatment goals Added Global Assessment of Functioning rating Drop-down menus facilitate reference to commonly used treatment goals

and associated evidence-based interventions Adolescent and Young Adult Needs Assessment (Barakat et al., in press)

Most common challenges included treatments and associated physical changes, barriers to pursuit of academic/vocational goals, and social isolation

For preferred program focus, AYA ranked highest increasing strength and endurance/reintegration into sports and dealing with physical changes resulting from treatment

Preferred modalities for program delivery were one-on-one/in person and online through message boards/Facebook

Next Steps Universal Services

PFE AYA education at diagnosis Families moving off treatment

AYA space in new ambulatory care center Relaxation recordings for caregivers and AYA VitalHearts training for staff support

Targeted Programs Executive Function Clinic Education Liaison – new position for Master’s special education teacher Stem Cell Transplant Protocol (to mirror Proton Protocol) Maternal Problem-solving Training (Bright IDEAS)

Clinical Interventions Psychology Consultation QI to assess value of psychology services via provider

satisfaction with: Time to consultation Communication from the pediatric psychologist Contribution of pediatric psychology consultation to plan of care

Needs-Based Psychosocial Care

Amii C Steele, PhDLevine Children’s Hospital at Carolinas Medical

CenterCharlotte, NC

Levine Children’s Hospital

• Southeast United States • Charlotte, North Carolina

– Population: 2.5 million • Carolinas Medical Center

(864 beds)• 234 bed children’s hospital• 24 bed inpatient

Hematology, Oncology, & BMT

• 147 new Oncology patients in 2014• 348 Sickle Cell patients in 2014• 9 Physicians• Insurance

– Commercial 48 %– Government 52 %

Psychosocial Services

• Inpatient/Outpatient– 1 FTE Pediatric Psychologist– 3 FTE Licensed Clinical Social Workers (Onc/BMT)– 1 Child Life Specialist

• Inpatient – 1 FTE Child Life Specialist – .5 FTE Child Life Assistant– 1 FTE Chaplain – 1 FTE School Teacher – Child and Adolescent Psychiatry – Pediatric Palliative Care

Psychosocial Care

Social Work & Child Life

All Oncology Patients

Psychology Consult

Elevated Distress ScorePhysician ConcernParental Request

Psychiatry Consult

Evaluation for Medication Physician Concern(Inpatient Only)

Psychological Services

Promote coping/adjustment to medical illness or injury

Cognitive and Behavioral Strategies

Improve treatment adherence and compliance

Non-pharmacologic Pain Management

Relaxation and Biofeedback techniques

End of Life and Bereavement support and therapy

Psychological Assessment

Consults

• Primary referrals:

– Depressed Mood

– Anxiety

– Difficulties Coping with Medical Illness

– Family Coping Difficulties

65%4%

17%

9%4%

Psychologist Time Spent in Activity

InterventionAssessmentSupervisionProgram Devel-opmentResearch

A Typical Day

Tips for Success

• Funding• Support

– Billing – Administrative

• Equipment: assessment measures• Frills• Education

How Pediatric Psychology Services Differ From Traditional Psychotherapy

Source: Casciani, 2004

Promoting Positive Adjustment for Sibling Donors of Bone Marrow:

A Psychosocial Model of Care at a Single Institution

Nupur Gupta, PsyD; Steven J. Hardy, PhD; Amanda L. Thompson, PhD

BACKGROUND

Children’s National Health System• Large Mid-Atlantic urban hospital in Washington, DC

Center for Cancer and Blood Disorders (CCBD)• 300 newly diagnosed patients seen annually• 30 inpatient beds

Division of Blood and Marrow Transplantation• ~ 65 bone marrow transplants conducted annually

• ~ 40 allogeneic bone marrow transplants

PSYCHOSOCIAL TEAM

• Psychology: 2 attendings, 2 postdoctoral fellows, 2 graduate student externs

- Routine for all newly diagnosed patients with cancer

- Hematology and BMT patients by consult only

• Social Work: 9 total across disease teams (1 dedicated to BMT)

- All patients within CCBD receive social work support

• Child Life: 2 Specialists (1 inpatient, 1 outpatient)- Routine for all newly diagnosed patients with cancer and those receiving a BMT- Hematology patients by consult only

PSYCHOSOCIAL TEAM

Additional team members and services available to all patients and families:

• Art Therapy: 4 Art Therapists• Pastoral Care: 4 Chaplains• Education: 1 Educational Specialist• Music Therapy: 1 Music Therapist• Yoga Therapy: 1 Yoga Therapist• Patient Navigator: 1 Navigator/Teen Room

Coordinator

PSYCHOSOCIAL CARE of SIBLING DONORS

• New model of care developed by psychology in collaboration with BMT team members

