Shirley Otis-Green, MSW, ACSW, LCSW, OSW-C

Founder & ConsultantCollaborativeCaring

Shirley@CollaborativeCaring.net

Enhancing the Social Work Role in Enhancing the Social Work Role in Family Conferencing: Integrating Family Conferencing: Integrating Screening into Evidence-Informed Screening into Evidence-Informed PracticePractice

Presentation GoalsTo Discuss & Explore…

Systemic Perspective as Related to Oncology Care: An Invitation for Inter-Professional Collaboration

Strategies to Enhance Social Work Expertise & Leadership in Family Conferencing

Role of Screening & Assessment in Providing Evidence-Informed & Culturally-Congruent Care

Shared Perspective… What’s in the best

interests of the patients and

families that we serve?

What is Distress Screening? Distress: “A multifactoral unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope with cancer, its physical symptoms and its treatment.”

National Comprehensive Cancer Network, 1999

An essential element of quality cancer care 30-40% prevalence of clinically significant levels of distress across adult outpatients1-3

1Trask P, Paterson A, Riba M, et al, 2002; 2Jacobsen PB, Donovan KA, Trask PC, et al, 2005; 3Zabora et al., 2001

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33% experience adjustment disorders & other

psychological challenges:Need Screening,

Assessment, Referral& Counseling2

72% encounter serious problems and barriers related to the social, practical, psychological,

informational, spiritual aspects of illness and treatment:Need Screening, Assessment, Navigation,

Referral & Counseling3

100% need on-going education, information and guidance:Need Screening, Service Navigation

& Coordinated Patient & Family Education Services *

1IOM, 2008 2Zabora, et al., 20033Loscalzo & Clark, 20074Zabora, et al., 2001

Psychiatric or mental health disorders1

5 -10%

Distress varies by cancer site4

Need Referral& Counseling1

Claim the Domain: Create A Culture For Screening, Assessment & Family Conferencing

“Get our psychosocial house in order” (Loscalzo, 2011)

Standardize your message: Integrate your message into disease-directed care

Over-communicate about⁻ The value; positive outcomes⁻ Improved processes and systems – fewer

disruptions in clinical services and flow(administrators HATE disruption and lack of

predictability)

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Keeping, Tracking, Using DataTo document the extent of patient/family

challengesTo provide your institution with data for

enhancing care (Quality Improvement/Quality Assurance)To inform development and implementation of

practice, institutional programs, and policiesTo demonstrate impact and raise profile of

oncology social work Make a case for additional staffing, based on

“home-based” data7

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Data Analysis ~ Example 1. Count how many patients check an item in the problem checklist (e.g. “Dealing with partner”).

2. Divide the number of patients who checked an item by the total number who completed DTs.

3. The result is the RATE or PERCENTAGE of patients challenged by the item.

4. Alternatively, add the number of checks within a category (e.g., Family Problems) for each patient.

5. Divide this number by the total number of DTs.

6. This number is the Average number of problems reported by patients seen in your unit.

What are your questions, concerns, challenges around distress screening? How have you addressed these challenges? Instrument selection? Implementation? Turf Battles? Social Work’s Competing Priorities? Other Obligations? Unclear Responsibility? Accountability? Limited Resources?

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Screen to InterveneNormalizes need for help and supportEstablishes social worker’s professional roleIncreases knowledge research base on

psychosocial impacts of cancerEfficacy of psychosocial support for cancer

patients is well-established [Faller, et al., (2013), Journal of Clinical Oncology; Jacobsen, et al., (2008), CA: A Cancer Journal for Clinicians; Gottlieb & Wachala, (2007), Psycho-Oncology; Cwikel, Behar, & Zabora, (1997), Journal of Psychosocial Oncology, 1997; Meyer & Mark (1995), Health Psychology]

Evidence-Based Medicine (EBM)Why do we do what we do when we do for whom we do? (Too often because

that’s they way it’s always been done).Evidence-based medicine is the conscientious, explicit, & judicious use of the

best current evidence in making decisions about the care of individual patients. (Sackett, et al., 1996; 1971)

Five Steps of Evidence-Informed Care1. Ask focused questions: Convert uncertainty into

answerable questions 2. Systematically retrieve the best evidence with

which to answer the questions3. Critically appraise evidence for its validity,

clinical relevance & applicability 4. Make a decision: Apply the results of this

appraisal in your practice 5. Evaluating performance: Auditing evidence-

based decisions

(http://www.cebm.net/index.aspx?o=1914)

Goal: Evidence-Informed PracticeCritical thinking is keyCuriosity regarding outcomesCommitment to explore options &

compare outcomesIntentionality in selecting

interventionsProfessionalism requires contribution

to build a strong evidence base

Tie Theory to Evidence to Bring Research to Practice ~Teams are intricate Systems with their

own dynamics and lifespan They exist within the larger healthcare

system and interact with and respond to the dynamics of the larger system

Family Systems Theory:Changing anything…changes everything!

Example: Communication with Families Facing Life-Threatening Illness: A Research-Based Model for Family Conferences (Fineberg, et al,(2011), Journal of Palliative Medicine) Virginia Satir

What are some of the major challenges encountered with family conferences? Lack of space to accommodate familyDifficulty establishing preconference meeting

with the health care providersDifficulty establishing “off-hour” meetings

(weekends, outside 9am-5pm)Difficulty communicating with family due to

language barriers, lack of a translatorLack of clear “team” to facilitate family

meetings

Key Elements of a Highly Functioning Team Consensual Goals (clarity of purpose)Tendency to “default” on the side of trust

vs. mistrust (“don’t assume the worst about others”)

Willingness to “roll up one’s sleeves and do what needs to be done” (functional “nimbleness” & “role flexibility”)

Perspective of “we’re all in this together” (shared credit & shared responsibility)

Conscious playing off people’s strengths and supporting other’s weaknesses (without focus on fault finding or blaming)

Informal dept. survey (2007) of what makes a team work…

Goal: Enhanced Team Functioning

Most health care professionals receive predominantly discipline-specific training yet are expected to translate this into effective team functioning…(perhaps, not surprisingly this becomes a challenge!)

