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Meeting Psychosocial Needs of Women with Breast Cancer 7 Barriers to Appropriate Use of Psychosocial Services Although there is a general consensus that psychosocial services are needed and valuable, less is known about why services are not widely offered or used. Individuals may face barriers to receipt of psychosocial services because they do not have access to care, because they lack either health insurance or coverage that includes mental health services, or because they do not ask for help because of stigma. Among the barriers imposed by providers and systems of care are: patient–provider miscommunication, failure to implement clinical practice guidelines, inexperience with assessment for psychosocial distress and rapid screening tools, poor coordination and fragmentation of complex care, a lack of provider familiarity with community resources, and limited systems of quality assurance and accountability. This chapter reviews available evidence regarding these barriers to receipt of appropriate psychosocial care. ACCESS TO CARE The link between poor access to care and poor health outcomes is well established (IOM, 2001, 2002), but the reasons for inadequate access are not well understood. Some of the connections are intuitive and obvious: women without health insurance have breast cancer detected at later stages and have poorer survival rates than women with insurance (Ayanian et al., 1993; Lee-Feldstein et al., 2000; Roetzheim et al., 2000, 1999). People who lack health insurance are also less likely to receive mental health services (Landerman et al., 1994).
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Meeting Psychosocial Needs of Women with Breast Cancer One in seven adult women in the United States lacks health insurance, which creates a general barrier to getting medical care of any kind (U.S. Census Bureau, 2002). Some other barriers to receiving appropriate care are less obvious. Non-financial barriers that may prevent people from “getting to the door” of a health-care provider include geography (travel distance), language, fear and distrust of health care providers, and difficulties getting through appointment or “gatekeeper” systems. Once “in the door,” other barriers to access may surface when attempting to navigate the system: for example, getting from a primary care provider to a specialist. This is especially problematic for referral to mental health and psychosocial services. Within the system, providers may lack information about the diagnosis and management of distress, have difficulty communicating with patients or understanding their problems due to cultural differences, or have insufficient staff to adequately explore patients’ psychosocial needs and provide referral to needed services. The cancer care system is complex, and for breast cancer, it may involve the surgeon, radiologist, and oncologist at different times (see Chapter 5 for a description of breast cancer care). Consequently, various barriers that serve to limit access may surface during each phase of care. These barriers to optimal care are themselves a potential source of psychosocial distress for many women (Hinestrosa, workshop presentation, 2002). Access, as defined by the Institute of Medicine (IOM, 1993), is the timely use of personal health services leading to the best possible health outcomes. This definition of access implies the use of health services, the quality of such services, and the degree to which access has been achieved. The test of equity of access involves first determining whether there are systematic differences in use and outcomes among groups in United States society and, if there are, the reasons for these differences (IOM, 1993). Some of the factors that have been investigated as possibly affecting access to mental health services include: Health insurance coverage and type of coverage; Cost, including health insurance and out-of-pocket costs; Attributes of the health care delivery system (e.g., geographic distribution of cancer care facilities, lack of service coordination; separation of medical and behavioral (mental) health in different and unrelated contracts); Attributes of individuals (lack of knowledge or misperceptions about mental health services; linguistic or cultural attributes); and Attributes of health-care providers (e.g., lack of knowledge about mental health resources; communication styles). This section of the report describes these barriers in the context of access to mental health services among women with breast cancer.
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Meeting Psychosocial Needs of Women with Breast Cancer Health Insurance Coverage and Type of Coverage Women with breast cancer are more likely than other women to be insured, because as many as 45 percent of newly diagnosed cases occur among women age 65 and older who generally are covered by Medicare (in 2001, an estimated 46 percent of incident cases and 59 percent of women dying of cancer were covered by Medicare). Nevertheless, of the 203,500 women diagnosed with invasive breast cancer in 2002, an estimated 16,350 women, or 8.0 percent of women with breast cancer and 6.1 percent of women who died of cancer, would have been expected to be uninsured (Table 7-1). Nationally, 14 percent of adult women were uninsured in 2001 (U.S. Census Bureau, 2002). The diagnosis of cancer can, in itself, lead to a loss of health insurance coverage or to higher insurance premiums. In 1992, 7 percent of cancer survivors who were insured prior to their diagnosis reported that their health TABLE 7-1 Estimates of Health Insurance Coverage Among Women with Breast Cancer (diagnoses and deaths), United States, 2001 U.S. Female Population (age 18+) Breast Cancer Diagnoses Breast Cancer Deaths Health Insurance Coveragea Number (in 1,000s) % Number % Number % Total 108,752 100.0 203,500 100.0 39,600 100.0 Private or government insurance 93,462 85.9 187,151 92.0 37,171 93.9 Private insurance 77,577 71.3 140,550 69.1 26,319 66.5 Employment-based 66,036 60.7 106,388 52.3 18,390 46.4 Government insurance Medicaid 9,697 8.9 18,196 8.9 3,775 9.5 Medicare 21,480 19.8 93,930 46.2 23,474 59.3 Militaryb 3,305 3.0 7,984 3.9 1,667 4.2 No health insurancec 15,291 14.1 16,350 8.0 2,429 6.1 aCategories are not mutually exclusive. bIncludes CHAMPUS (Comprehensive Health and Medical Plan for Uniformed Services)/ Tricare, Veterans, and military health care. cEstimates are of women without health insurance coverage for the entire year. NOTE: Age-specific insurance rates among U.S. women age 18 and older were applied to incident breast cancer cases and deaths, stratified by age. SOURCES: Insurance rates are from the U.S. Census Bureau, Current Population Survey, Annual Demographic Supplements, Income Statistics Branch/HHES Division, January 30, 2003. Estimates of the number of incident breast cancer cases and deaths are from Cancer Facts & Figures 2002. Estimates of the age distribution of breast cancer incident cases and deaths are from SEER.