• Expansion of psychology services to include assessment and monitoring prior to transplant through three months post

RATIONALE

• Limited literature on psychosocial functioning and care of sibling donors of pediatric bone marrow

• Past findings suggest that sibling donors can be adversely affected by their experience

RATIONALE

• Common concerns:

– Feelings of coercion or exclusion– Anticipatory fears– Feelings of isolation– Depressive symptoms, anxiety, low self-esteem– Feelings of anger and blame, particularly when

transplantation is unsuccessful

RATIONALE

Ethical Assumptions

Ethical Considerations

How to buffer against

psychological risks

How to help siblings feel more involved

How to reduce

feelings of

responsibility

Not a major medical risk to donor

Parents provide

ultimate consent

Better to save a family member’s life

Ethical care of sibling donors requires us to reevaluate our assumptions about donation and consider their needs more closely. Goals for current model of care:

• Increase sibling involvement in decision-making conversations

• Increase developmentally appropriate psychoeducation

• Encourage siblings to ask questions and discuss their experience

• Ensure siblings feel well-supported• Early identification of risk factors or

concerns to be addressed and monitored throughout

MODEL of CARE

Pre-Transplant

• In addition to full pre-transplant work-up conducted by donor physician and transplant social worker, psychology meets with sibling donors to:

– Assess siblings’ understanding of transplant, attitudes toward donation, impact of patient’s illness, current psychological functioning

– Provide psychoeducation and recommendations for promoting sibling well-being

• Psychology visit is billed under patient’s account as part of the transplant work-up

MODEL of CARE

1 and 3 Months Post-Transplant

• Psychology speaks with sibling donors in-person or over the phone to:

– Assess any new or ongoing concerns regarding the donation and transplant process, current coping, psychological functioning, program evaluation

– Provide brief interventions, recommendations for ongoing support, and additional resources as needed

• Not currently being billed

IMPLEMENTATION

Concerns identified at pre-transplant

Limited Awareness

Limited Understanding

Limited SupportAnxiety and

Transplant-Related Worries

IMPLEMENTATION

Reported benefits of model of care

ValidationReassurance

and Clarification

Helpful Recommendations

Decrease in Anxiety

Symptoms

IMPLEMENTATION

Data Tracking for Future Statistical Analyses

• Demographic Information• Transplant-Related Information • Transplant Evaluation Findings/Themes

IMPLICATIONS• Increase attention to the rights and needs of sibling

donors, in line with calls from the National Marrow Donor Program and American Academy of Pediatrics

• Enhance and standardize ethical care of sibling donors

Model of Care at Nationwide Children’s Hospital

Tammi Young-Saleme, Ph.D., Jennifer Hansen-Moore, Ph.D, ABPP, Stacy Flowers, Psy.D.

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• Located in Columbus, Ohio

• Ranks 7th in U.S. News and World Report for Cancer Specialty

• NCH Inpatient Beds on Main Campus - 464

NCH Hem/Onc/BMT Stats

• Hem/Onc/BMT Ambulatory Clinic– BMT Clinic – 6 rooms – Infusion Clinic / Day Hospital – 14

rooms – Hem/Onc Clinic – 14 rooms – Apheresis – 4 bays

• Hem/onc/BMT Inpatient– 42 rooms/beds

• 12 BMT only rooms/beds• 1 MIBG room• 1 comfort care room• 28 regular rooms/beds

• 180 new oncology diagnosis per year

• 60 BMT per year

Early Days at NCH

• Psychosocial Staffing was sparse, inconsistent, and not integrated

• Average 165 new patients each year

Social Worker1 FTE

Inpatient Child life

1 FTE

Psychology crisis

consults

Present Day Psychosocial StaffingStaff FTESocial Workers 5.0

Psychology 3.0

Child Life 3.0

Pastoral Care 1.0

Music Therapy 1.0

Therapeutic Rec 2.0

Massage Therapy 3.0

Art Therapy 1.0

Educational Program Liaisons 2.0

Columbus Public School Teachers 2.0

Genetics Counselors 1.5

Community Events Coordinator 1.0

Grand Total 25.5

How did we grow?