Inter-Professional/Transdisciplinary Care: Integrative, holistic, innovative, hospice/anthropology concept.Implies a revolution of the medical hierarchy.Collaboration/communication/compassion amongst

team members based upon team-training.

Transformation in Palliative Care: Traditional Multi-Disciplinary Practice

(Typically a “reactive” physician-led model with ad hoc membership using a consultative format)

Interdisciplinary Team(More “proactive” model; theoretically recognizes contributions of all, but typically MD-RN based and

physician-led)

Transdisciplinary Team(Shared team vision; recognized role-overlap;

integrated responsibilities, training, leadership & decision-making)

- Dale Larson, (1993), The Helper’s Journey, Research Press.

1. What is Medically AppropriateBased on current medical

information what current and future medical interventions does the team believe will improve and which will worsen or provide no benefit the patient’s current condition in terms of function/quality/time

(Adapted from: EPERC Fast Facts ~ Medical College of Wisconsin, 2006)

10 Steps of the Family Conference

Pre-Meeting with Patient/Family: To Ensure Culturally Congruent Decision-MakingConducted by: Social Worker? Chaplain?

Nurse?Obtain history & assess the patient and

family’s needs & understanding of the situation – what are their goals, priorities, hopes, fears, cultural & spiritual concerns?

Determine: Who makes decisions in the family?Who else should be included in the discussions

(in person, via SKYPE, etc)? Scheduling preferences?Determine if “full disclosure” is desired?

Culture/Spirituality Provides the Lens

Through Which We View

Our Experiences

2. Pre-Meeting PlanningCoordinate medical opinions

between consultants and primary MD

Obtain patient/family psychosocial data

Review Advance Care Planning DocumentsIs patient decisionalIs there a power of attorney

Review medical history/treatment options/prognostic information

3. EnvironmentChoose a proper

environmentQuiet, comfortable,

chairs in a circleInvite participants

to sit downCheck your

appearance, turn off pagers,

4. IntroductionsIdentify legal decision maker or family

designated decision makerIntroduce self and have others introduce

themselves and relationship to patientReview your goals; ask family if these

are the same or different than their goalsEstablish ground rules

Everyone can talk, but only one at a timeNo interruptions

Build RapportBuild a relationship

Ask the family to tell you something about the patient;

“I know about the patient’s illness but I was wondering if you could tell me something about her as a person, her hobbies or interests?”

5. What does the patient know?Make no assumptions; Find out what

the patient/family already knowsWhat do you understand about your condition?What have the doctors told you?How do you feel things are going with your

treatment?

Chronic Illness: tell me how things have been going for the past 3-6 mos. what changes have you noticed?

6. Medical ReviewPhysician presents medical information succinctlyPresent the Big PictureCurrent condition;

Expected CourseSpeak slowly,

deliberately, clearlyNo medical jargon

Semantics Matter…Avoid depersonalizing labels:

“The breast in room 603;” “The DNR in ICU”

Lack of common language to discuss illness, planning and options:Artificial Nutrition and Hydration vs.

providing food and waterDo not or withhold vs. allow (DNR vs. AND)Avoid: “Do everything” or “there is nothing

more we can do”

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7. Reactions, QuestionsAllow silence, give patient/family time to

react and ask questionsAcknowledge and validate reactions prior

to any further discussionInvite questions

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“For most patients, two fundamental facts ensure that the transition to death will remain difficult.

First is the widespread and deeply held desire

not to be dead.

Second is medicine’s inability to predict the future … to give patients a precise and reliable prognosis…

When death is the alternative, many patients who have only a small amount of hope will pay a high price to continue the struggle.”

(Finucane, T.E. 1999)(Finucane, T.E. 1999)

8. Review Care OptionsAllow for pushback from patient and familyConsider that recommendations for treatment

might be on a trial basisCheck again for clarity and consensusAsk for more questionsConfirm plan of care: Goal is to identify Shared

Goals of Care that are tailored for this particular patient/family at this particular point in time

Consider all options and repercussions of these options and provide recommendations based upon mutual understanding of situation.

9. Confirm Plan of CareBased on the decision what do they

want/need in the time remainingConfirm Goals- so what you are saying isEstablish a Plan

Decide on steps to achieve plansUsually involves discussion of CPR, ICU,

artificial nutrition/hydration, home hospice

If test or treatment won’t meet goals it’s best not to start it

Confirm plan & summarize to ensure that everyone shares understanding of plan

10. ConclusionSummarize areas of consensus and

any disagreementsCaution against unexpected outcomesProvide continuityDocument in the medical record &

provide summary documents to familyWho was present, what was decided, next steps

Discuss results with other concerned healthcare professionals not present

Implications for Your Institution?

SummaryA Commitment to Excellence is Needed if We

are to Transform the Delivery of Care toThose We Serve

Importance of Screening & Assessment in Determining Evidence-Informed Interventions

Family Conferencing Offers Leadership & Advocacy Opportunities for Oncology Social Workers

Our Skills in Understanding Systems can be Useful to Enhance Team Dynamics and Improve Family Functioning