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Meeting Psychosocial Needs of Women with Breast Cancer insurance changed following their cancer diagnosis (e.g., 5 percent said that their insurance costs increased (Hewitt et al., 1999). Congress tried to remedy this problem in 1996, enacting the Health Insurance Portability and Accountability Act (Kennedy-Kassebaum Act) to improve the portability and continuity of health insurance coverage in private insurance markets and among employer-sponsored group health plans. The act limits the ability of insurers to deny or discontinue coverage because of preexisting conditions such as cancer. The increased cost of premiums for portable insurance products and difficulties in implementing the law, however, have limited the value of these protections for consumers according to the U.S. General Accounting Office. If individuals are uninsured and not eligible for Medicaid, medical expenses related to cancer may force them to “spend down” to become eligible for Medicaid—that is, to deplete their assets until they meet eligibility criteria. Alternatively, individuals who are disabled by cancer for a period of 2 years may become eligible for Medicaid coverage through the Supplemental Security Income (SSI) program. Some hospitals are obligated to provide some charity care to the uninsured (i.e., under the Hill-Burton Act of 1946). State and federal programs provide free cancer screening and sometimes cover the expense of treatment for the uninsured (e.g., the state option to provide Medicaid coverage for women diagnosed through the Centers for Disease Control and Prevention [CDC] National Breast and Cervical Cancer Early Detection Program) (http://www.cdc.gov/cancer/nbccedp/law106-354.htm, accessed April 17, 2003). More than half the states operate high-risk insurance pools to help provide coverage to individuals with serious medical conditions who have been denied private health insurance in the individual market (Achman and Chollet, 2001). The insurance provided through these state risk pools (also known as Guaranteed Access Programs) generally costs more than regular insurance, and in some states there are long waiting lists or the programs are closed to new applicants altogether. More than 153,000 individuals are currently covered by state risk pools (DHHS, 2002). Many charitable organizations (e.g., Cancer Care, American Cancer Society) provide free services or financial assistance to individuals with cancer who lack the means to pay for their care. These programs and services cannot substitute for adequate insurance coverage for cancer care, but they can ease the financial burden for small numbers of individuals in need. Cost, Including Health Insurance and Out-of-Pocket Costs1 Health insurance coverage may not adequately protect individuals from the high costs associated with cancer treatment and may not cover mental 1 Much of this section of the report is based on Mental Health: A Report to the Surgeon General, 1999.
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Meeting Psychosocial Needs of Women with Breast Cancer health services. Some policies have high deductibles (e.g., some catastrophic policies may contain a deductible as high as $15,000 or more), and copayments or coinsurance over the course of cancer treatment can be substantial. Relatively few studies specific to cancer exist regarding the magnitude of the financial burden associated with out-of-pocket costs, but available evidence suggests that it is substantial (Sofaer et al., 1990). Unlike the great majority of employer-provided insurance plans, Medicare does not cap beneficiaries’ total payments for cost sharing (AARP, 1997). Medicare HMOs typically have lower cost sharing than the traditional Medicare program and may offer additional benefits such as outpatient prescription drug coverage, but they may impose certain restrictions on use of specialty providers (AARP, 1997). Relatively few Medicare beneficiaries are enrolled in HMOs (12 percent as of 2003) (http://cms.hhs.gov/healthplans/statistics/mmcc/, accessed April 18, 2003). Before 1990, most mental health care was covered by indemnity plans that used benefit limits and patient cost sharing to control service use and spending. By the late 1990s, managed care was the norm in health service delivery, covering an estimated 56 percent of Americans. With the growing complexity of care, it can be difficult to distinguish one type of managed care plan from another, but major types of such plans include: Health maintenance organizations (HMOs) provide all medical services on a prepaid, per capita basis. Medical staff members may be salaried, but increasingly HMOs have developed networks of physicians—so-called Independent Practice Associations, or IPAs—who are paid on a fee-for-service basis and function under common management guidelines. Preferred Provider Organizations (PPOs) are managed care plans that contract with networks of providers to supply services. Providers are typically paid on a discounted fee-for-service basis. Enrollees are offered lower cost-sharing to use providers on the “preferred” list but can use non-network providers at a higher out-of-pocket cost. Point-of-Service (POS) plans are managed care plans that combine features of prepaid (or capitated) and fee-for-service insurance. Enrollees can choose to use a network provider at the time of service. A significant copayment typically accompanies use of non-network providers. Although few plans are purely of one type, an important difference between a PPO and POS is that in a PPO plan, the patient may select any type of covered care from any in-network provider, while in a POS plan, use of in-network services must be approved by a primary care physician. Increasingly, mental health services are being provided by managed behavioral health organizations, which are estimated to cover approximately 200 million Americans (IOM, 1997; Goff, 2002). Often mental health ser-