• Education• Stepwise and strategically• Patient experience emphasized• National Standards of practice and policy • Partnership with Leadership• Emphasis on Quality• Collaboration with Foundation

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Unique aspects of NCH Psychosocial Program

• Director of Psychosocial Services• Matrix reporting • Comprehensive and Preventative Model of Care

– Each patient and family is seen by a consistent care team including a Psychologist at diagnosis

• Integration/alignment of psychosocial service providers into healthcare teams • Continuity of Care

– Consistency in providers across inpatient and outpatient • Collaboration with Palliative Care Team and Home Based Hospice• Training Programs (social work, psychology, child life, pastoral care) • Strong partnership with NCH Foundation to ensure funding stream • Collaboration with community partners to maximize support of patients and

families outside of NCH

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Model of Care at Diagnosis

• Psychology – Assessment of family risk and resiliency factors

• Social Work – Assessment of financial and resource Needs

• Child Life – Assessment of child’s risk for negative psychological outcomes due to hospitalization

• Pastoral care– Assessment of Spiritual needs

• Educational liaison– Assessment of educational needs

• Therapeutic Recreation– Assessment of baseline peer and social interactions

• Massage Therapy– Assessment of anxiety to utilize massage for promoting pain relief, healing and

relaxation

Continuity of Care

During on going treatment Contacts at each admission Medical Clinic visits Outpatient services available

At the End of treatment Coming off therapy transition meetings

Survivorship Involvement in Long term survivorship program

End of Life Hospice care/palliative care

Growth of Service Metrics

• 2,894 inpatient psychosocial consults in 2010

• 5,975 inpatient psychosocial consults in 2014

• 34,417 patient encounters from the psychosocial team in 2014

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Program Improvements

• Psychosocial Coordination of Care Task Force• AYA Program• Bereavement Program• Nursing and MD Fellowship Education/Training• Care for the Caregiver• Sibling Donor Advocacy Program for BMT• Psychosocial Screening for patients and families who will undergo MIBG at

NCH

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Quality Improvement Engagement

– Psychosocial Bundle Compliance– Cure Me Cancer Index– End of Treatment Care Meetings

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MassageTherapy

MusicTherapy

Adolescents/Young AdultsEducational & Social Events

Inpatient Parent Dinners

BluejacketsFashion

Show

Art

Therapy

KidsKickingCancer

CentralOhio NHF Sports

Rehab

PediatricPsychology

Individual

Family

Sibling Support

PastoralCare

Grief & Bereavement

SocialWork

Counseling

Disease Education

Community

Financial

SchoolProgramSchool Liaison / Reentry

Early Intervention

Inpatient Classroom/SmartboardMedical

TeamChildLife

Bravery Beads

Lavender Ribbons Coping Kits

Gabe’s My Heart Chemo Duck

FamilyAdvisoryCouncil

Flashesof

Hope

SurvivorshipCelebration

Sickle Cell Peer Mentoring

Sickle Cell Scholarship DinnerSickle Cell

Transition to OSU

Sickle CellCommunity Health Fairs

Sickle Cell Minority HealthMonth Family Education Day

HemophiliaAnnual Dinner

InfusionWeekend

NHF Partnership Events

vWD Retreats

Wildlights at the Zoo

F.A.M.O.H.I.O

FHF CampVolunteers

Woods Foundation Jewelry Making

Sam BishFoundation Parties

Family Appreciation Day

HemophiliaWalk

CampBold Eagle

Kids n Kamp

A Kid Again

Nellie’s Catwalk

Makea Wish

Special Wish

Therapeutic Recreation

ClinicalTherapies

Physical TherapyOccupational Therapy

Standard of Psychosocial Care for Pediatric BMT/HSCT Admissions

Kris Kullgren, PhDChristina Limke, PsyD

Taylor Mosley

University of Michigan/CS Mott Children’s Hospital

• Opened December 2011• 12-story inpatient wing and a 9-story

outpatient wing• 348 beds

BMT at UM/Mott Children’s Hospital

• 32 bed hematology/oncology unit• 120 new cancer diagnoses/year• 40-50 BMTs/HSCTs per year

– leukemia, lymphoma, immunodeficiencies, bone marrow failure syndromes, lymphoproliferative diseases, neutrophil disorders, neuroblastoma, Wilm's tumor, brain tumors, retinoblastoma, sickle cell disease, thalassemia, inborn errors of metabolism

BMT Psychology Consultation Liaison (CL)

• BMT is part of our general psychology CL service• Between October 2011 and November 2014

– 1017 new consults total– 30% hematology/oncology– 15% BMT

• 152 BMT consults

Onc/BMT Psychosocial TeamStandard Orders

• Psychologist (1)– Trainees (practicum,

intern, fellow)• Social worker (4) • Child life (6)

By referral

• Music therapy • Pet therapy • Art therapy• Med buddies • School

– Teacher– Educational specialist

• Psychiatry• Spiritual care

Model of Care• Social work—outpatient pre-transplant evaluation

– Relocation, caretaker plan, finances, school plans, insurance, lodging, mental health history, adherence

• Psychology—inpatient pre-transplant evaluation – Health/mental health history, hospitalization experience, social

support, expectations for transplant, coping skills, adherence history

• Determine follow-up intervention based on need• Attend family centered bedside rounds weekly• Billing/finance

– See everyone– Bill psych CPT or H&B as appropriate (no pre-auths)

