Comprehensive and Equitable Care for Vulnerable Veterans With Integrated Palliative, Psychology, and Oncology Care

Abstract

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, Af-rican 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.

Oncology distress screening within predominately Black Veterans: Outcomes on supportive care utilization, hospitalizations, and mortality

“…In clinics with embedded QI team members, veterans could be flagged for an individual assessment either by the results of their completed screen or by referral from a medical oncology physician. 10 , 27 …”

“…The QI team member, prior to their assigned clinic, needed to predetermine and follow which patients qualified for screening as these were general hematology‐oncology clinics also serving patients with non‐malignant issues. In clinics with embedded QI team members, veterans could be flagged for an individual assessment either by the results of their completed screen or by referral from a medical oncology physician 10,27 …”

“…Distress screening and treatment integration occurred within one physical space with co‐located QI team members functioning in unison with oncology staff (physicians, nurses, and administrative staff), allowing real‐time discussion between oncology staff (attendings, fellows, nurses) and the QI team members to review clinical evaluations and subsequent referrals to address patients' needs. Previous analyses identified that 25–50% of all new consults and similar rates of current patients were screened 10,27 ; Patients were not screened because they either had primary hematologic concerns, were not receiving their primary treatment through the VA, denied screening often because they denied symptoms/needs, or because they were missed during an appointment time. For patients with elevated psychosocial needs, 36% were connected with psychosocial services before screening and 77% were connected with psychosocial care after screening 10 …”

“…In clinics with embedded QI team members, veterans could be flagged for an individual assessment either by the results of their completed screen or by referral from a medical oncology physician. 10,27 Ethical approval was received from the Institutional Review Board of the Jesse Brown VA as a QI Project (SQUIRE-guidelines); not requiring written informed consent (GCL#21270). 29 This project was implemented between January 2017-January 2020.…”

“…The Jesse Brown VA Medical Center was chosen to evaluate cancer‐related concerns and improve access to supportive oncology. We previously published distress screening findings of our interdisciplinary, supportive care quality improvement (QI) initiative including feasibility of the primary project with screening rates, distress prevalence, 10 and descriptions of the program's palliative care integration process within outpatient oncology 27 in this mostly Black, older cohort of male Veterans. With the completion of the program's implementation cycles (2017–2020), we prospectively evaluated the associations between distress screening, subsequent supportive care utilization, hospitalization, and mortality in this underserved sample.…”