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Meeting Psychosocial Needs of Women with Breast Cancer vices are covered in a separate contract between the payer (insurer or employer) and a behavioral health provider. These so-called “carve-out” managed behavioral health care arrangements allow payers to isolate mental health services from overall insurance risk and have mental health care services managed separately from general health care (Box 7-1). This separation is generally acceptable for physically healthy individuals. However, this arrangement is highly disadvantageous to patients with a life-threatening or chronic illness who require psychiatric/psychological consultation for related mental disorders (e.g., confusion/delirium from disease or medication or severe anxiety or depression). The separation of care delivery can lead to fragmentation of services across medical and behavioral health providers. Managed care may also serve as a barrier to appropriate psychosocial services when mental health providers who are trained in psycho-oncology and management of distress in patients with cancer are not available within the behavioral health plan’s service network. Concerns have been raised that mental health providers in networks often do not have expertise in psycho-oncology (Wellisch, IOM workshop, October 2002). BOX 7-1 Carve-Out Managed Behavioral Health Care Many HMOs and other health plans carve out mental health care for administration by a managed behavioral health company. This arrangement permits a larger range of services than can be provided within the health plan and permits the application of specific cost controls to behavioral health care. Carve-outs generally have separate budgets, provider networks, and financial incentive arrangements. Covered services, utilization management techniques, financial risk, and other features vary depending on the particular carve-out contract. The employee as a plan member may be unaware of any such arrangement. These separate contracts delegate management of mental health care to specialized vendors known as managed behavioral health care organizations. There are two general forms of carve-outs: In payer carve-outs, an enrollee chooses a health plan for coverage of health care with the exception of mental health and must enroll with a separate carve-out vendor for mental health care. In health plan subcontracts, administrators of the general medical plan arrange to have mental health care managed by a carve-out vendor; the plan member does not have to take steps to select mental health coverage. SOURCE: U.S. Surgeon General’s Report, 1999.
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Meeting Psychosocial Needs of Women with Breast Cancer There is a range of management controls currently applied to enrollees in managed care plans (e.g., utilization review). Some are concerned that excessively restrictive cost containment strategies and financial incentives to providers and facilities to reduce specialty referrals, hospital admissions, or length or amount of treatment contribute to lowered access and quality of mental health care (DHHS, 1999). Despite these significant concerns, raised repeatedly by mental health professionals, particularly consultation-liaison psychiatrists who work with the medically ill, the actual impact of these policies has received relatively little systematic study. There are currently no benchmark standards for access to specialized mental health services for medically ill patients, making assessment of access difficult. Some evidence suggests that, in the general population, the use of mental health care increases after managed behavioral health care is implemented in private insurance plans (Goldman et al., 1998). This is, in part due to shifts from in-hospital to outpatient mental health care. Most Medicare beneficiaries have coverage of outpatient health services, including mental health services, through Medicare Part B. Medicare beneficiaries are much less likely than individuals covered by private insurance or Medicaid to be in a managed care plan. An estimated 88 percent of beneficiaries are covered under the traditional Medicare fee-for-service program. Mental health services reimbursed by Medicare include psychiatric diagnostic or evaluative interview procedures, individual psychotherapy, group psychotherapy, family psychotherapy, psychoanalysis, psychological testing, and pharmacologic management (DHHS, 2001). Practitioners who can provide mental health services to Medicare beneficiaries include: physicians, clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants (Code of Federal Regulations, Title 42, Part 410). Under Medicare, professional fees are based on a relative value scale. Psychologists and social workers are paid on a percentage markdown from psychiatrists (Frank, 2000). Under traditional Medicare, beneficiaries pay 50 percent of Medicare’s allowed fee for outpatient mental health therapy. Most Medicare Plus Choice plans also require some cost-sharing for these services (Gold and Achman, 2001). Coverage of mental health benefits under Medicaid is complex, because of the program’s variation in coverage by state. Mandated benefits under Medicaid include general hospital inpatient care, physician services, outpatient services in general hospitals, nursing home care, and prescription drugs. States have had the freedom to choose a number of optional benefits, for example, non-physician services, services provided in free-standing outpatient clinics, and case management. States have often limited costs and coverage through their reimbursement policies. Fees to professionals are commonly set well below market levels of reimbursement,
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Meeting Psychosocial Needs of Women with Breast Cancer which limits the supply of physician services to Medicaid beneficiaries (Frank, 2000). State Medicaid programs are increasingly delegating management of mental health services to managed behavioral health care organizations (Frank, 2000). Reimbursement of the treatment of psychosocial services for women with breast cancer through public and private insurers may be facilitated by the development of six reimbursement codes for psychological services to patients with physical health diagnoses (APA, undated memo; http://www.apa.org/practice/cpt_2002.html, accessed April 17, 2003) (see Box 7-2). The new CPT codes, which became effective January 1, 2002, cover behavioral, social, and psychophysiological procedures for the prevention, treatment, or management of physical health problems. These codes, for the first time, permit reimbursement for treatment by a psychologist without the need for a mental health diagnosis (in fact, they cannot be used for treating patients with a psychiatric diagnosis). Types of assessment and intervention services that will be covered by the codes include patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. For private and third-party insurance plans, the services will likely be treated under the physical illness benefits, and thus not be relegated to behavioral health “carve out” programs. BOX 7-2 New Health and Behavior CPT Codes and Associated Medicare Reimbursement Rates Approximate Medicare Payment (in dollars) CPT Code Service 15 min (1 unit) 1 hour (4 units) 96150 Assessment-initial $26 $106 96151 Re-assessment 26 103 96152 Intervention: individual 25 98 96153 Intervention: group (per person) 5 22 96154 Intervention: family w/patient 24 96 96155 Intervention: family w/o patient 23 93 SOURCE: APA, undated memo; http://www.apa.org/practice/cpt_2002.html, accessed April 17, 2003.
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Meeting Psychosocial Needs of Women with Breast Cancer There have been many efforts to bring coverage of services for mental illness on a par with that for somatic illness. The Mental Health Parity Act of 1996 (PL 104-204) has improved insurance coverage for mental illnesses, but many gaps remain (www.nami.org/update/parity96.html). Implemented in 1998, this legislation focused on only one aspect of the inequities in mental health insurance coverage: “catastrophic” benefits. It prohibited the use of lifetime and annual limits on coverage that were different for mental and somatic illnesses. The law does not mandate coverage and applies only to employers that offer mental health benefits. It also does not affect rules for service charges, such as co-payments, deductibles, and out-of-pocket payment limits. A growing number of states have parity legislation, but some states have targeted their legislation narrowly to include only people with severe mental disorders. The experience of a pilot project to incorporate psychosocial support services into an outpatient medical oncology practice illustrates some of the problems encountered in insurance coverage (Sellers, 2000). The project placed a medical family therapist for 20 hours a week in a multi-specialty practice in Seattle. After 6 months of this collaborative practice, the providers reviewed the financial costs and levels of reimbursement for psychosocial care. In this practice, 60 percent of patients receiving psychosocial services had some form of behavioral health coverage and of these 30 percent were Medicare patients. The analysis showed that insurance reimbursements covered 60 percent of the program cost and that external funding would be needed to support the service. The following problems with insurance coverage were noted: Because of frequent changes in insurance carriers and plans, behavioral health benefit review was needed for each new patient prior to a visit. The amount of time and effort required to track down a relatively small number of reimbursement dollars was not cost effective. Medicare reimbursement was relatively low, roughly half of non-Medicare reimbursement. For Medicare reimbursement, patients could not see the psychosocial provider on the same day as a physician visit. Attributes of the Health Care Delivery System How breast cancer care is organized and delivered can greatly affect access to mental health care services (see also Chapter 6). There is limited information on the extent to which women’s breast care is coordinated and organized to facilitate the identification and management of psychosocial distress. One important study in this area found breast cancer care sites in New York City to lack comprehensive systems to ensure care coordination
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Meeting Psychosocial Needs of Women with Breast Cancer (Bickell and Young, 2001). While this study’s findings may not be applicable to other geographic areas, it suggests an important link between care coordination and the provision of support services. As part of their study of institutional approaches to coordinate care for women with early-stage breast cancer, Bickell and colleagues completed in-depth semi-structured interviews at six hospitals with providers of breast cancer care and their support staff. Systematic use of patient support programs, such as patient educators and navigators, were perceived to be valuable in coordinating care. Three of the six sites had patient support programs, which all provided: a systematic method to identify patients; education about breast cancer including treatment options and counseling; calls to patients to remind them of upcoming appointments; and navigators to bring patients to appointments or enable them to attend appointments, for example, by arranging for child care or transportation. Two of the three programs were staffed with trained volunteers. Physicians found the programs to be extremely valuable because they provided services that were otherwise missing at the sites or supplemented services, thereby reducing physicians’ work-load. The patient education and counseling provided were viewed as improving patient’s understanding and ability to make informed treatment decisions. Also valued were practical social and financial support, such as assistance with (Bickell, workshop presentation, 2002): navigation through the care system, forms to get home health aides, arranging transportation and child care, completing insurance forms, and applying for compassionate drug programs. Particularly helpful was having systematic case finding to identify new patients and ensure that the need for supportive care services was assessed and offered. In some cases, women were approached by a person at preadmission testing so that a connection was made to a person who would contact them later. Other programs placed volunteers at key sites, for example, the breast clinic, mammography clinic, and radiation therapy and infusion suites. According to institutional staff, physician “buy-in” was crucial to program success. Physicians tended to be initially resistant, but later
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Meeting Psychosocial Needs of Women with Breast Cancer came to rely on services (Bickell, workshop presentation, 2002). In general, barriers to program coordination included: lack of physician referral; the fragmentation of care (dispersed offices); lack of hospital support (i.e., reliance on philanthropy); difficulty in finding/keeping committed volunteers, especially in poor communities; and reaching speakers of languages other than English. Findings from this study of breast cancer care delivery are consistent with the emerging chronic disease model of care (Von Korff et al., 1997; Wagner et al., 1996). The chronic disease model posits that through more productive interactions between patients and provider teams, functional and clinical outcomes can be improved. The model calls for improvements in coordinated delivery systems including connecting health systems with community resources to support patients in a meaningful way (www.Improvingchroniccare.org). Research and demonstration projects to evaluate this model of care are being supported by the Robert Wood Johnson Foundation. The most extensive effort to improve psychosocial care at a population level has been in Australia where a National Breast Cancer Center has undertaken review of evidence-based research for psychosocial interventions and developed the findings into recommendations and clinical practice guidelines. National efforts have involved oncologists, mental health professionals, and breast cancer advocacy groups to change current practices through demonstration projects and education (Redman et al., 2003). Attributes of Individuals Lack of knowledge or misperceptions about mental health services are among the most significant barriers to receipt of appropriate care. According to a recent survey, only 55 percent of Americans understand depression is a disease and not a state of mind that a person can snap out of (NMHA, 2001). The 1999 Surgeon General’s report on mental illness identified stigma as a major barrier to addressing the nation’s mental health needs. Stigma can be defined as a label that sets a person apart from others and links that person to undesirable characteristics. People tend to reject and avoid stigmatized people. The stigma associated with mental illness may be declining with the growing acceptance of depression and other conditions as treatable health problems. Despite this, patients with a life-threatening illness like cancer often express their reluctance to request psychological
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Meeting Psychosocial Needs of Women with Breast Cancer A stepped care approach can be envisioned so that individuals with mild distress could be treated by oncology providers, moderately distressed patient referred to community resources, and severely distressed patients referred to psychologists and psychiatrists. This model has been adapted from the widely used WHO Analgesic Ladder for pain management (Figure 7-3). The inclusion of a nursing or mental health specialist as part of the care team in larger practices such as comprehensive breast care programs can facilitate both screening and the provision of services (Sorensen and Liu, 1995). In these settings, early contact with a mental health professional is routine which destigmatizes use of services and facilitates referral for individual or group counseling. While this approach may not be feasible in all practice settings, use of the screening tools described earlier in all patients could alert the practicing physician to patients who need appropriate referrals. In a study of the effect of counseling by a nurse specialist on recovery among breast cancer patients following mastectomy conducted in the late 1970s, the nurse’s regular monitoring of women’s progress facilitated the recognition and subsequent referral of three-quarters of women who needed psychiatric help (Maguire et al., 1980). FIGURE 7-3 Stepped care approach to managing psychosocial distress. SOURCE: Holland, workshop presentation, October 2002
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Meeting Psychosocial Needs of Women with Breast Cancer Psychosocial needs change over the cancer care trajectory, so that reassessment is necessary during and after treatment or during the recovery phase. The assessment must be sensitive to the changes in psychosocial needs. Survivorship issues like sexual problems, distress related to body image, cognitive function, and lymphedema may only emerge following treatment. Assessments must take into consideration the context of a woman’s age and social situation. Family, career, sexual, and reproductive issues may be at the forefront of concerns for younger women. Women in midlife may, in addition, have concerns related to menopause, while elderly women may have distinct concerns regarding other chronic health conditions. Some issues not of concern around the time of diagnosis may emerge later as sources of distress, for example, body image. How often an assessment is done may depend on the planned schedule of visits for follow-up for women with breast cancer. Who performs the assessment may vary depending on whether women are followed by their oncology or primary care provider. There is a fear that screening will result in identifying so many women that they cannot be given the psychosocial services needed. Where routine screening has been adopted, for example, at the Johns Hopkins Oncology Center, this has not occurred. In fact, screening all patients helps deploy available services to those most in need and allows referral of others to groups and community resources. Assistance to the primary oncology team in identifying patients who are distressed, by means of a screening tool, can also provide a triage algorithm to use for referral to specialized psychosocial services. This has proved to be the case in pain management which has improved by asking patients to rate their pain on a scale of 1 to 10, and using any score above 5 as indication for a pain consultation. The NCCN distress thermometer follows the same algorithm. Inadequate Quality Assurance and Accountability There is no one system to assure the quality of cancer care, but several programs in place could potentially serve to improve access to psychosocial services. As described in Chapter 6, there are two sets of standards that address cancer-related quality of care, those of the American College of Surgeons’ (ACoS) Commission on Cancer (CoC), and those of the Association of Community Cancer Centers (ACCC). Of the two, the standards of the CoC affect more individuals with cancer because an estimated 82 percent of new cases of cancer are seen in the 1,428 hospitals approved by the CoC. Staffing and programmatic needs are outlined in these standards to ensure, at a minimal level, the capacity to provide psychosocial service. The American Cancer Society (ACS) has launched an ambitious community-based Quality of Life initiative aimed at cancer patients and their caregivers and families. The provision of psychosocial services is an important component of its initiative (Box 7-4).
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Meeting Psychosocial Needs of Women with Breast Cancer BOX 7-4 American Cancer Society Nationwide Objectives to Improve the Quality of Life (QoL) of Cancer Patients and Their Caregivers and Families QoL Goal: Measurable improvement in the quality of life (physical, psychological, social, and spiritual) from the time of diagnosis and for the balance of life of all cancer survivors by the year 2015. PHYSICAL ASPECTS OF QUALITY OF LIFE Physical Effects: By 2015, provide appropriate care for symptom control, emphasizing pain, fatigue, rehabilitation, and side effects of treatment based upon an appropriate care plan using uniform standards of care for 90% of cancer survivors. Pain Control: By 2015, provide appropriate care for the control of pain based upon an appropriate care plan using uniform standards of care for 90% of cancer survivors. By 2005, 75% of health care systems will have institutionalized quality standards for the management of pain. Physical Appearance: By 2015, the negative impact of cancer on physical appearance and body image will be substantially reduced in 75% of those affected cancer survivors. SOCIAL ASPECTS OF QUALITY OF LIFE Social Support: By 2005, the number of cancer survivors, their families, and caregivers who participate in appropriate ACS patient support programs or are referred to other community programs will increase by at least 50%. By 2005, 60% of survivors, their families, and caregivers will be aware of and have knowledge about American Cancer Society quality of life education and support services. PSYCHOLOGICAL AND SPIRITUAL DOMAINS Psychological, Emotional, Spiritual Effects: By 2015, 90% of cancer survivors and families and caregivers of those affected by cancer will receive appropriate care or appropriate referral to services for identified psychological, emotional, and spiritual problems and/or needs. Provider Education: By 2015, 90% of health care providers will assess psychological, emotional, and spiritual needs of cancer survivors and families and caregivers of those affected by cancer and provide appropriate care or appropriate referral to services. SOURCE: B. Teschendorf, October workshop, 2002.
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Meeting Psychosocial Needs of Women with Breast Cancer Achieving these national goals will involve actions at the 17 ACS Divisions throughout the country (B. Teschendorf, IOM workshop, 2002). To aid in implementation, assessments of community resources are taking place and a database is being created, by state, within each Division. The database will be used for referral and as a navigation tool. Certain areas will aim to be designated as “Communities of Excellence” through the setting of specific goals and the measurement of their achievement. Working with advocates and consumers, some communities might elect to focus on pain, social support, or other areas within the broad set of quality of life measures. Worksites provide another opportunity to implement the ACS goals. ACS is planning a program for large employers to ease the transition of cancer survivors back to work. Other cancer advocacy organizations have promoted an awareness of psychosocial services as a part of quality cancer care. The National Breast Cancer Coalition (NBCC), for example, has published a Guide to Quality Breast Cancer Care for consumers that identifies social and support services as part of comprehensive care (NBCC, 2002). The National Coalition for Cancer Survivorship (NCCS) has published quality imperatives (Box 7-5) that include the need for psychosocial services (see principle 5 below) and BOX 7-5 Quality Cancer Care: Declaration of Principles, National Coalition for Cancer Survivorship Principle 1 People with cancer have the right to a system of universal health care. This access should not be precluded because of preexisting conditions, genetic or other risk factors, or employment status. Principle 2 Quality cancer care should be available in a health care system whose standards and guidelines are developed in consideration of treating the whole person with cancer. Health care plans must regard the cancer patient as an autonomous individual who has the right to be involved in decisions about his or her care. Principle 3 Standards of cancer care should be driven by the quality of care, not only by the cost of care, and should include participation in clinical trials and quality of life considerations. Principle 4 All people diagnosed with cancer should have access to and coverage for services provided by a multidisciplinary team of care providers across the full continuum of care. Health care plans should be held
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Meeting Psychosocial Needs of Women with Breast Cancer accountable for timely referral to appropriate specialists when symptoms of cancer or its recurrence may be present. Principle 5 People with cancer should be provided a range of benefits by all health care plans that includes primary and secondary prevention, early detection, initial treatment, supportive therapies to manage pain, nausea, fatigue and infections, long-term follow-up, psychosocial services, palliative care, hospice care, and bereavement counseling. Principle 6 People with histories of cancer have the right to continued medical follow-up with basic standards of care that include the specific needs of long-term survivors. Principle 7 Long-term survivors should have access to specialized follow-up clinics that focus on health promotion, disease prevention, rehabilitation, and identification of physiologic and psychosocial problems. Communication with the primary care physician must be maintained. Principle 8 Systematic long-term follow-up should generate data that contribute to improvements in cancer therapies and decreases in morbidity. Principle 9 The responsibility for appropriate long-term medical care must be shared by cancer survivors, their families, the oncology team, and primary care providers. Principle 10 The provision of psychosocial services must be safe-guarded and promoted. Persons diagnosed with cancer should receive psychosocial assessments at critical junctures along the continuum of cancer care to determine availability of needed support and their ability to seek information and to advocate on their own behalf. Principle 11 Psychosocial research is integral to comprehensive cancer care and, as such, psychosocial outcome measures should be included in all future clinical trials. The importance of this research and its application and transfer to oncology care plans should be recognized and encouraged. Principle 12 Cancer survivors, health care providers and other key constituency groups must work together to increase public awareness; educate consumers, professionals, and public policy makers; develop guidelines and disseminate information; advocate for increased research funding; and articulate for and promote survivors’ rights. SOURCE: NCCS, 1995.
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Meeting Psychosocial Needs of Women with Breast Cancer has created a cancer survivorship tool kit to help patients advocate for care that meets these quality standards (http://www.canceradvocacy.org/). With nearly half (45 percent) of new cases of breast cancer occurring among women age 65 or older, the Medicare program has an interest in ensuring the delivery of quality care to its beneficiaries. The agency overseeing the Medicare program, the Centers for Medicare and Medicaid Services (CMS), has systems in place to monitor quality of care, but assessments to date on cancer-related care have focused on breast cancer screening (IOM, 2003). Assessments of the delivery of psychosocial care are hampered by the lack of validated measures of quality. The National Quality Forum (NQF) is a not-for-profit membership organization created in 2000 to develop and implement a national strategy for healthcare quality measurement and reporting (http://www.qualityforum.org/, accessed April 18, 2003). In 2002 the NQF formed a Cancer Care Quality Measures Steering Committee to reach consensus on a core set of quality measures. Breast cancer is one of the focus areas of this activity, as well as symptom management and palliation. There is more experience with quality of care measurement for breast cancer care, relative to other types of cancer care (IOM/NRC, 2000). The Foundation for Accountability (FACCT), for example, developed a set of breast cancer quality indicators which included satisfaction with care, and quality of life as measured by the Cancer Rehabilitation Evaluation System (CARES) instrument (see Chapter 3 for a description of this instrument). The Providence Health System uses FACCT to assess breast cancer care within its 17 member institutions (located from California to Alaska) (http://www.providence.org/Oregon/Programs_and_Services/Research/CORE/performance, accessed April 18, 2003). More direct measurement of the provision of psychosocial care within systems of care have not yet been performed, but could likely be incorporated into assessments of satisfaction of care. In a review of quality-of-care measure that could be used to assess oncology practice, Mandelblatt and colleagues suggest that rates of clinical assessment of the need for psychological support services (both group and individual) could be documented and serve as a process measure of rehabilitative care (Mandelblatt et al., 1999). Evaluations of the feasibility and value of such quality of care assessments are needed. SUMMARY AND RECOMMENDATIONS Many barriers need to be overcome to meet the psychosocial needs of women with breast cancer. Lack of access to health care is a general societal problem in America. An estimated 8 percent of women with breast cancer lack health insurance coverage, and many more have inadequate health insurance coverage for even basic health care needs. Health insurance cov-
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Meeting Psychosocial Needs of Women with Breast Cancer erage often provides poor coverage of mental health benefits or imposes restrictions on benefits through high out-of-pocket payments or limits on care. At the individual level, the stigma associated with seeking mental health care can inhibit use of services, but such stigma may be waning with the well-publicized successes of the treatment of common disorders like depression. Health-care providers can serve as barriers to appropriate psychosocial care if they fail to acknowledge such issues in the course of providing cancer care or if they do not refer patients to available services. Implementing clinical practice guidelines that incorporate assessment and treatment of psychosocial distress is a promising strategy to overcome many of these barriers. While there is limited evidence on the use and effectiveness of such guidelines in reducing psychosocial distress and improving quality of life of women with breast cancer, the guidelines have established the first standards for care in this “soft” area of clinical work. As such, these guidelines have provided the first benchmarks against which to monitor psychosocial care and services. At present there is little evidence that psychosocial interventions are integrated into routine breast cancer care. In general, the oncology nurse and social worker serve as front line staff to identify patients in need of psychosocial services. Guidelines are available to help clinicians identify and manage individuals with cancer who are distressed, but the Board could identify no studies of their use. Perhaps a demonstration project could explore this. Certain organizations, for example, the American College of Surgeons’ Commission on Cancer, have developed standards to ensure the availability of psychosocial services, but a consideration of such standards is usually outside of the scope of ongoing quality assurance programs. To overcome the range of barriers to delivering psychosocial services to women with breast cancer, the Board recommends that: Breast cancer care clinicians, such as oncologists and other medical professionals, responsible for the care of women with breast cancer should incorporate planning for psychosocial management as an integral part of treatment. They should routinely assess and address psychosocial distress as a part of total medical care. Validated assessment tools are available to screen for psychosocial distress and especially for anxiety and depression. Quality of life instruments also can be used to identify function (psychological, social, physical, sexual) and to facilitate discussion of patient concerns, and serve as a basis for referral. Financial considerations may dictate that in most instances screening is carried out using simple, rapid tools such as the Distress Thermometer or Hospital Anxiety and Depression Scale (HADS).
