Cancer’s effects range from the cells to the psyche. Distress in patients with cancer can lead to low-quality care, poor quality of life, disease recurrence and mortality (JNCC, 2013). Evidence-based services to treat distress in these patients are core to high-quality care. Ganz (2013) strongly recommends providing these services to these patients and their loved ones.

Distress in patients with cancer is often unrecognized and unaddressed. Many factors contribute to this problem. For example, limitations in time, staffing and space make it difficult for providers and staff to properly assess and care for patients’ distress. Additionally, available psychological services are too few and too difficult to access, especially in rural and frontier areas. When it is available, it may be provided by those unfamiliar or uncomfortable with the complexities of cancer care and comorbid conditions (Weaver, Geiger, Lu, & Case, 2013).

The Avera Cancer Institute (ACI) in Sioux Falls, South Dakota, is not immune to these problems. As a result, in 2016 its leadership took steps to close this gap in care and developed a comprehensive psycho-oncology program to ensure availability and accessibility to psychological care. Master’s-prepared social work (MSW) staff now provide short-term supportive counseling in each clinic. These MSWs provide three to six sessions of informal supportive counseling in the clinic or infusion setting. They also address community resource needs, crisis intervention, survivorship issues, end-of-life support and referrals. The support service staff also includes other disciplines—chaplaincy, dietary, patient advocates, Integrative Medicine and a Palliative Medicine team.

An attempt was made to identify how the exisiting certified and licensed MSWs could provide uninteruppted 50-minute fee-for-service, on-site therapy. Unfortunately, there was no way to provide sufficient coverage for them to step away from their routine clinical duties. As a result, the decision was solidified to advocate for funds and work toward hiring a mental health provider to deliver on-site psychotherapy services to patients and their loved ones. This article summarizes the process of development that ACI embarked on to make the Oncology Outpatient Therapy Services a reality.

Assessing the Needs For Service

As a first step, ACI completed a needs assessment. Results revealed strong patient, provider and staff support for the addition of on-site psychotherapy services. More than 50 percent of patients listed these services as a top priority. Additionally, providers and staff identified on-site psychotherapy as a highly needed, but unavailable, service.

Next, the needs assessment was followed up by reviewing other cancer institutes with established psycho-oncology programs and identifying how their services are organized. Nine national cancer centers with psycho-oncology programs were identified and areas reviewed included: model of service delivery, referral process, billing and platform. Internal needs assessments, supporting research and the recommendation of an interdisciplinary supportive services workgroup, which included physicians, were the factors that secured administrative support in the cancer program.

Implementation

Talks began about the logistics and barriers of implementing and billing for this new type of service and service provider in our provider-based outpatient oncology setting. It was important to collaborate with internal experts at Avera Behavioral Health. Efforts to use existing infrastructure led to decisions to have this provider work out of the same EMR as the other mental health providers and hospital rather than the oncology EMR, using the same documentation templates, diagnosis and code capture libraries, and receive inpatient consult notifications. This allowed a proficient coder who works with existing mental health providers to code for this position.

In our oncology program we have an Integrative Medicine Clinic. This nonprovider-based clinic already existed on the same EMR as the hospital and outpatient programs and offers services through providers who are not oncologists but whose care often compliments the treatment plans of our oncology patients. The wholistic mind, body, spirit approach and serene environment were a match with this service while the perks were that they were in the cancer center, were a separate department to lessen billing complications if patients are seen the same day as other appointments and allowed us a contingency in our business plan that, if we were not to capacity with oncology clients, the Integrative Medicine physicians would be allowed to refer nononcology clients to our provider. The Integrative Medicine clinic was able to gain FTE for a patient service representative through the business plan of this position, which overall helps their department meet a need they had.

In order to ensure the therapist had available time to see oncology patients and their loved ones, counseling referrals and parameters were established. The focus is solely on cancer-related adjustment issues for individuals or family members. Marital counseling, child/teen counseling and substance abuse treatment are referred to other Behavioral Health providers. Referrals are made directly from a medical provider or through the oncology social worker. It is important to have the clinic social workers involved in the referral process to ensure that their free support services are offered to the patient or loved one prior to referral. This also cuts down on the confusion for providers and patients regarding the role of the therapist vs. the oncology social worker in the clinic. Once a referral is made and a patient has established care with the oncology therapist, a message is sent to the referral source thanking them for the referral and letting them know that the patient is proceeding with therapy. This also acts as an alert to the referring provider that the note is available in the nononcology EMR for reference.

Marketing the new clinic counseling service included a picture flyer, business card, website provider information and introductory meetings with each internal oncology clinic. In addition, the therapist provides ongoing education sessions on various topics as a part of the monthly staff education series within the Avera Cancer Institute. The provider also participated in education sessions at the annual cancer symposium.

After implementing the position, another challenge arose—difficulty in identifying the correct process of handling psychotherapy notes versus all other medical notes. The EMR used by Behavioral Health is different than the ACI, so multiple conversations with providers, oncology staff and behavioral health providers took place to create consensus on how and when the therapy notes would be accessed. Through collaboration with our Avera Behavioral Health counterparts, the decision was made to have the psychotherapy notes left out of the oncology EMR. Once that decision was made, there was a need to educate oncology interdisciplinary team members to explain the importance of leaving the records separate. Oncology providers can access them, as needed, through the appropriate EMR.

Results to Date

In order to track results, reports were built into the EMR to generate a summary of patients seen each month, which includes the number of no shows or cancellations. A full-time maximum caseload is six billable clients per day or 30 billable hours per week. After five months of operation, the therapist had an average five clients per week. Contingency plans were made to meet the goal of 25 billed hours per week including taking referrals from integrative medicine, opening therapy services via telemed to our regional ACI locations and accepting clients with chronic illnesses other than cancer. Nine months after start, a PRN position was added to provide back up to the therapist. This consideration was made specifically due to the need for inpatient consult availability and acute counseling requests. The contingency plans are not needed at this time due to the growth we have experienced; however, we will consider telemed visits as a long-range goal as well as incorporation of an onsite psychiatric clinic.

Avera’s belief and dedication to restoring patients’ wholeness reminds us of the importance of their psychological, social and spiritual needs. The problems and solution identified are in line with this overarching philosophy and the ACI’s mission to provide evidence-based and multidisciplinary care to heal patients’ whole person. The new psychotherapy service has enhanced care for patients and loved ones at ACI by providing additional support services. Individuals do not need to go elsewhere to get the oncology or mental health care they need.

References

Ganz, P. (2013). Institute of medicine report on delivery of high-quality cancer care. Journal of Oncology Practice, 10(3), 193-195. doi:10.1200/JOP.2013.001369

JNCCN – Journal of the National Comprehensive Cancer Network. (2013). 11(2). Retrieved from http://www.jnccn.org/.

Weaver, K., Geiger, A., Lu, L., & Case, D. (2013). Rural‐urban disparities in health status among US cancer survivors. Cancer, 115 (5), 1050-1057. doi:10.1002/cncr.27840