Program Evaluation: Our Process

• Clinical database for QI • Track every new consult order

Program Evaluation: Our Patients• Gender: 45% female• Age: 12.6 years

– range 2 months – 31 years• Ethnicity: 79% Caucasian, 9% African-

American• Payor: 34% Medicaid• Length of stay: 1-96 days

– mean = 26.5 days, (SD = 15.8 days)• Mortality: 3.3% died during admission

Program Evaluation: Our Service• Provider: 32% seen by trainee• Referral question:

– 76% transplant evaluation– 10% coping/adjustment

• Contacts: mean = 3.3, mode = 1, max = 16• Units (15 mins) of care: mean = 6.3 (6.4)• Repeat consults: 35% seen at prior

admissions

Program Evaluation: Our Service

• Disposition: 22.4% referred to outpatient therapy

Primary Intervention

Problem-fo-cused copingAssessment onlyGeneral supportCBTRelaxation

24%

19%18%

15%

8%

Intervention Target

ChildParentFamily61%13%

26%

Challenges

• Staffing– Trainees increase accessibility

• Misses when unable to see• Time commitment for rounds

– Unable to bill• Only service that we provide this level of care• Outpatient therapy resources

Lessons Learned

• High need population• Diverse age range• Diverse needs• Integration into team works best• High commitment• Good communication with team members• Helpful to meet patients early in admission• Move toward formal screening for triage

Models of Care in Pediatric Psycho-Oncology

Discussant & Co-Chair of APA Div 54 Hem/Onc/BMT SIG

Kristin Bingen, PhDChildren’s Hospital Of Wisconsin/Medical College of WIPediatric Hem/Onc/BMT

Models of Psychosocial Care-Similarities

• Multidisciplinary psychosocial team• Social Work & Child Life services provided to all patients

at diagnosis.• Inpatient & outpatient psychosocial services• Psychosocial assessment/screening• Psychosocial services aimed at promoting patient &

family’s healthy coping/adjustment to cancer across the cancer care continuum

• QI/Program development/evaluation to improve/provide quality care to patients & families

• Billing for Psychology services (health & behavior mental health CPT codes)

Models of Psychosocial Care-Differences

• Different psychosocial assessment/screening methods:– Psychosocial interview &/or questionnaire/survey (PAT2.0, DT, PedsQL)

• Different models of psychosocial care delivery:– Patients are seen by all core members of psychosocial team, including

psychology, at diagnosis VS patients screened for level of distress/psychosocial risk and triaged to appropriate level of intervention (i.e., PPPHM model).

– Consistent psychosocial providers across inpatient & outpatient settings VS different providers/teams for inpatient vs outpatient

• Different QI/Program Evaluation Approaches

• Differences in staffing , trainees and resources

Comparison of Pediatric Onc/BMT Psychosocial Staffing

Cancer Center # of inpatient beds Annual # of new patients/diagnoses

Staffing (1.0 = 1 full-time, .5 = part-time)

Levine Children’s 24 147 Social Work 3.0Child Life 2.0Psychology 1.0

Children’s National 30 300 Social Work 9.0 Child Life 2.0Psychology 2.0

U of Michigan/CS Mott Children’s

32 120 Social Work 4.0Child Life 6.0Psychology 1.0

Nationwide Children’s 42 180 Social Work 5.0Child Life 3.0Psychology 3.0

CHOP 50 550 Social Work 9.0Child Life 9.0Psychology 5.0

Models of Psychosocial Care-Unique Features

• Programs addressing the specific needs of families/vulnerable patient populations:– Sibling Donor Advocacy Programs for BMT– Caregivers– AYA– Patients who will undergo MIBG or proton therapy

• Integration of holistic therapies: expressive therapies, massage, pet therapy, yoga, recreational activities

• Integrated medical & psychosocial education programs (i.e., Oncology Home Management Class, End of Treatment Care Meetings)

Take Home Message…

• Despite differences in delivery of psychosocial care, all pediatric oncology programs universally provide:– Psychosocial screening to determine need for/level of

psychological intervention– Access to psychosocial care– Multidisciplinary psychosocial care, integrated into medical

care

• No matter the size of the cancer center or the number/amount of psychosocial providers or resources, standards of psychosocial care can be achieved.

Program Evaluation

• Are we meeting the standards of psychosocial care?

• Are we providing evidence-based, quality psychosocial care?

• Are we improving patient & family outcomes?

Program Evaluation Approaches• Service Utilization/Access

– Patient demographics– # of psychosocial consults, by discipline– # of patient encounters – Compliance with placing and carrying out psychosocial consults-time to consultation

• Patient/Caregiver Experience and Satisfaction

• Consideration of pre-/post-comparison when implementing a new program or providing psychosocial services to new population

• Psychosocial Outcomes (health-related QOL, psychosocial functioning, distress)

• Health Care Economics

Questions?