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Meeting Psychosocial Needs of Women with Breast Cancer Providers of cancer care should meet the standards of psychosocial care developed by the American College of Surgeons’ Commission on Cancer and follow the National Comprehensive Cancer Network’s (NCCN) Clinical Practice Guidelines for the Management of Distress. Education about psychosocial needs and services should be undertaken through collaboration between professional organizations and advocacy groups. The NCI, the American Cancer Society (ACS), and professional organizations (e.g., American Society of Clinical Oncology, American College of Surgeons, American Association of Colleges of Nursing, American Psychosocial Oncology Society, American Society of Social Work, American Society for Therapeutic Radiology and Oncology, Oncology Nursing Society) need to partner with advocacy groups (e.g., National Breast Cancer Coalition, National Alliance of Breast Cancer Organizations,Wellness Community, NCCS) to focus attention on psychosocial needs of patients and resources that provide psychosocial services in local communities and nationally. Organizations with effective outreach to cancer constituencies should be assisted in making resource directories available to providers and patients; these directories would identify the range of supportive services, from the free services of advocacy groups to services provided by mental health professionals. Translational research is also needed to test interventions to overcome barriers to the provision of effective psychosocial care within practice settings. The current status of psychosocial research and the Board’s recommendations for research action are discussed in Chapter 8. REFERENCES Achman L, Chollet D. 2001. Insuring the Uninsurable: An Overview of State High-Risk Health Insurance Pools. Mathematica Policy Research, Inc. Princeton, NJ. [Online]. Available: http://www.mathematica-mpr.com/3rdlevel/uninsurablehot.htm [accessed March 21, 2003]. American Association of Retired Persons (AARP), Public Policy Institute and the Lewin Group. 1997. Out-of-Pocket Health Spending by Medicare Beneficiaries Age 65 and Older: 1997 Projections. Ayanian JZ, Kohler BA, Abe T, Epstein AM. 1993. The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med 329(5):326–331. Baile WF, Kudelka AP, Beale EA, Glober GA, Myers EG, Greisinger AJ, et al. 1999. Communication skills training in oncology: Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer 86:887–897. Barlow DH, Barlow DB. 1995. Practice guidelines and empirically validated psychosocial treatments: Ships passing in the night? Behavioral Healthcare Tomorrow May/June 25–29, 76. Benedetti C, Brock C, Cleeland C, Coyle N, Dube JE, Ferrell B, Hassenbusch S 3rd, Janjan NA, Lema MJ, Levy MH, Loscalzo MJ, Lynch M, Muir C, Oakes L, O’Neill A, Payne R, Syrjala KL, Urba S, Weinstein SM. 2000. NCCN practice guidelines for cancer pain. Oncology (Huntingt) 14(11A):135–150.
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Meeting Psychosocial Needs of Women with Breast Cancer Bickell NA, Young GJ. 2001. Coordination of care for early-stage breast cancer patients. J Gen Intern Med 16(11):737-742. Butow PN, Dunn SM, Tattersall MHN. 1995. Communication with cancer patients: Does it matter? J Palliat Care 11:34–38. Canadian Medical Association–Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. 1998. Follow-up after treatment for breast cancer. Canadian Medical Association Journal 158:565–570. Carlson RW, Anderson BO, Bensinger W, Cox CE, Davidson NE, Edge SB, Farrar WB, Goldstein LJ, Gradishar WJ, Lichter AS, McCormick B, Nabell LM, Reed EC, Silver SM, Smith ML, Somlo G, Theriault R, Ward JH, Winer EP, Wolff A. 2000. NCCN practice guidelines for breast cancer. Oncology (Huntingt) 14(11A):33–49. Cull A, Gould A, House A, Smith A, Strong V, Velikova G, Wright P, Selby P. 2001. Validating automated screening for psychological distress by means of computer touchscreens for use in routine oncology practice. Br J Cancer 85(12):1842–1849. Department of Health and Human Services, CMS. 2002. HHS to Help States Create High-Risk Pools to Increase Access to Health Coverage. Press release, November 26, 2002. [Online]. Available: www.hhs.gov/news/press/2002pres/20021126a.html [accessed January 31, 2003). Department of Health and Human Services. 2001. Medicare Part B Payments for Mental Health Services. Philadelphia: Department of Health and Human Services. Detmar SB, Aaronson NK, Wever LD, Muller M, Schornagel JH. 2000. How are you feeling? Who wants to know? Patients’ and oncologists’ preferences for discussing health-related quality-of-life issues. J Clin Oncol 18(18):3295–3301. Eakin EG, Strycker, LA. 2001. Awareness and barriers to use of cancer support and information resources by HMO patients with breast, prostate, or colon cancer: patient and provider perspectives. Psycho-Oncology. 10(2):103-113. Edgar L, Remmer J, Rosberger Z, et al. 2000. Resource use in women completing treatment for breast cancer. Psycho-Oncology. 9(5):428-438. Fallowfield L, Ratcliffe D, Jenkins V, Saul J. 2001. Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer 84(8):1011–1015. Frank RG. 2000. The creation of Medicare and Medicaid: The emergence of insurance and markets for mental health services. Psychiatr Serv 51(4):465–468. Gerrity MS, Cole SA, Dietrich AJ, et al. 1999. Improving the recognition and management of depression: Is there a role for physician education? J Fam Pract 48(12):949–957. Goff VV. 2002. Depression: A decade of progress, more to do. NHPF Issue Brief (786):1–14. Gold M, Achman L. 2001. Trends in premiums, cost-sharing, and benefits in Medicare+Choice health plans, 1999–2001. Issue Brief (Commonw Fund) 460:1–6. Goldman W, McCulloch J, Sturm R. 1998. Costs and use of mental health services before and after managed care. Health Aff (Millwood) 17(2):40–52. Hewitt M, Breen N, Devesa S. 1999. Cancer prevalence and survivorship issues: Analyses of the 1992 National Health Interview Survey. J Natl Cancer Inst 91(17):1480–1486. Holland JC. 1999. Update: NCCN practice guidelines for the management of psychosocial distress. Oncology 13(11A):459–507. Holland JC, Jacobsen PB, Riba MB. 2001. Distress management. Cancer Control 8(6):88–93. Institute of Medicine. 1990. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press. Institute of Medicine. 1993. Access to Health Care in America. Washington DC: National Academy Press. Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: National Academy Press. Institute of Medicine. 2001. