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Taking the Next Steps to Implement the IOM Recommendations for Integrating Psychosocial Services into Oncology Care

Rosenthal, Eric T.

doi: 10.1097/01.COT.0000313047.84925.11
Eric Rosenthal reports

Being granted a validated license and given the green light are critical first steps when setting off on a journey, but without a vehicle, fuel, money, and a good roadmap, compass, or GPS system, one won't get very far.

This situation is somewhat analogous to the next steps involved in disseminating and implementing the Institute of Medicine's recommendations to include psychosocial services as part of the standard of care for cancer patients. (OT, 12/10/07)

The landmark report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, issued last fall, was initially funded by the IOM for about $1 million, but as with many IOM initiatives, did not provide additional funds to implement the recommendations.

That task has fallen to various members of the IOM Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting, who drafted the 339-page report that highlighted 10 recommendations, beginning with the fact that cancer care should provide appropriate psychosocial health services by identifying each patient's needs, linking the patient with needed services in a specific care plan, and following up on the patient's psychosocial care plan.

Looking at the whole patient has been a gradual process, with quality-of-life and survivorship issues being addressed a few years ago.

OT contacted several members of the IOM committee as well as American Society of Clinical Oncology President Nancy E. Davidson, MD, to assess outreach efforts to disseminate the report and plans for making the recommendations a reality.



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‘Important Time for Looking at Cancer Patient Needs’

“The IOM report is a validation of the work many of us have done over many years, bringing in the evidence base and the prestige and influence of the IOM,” said Diane Blum, MSW, Executive Director of Cancer Care Inc., and Editor-in-Chief of ASCO's People Living with Cancer Web site ( for patients and the public.

“I see it as a very important milestone or marking point, but I also have enough perspective of more than 30 years doing this to see it's another important time for looking at cancer patient needs.”

The growth of the cancer patient advocacy movement goes back more than 20 years, and although many people may think these findings are new, they are more evolutionary, she noted.

“The IOM report says that this is really important, it's time to integrate this into the level of care and do this not just because it's nice or something to add to what you're already doing, but because it's a necessity.”

Ms. Blum said the report was written to be practical, and recommended steps that could be taken now with available resources, but noted that funding is a major issue. “We are in an era of constraints,” she said. “When I ask oncologists about incorporating psychosocial services, their reluctance is mostly financial. Things that have priorities seem to find money, and maybe this doesn't have the priority it should.

“Most respond that they'd be happy to include psychosocial services but want to know how to pay for them. They don't see it as something that can be supported easily.”

She said that for inpatient services, social work is rolled into per diems for reimbursement, but it's much more difficult to do that in outpatient settings or doctors' offices.

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Figure. Dia

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‘Getting Money Will Be Most Effective If It's Somebody's Job to Get that Money’

In addition, Ms. Blum said, for the provisions of the report to succeed it will be necessary for someone or some organization to take ownership of the project: “It is a step-by-step process and requires practical-based plans. But the reality is we will have to get funding from somewhere, and I believe that getting money will be most effective if it's somebody's job to get that money.”

Ms. Blum and Jessie Gruman, PhD, a social psychologist who is President of the Washington DC-based Center for the Advancement of Health, are responsible for planning the dissemination of the report, a process that began with a news briefing in November.

They are co-chairing a self-appointed voluntary subcommittee charged with keeping the increased visibility and momentum of the IOM Report going through collaborative efforts.

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3 Key Actions

Dr. Gruman said the subcommittee has discussed three issues:

  • ▪ Documenting the underutilization of existing services.
  • ▪ Finding support for one single, centralized updated resource for people to use to learn about good psychosocial services.
  • ▪ Educating physicians.

“It's important to note that the standard of care doesn't say that psychosocial services have to be offered; what it says is that psychosocial issues have to be asked about and services provided or referred to….You can't separate out the mind from the body. It's a big step forward and a big cultural change for many patients and doctors,” she said, adding that dissemination is about getting this standard of care to be part of cancer patients' expectations.

Various committee members will be spreading word of the report to their respective professional constituencies. For example, Ms. Blum will speak at the Association of Oncology Social Work Annual Meeting in May, and was interviewed for PLWC's Expert Corner on addressing the emotional and social needs of cancer patients (posted in the “Library” section under “PLWC Features”).

Jimmie C. Holland, MD, the Wayne E. Chapman Chair in Psychiatric Oncology at Memorial Sloan-Kettering Cancer Center, spoke at a community oncologist meeting earlier in the year, and will be part of a special Sunday session cosponsored by the American Psychosocial Oncology Society and the Oncology Nursing Society at APOS's upcoming 5th Annual Conference, with an ONS representative presenting that information later this spring at ONS's Annual Congress.

APOS President Ruth McCorkle, PhD, FAAN, the Florence S. Wald Professor of Nursing at Yale School of Nursing and Director of its Center for Excellence in Chronic Illness Care, was largely responsible for the joint APOS-ONS session that has invited all major professional cancer organizations and advocacy groups to discuss how individual organizations can collectively respond to the report and take actions to ensure that a standard is set and implemented.

“The conference will include people who were on the IOM committee presenting the report to attendees,” she said, “while the special session will talk about existing models that are already doing what the report recommends. We will probably break into groups to see if we can decide what the next action should be, and hopefully at our meeting next year in North Carolina we will be able to report in.”

Dr. McCorkle told OT she also hopes that APOS will be responsible for bringing these groups together for follow up, and will be able to get some funding to make it happen. She said when she steps down as President at the end of the conference she has offered to make herself available to write grants or solicit money from various cancer foundations.

Patricia A. Ganz, MD, Professor in the UCLA Schools of Medicine and Public Health and the Division of Cancer Prevention and Control Research at UCLA's Jonsson Comprehensive Cancer Center, has already presented the report's finding to ASCO's Quality of Care Committee, with the highlights scheduled to be featured in the March issue of the Society's Journal of Oncology Practice.

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Some Well-Intended Efforts Missed Mark

But some of these well-intended efforts have missed the mark, such as Dr. Holland's talk at the Community Oncology Symposium at the invitation of its chair, Lee S. Schwartzberg, MD, another IOM Committee member, who is Medical Director for the West Clinic in Memphis and had served as Chief Resident in Medicine during his fellowship at Sloan-Kettering at the time Dr. Holland founded the institution's ethics committee.

Dr. Holland's presentation was held concurrently with a session with the title of “Making Your Practice More Efficient,” given by a CPA, and as a result, Dr. Holland's session drew only a small percentage of oncologists in addition to a larger number of oncology social workers and nurses, many of whom were already converted to the cause.

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Not Just for Large Practices or Organizations

Dr. Schwartzberg, interviewed prior to the symposium, said that although many of the psychosocial services are available through many academic cancer centers and in some larger private practices such as his, most solo or smaller practices can still adopt some of the things.

“I think everyone should aspire to do something,” he said. “Big practices can be organized to do that, but the major thrust of the report was specifically that everybody can screen, everyone can use a distress thermometer, and it doesn't cost a cent, and you can teach patients how to do it, and oncologists will know right there if there's a psychological issue that needs to be addressed.”

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The timing of the report was also a little late to allow for integration into educational sessions at some oncology professional meetings such as ASCO's.

Dr. Davidson, Professor of Oncology and Breast Cancer Research Chair in Oncology at Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, said that although ASCO was not a lead player in the report's development, ASCO members like Dr. Ganz have played a crucial role.

“We support the recommendations that came out from this report,” Dr. Davidson said, “and we think that it offers important information and recommendations for health care providers about how we should meet patients' emotional and social needs in addition to their medical needs. I'm certain it will begin to feed into our education programs at next year's [2009] meeting, since a lot of the educational activity at the June meeting is already scheduled.”

Dr. Davidson also said that the Society was looking to develop specific psychosocial measures that would be included in ASCO's Quality Oncology Performance Improvement (QOPI) program, which allows oncologists to evaluate how they are doing within their practice as a means of measuring and improving their own performance.

“Thinking about the totality of patient care is very real for us—and we are concerned as oncologists that we can't do justice to all parts of that, so we're going to have to work all parts of the health care system to think how to address all of our patients' needs,” she said.





“I'd envision that the important parts of this that are relevant to oncologists and necessary to their education will roll out as part of the educational sessions scheduled at our small thematic meetings and our large meeting as appropriate.”

© 2008 Lippincott Williams & Wilkins, Inc.
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