Comprehensive and Equitable Care for Vulnerable Veterans With Integrated Palliative, Psychology, and Oncology Care
Objective: Veterans who live with cancer need comprehensive care. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer guidelines recommend evaluating distress and providing appropriate follow-up to all patients with cancer.
Methods: We created patient-centered, collaborative clinics to screen for and address cancer-related distress. Medical oncologists received education about available supportive services and instructions on how to make referrals. Participants completed the Coleman Supportive Oncology Collaborative screening questions.
Results: Patients in this outpatient US Department of Veterans Affairs medical oncology clinic were primarily older, African American men. Most veterans screened positive for ≥ 1 type of cancer-related distress. Patients screened for high levels of distress received in-person clinical follow-up for further evaluation and to make immediate referrals to supportive care services.
Conclusions: We evaluated patients’ needs, made referrals as needed, and helped bring care directly into the oncology clinic. Using a screening tool for cancer-related distress and managing distress with integrated psychosocial providers could improve care coordination and enhance patient-centered supportive oncology care, especially for high-risk patients. A full-time social worker was integrated into the medical oncology clinics based on our program’s success.
Funding
This program was funded by the Chicago-based Coleman Foundation as part of the CSOC. Funding was used to support a portion of time for administrative and clinical work of program staff, as well as data collection and analysis.
Results
We established 3 half-day integrated clinics where patients were screened and referred for services based on supportive oncology needs. In addition to our primary activities to screen and refer veterans, we held multiple educational sessions for colleagues, developed a workflow template, and integrated patient education materials into the clinics.
Screening
Veterans completed 1010 distress screens in 3 of 4 half-day oncology clinics over the 2.5-year project period. Veterans were screened at initial diagnosis and every 3 months, or during changes in their clinical care or disease status. As a result, 579 patients completed screening, with some patients doing several follow-up screens during their care. Integration of palliative care providers and health psychologists was instrumental in facilitating screening in these busy general medical oncology clinics. Most veterans were receptive to completing surveys with few refusing to fill out the survey.23 Medical oncology fellows often used the completed screener to inform their review of systems (by reviewing the Coleman screener Physical and Other Concerns section) and connect with the supportive care staff present in clinic for patient’s identifying severe needs (ie, mental health distress or complex psychosocial needs). Veterans’ rates of distress needs and successfuloutcomes of integration with mental health and social work services have been reported elsewhere.23
The mean (SD) age for veterans in this cohort was 72 (9.5) years. Participants were primarily African American veterans (70%), with mostly advanced disease (Table 1). Participants endorsed elevated distress needs compared with other patient populations screened in Chicago through the CSOC for depressed mood, pain, housing, transportation, and physical, nutrition, and treatment concerns.23 Elevated presence of needs was especially prominent for food, housing and insurance/medical needs; physical concerns; nutrition, and treatment- or care-related concerns. Veterans in this cohort reported extensive financial and housing concerns: 10.4% reported food and housing concerns, 18.6% reported transportation concerns, and 9.0% reported issues paying for medical care or medications (Table 2).20 Anecdotally, many experienced job loss or strain with their cancer diagnosis or were living at the poverty level before their diagnosis.
Social work referrals were often triggered due to transportation barriers to appointments/medication access, and food and/or housing insecurity. Social workers assisted with referrals for housing, transportation, financial reimbursement, on-site or community-based food banks, home health support, familial support, and hospice services. Social work consults increased 166% from 2016 (the year before the program start date) to the end of 2019.
Based on this increased volume of referrals for social work in our oncology clinics, an oncology-specific social worker was hired at the completion of our program to be based in all 4 half-day oncology clinics in response to results of our quality improvement intervention. The social worker currently sees all patients with a new cancer diagnosis and supports oncology fellows to identify veterans needing a palliative care referral or referrals to other supportive services.
Throughout program implementation, traditional areas of palliative care focus were particularly important as veterans reported significant concerns with understanding their illness (67.4%), wanting to understand their prognosis (71.3%), and having questions about their treatment options (55.1%).20 The palliative care providers spent time educating patients about their disease, coordinating goals of care conversations, promoting patients’ engagement in decision making, and making a large number of referrals to hospice and home health to support veterans at home.
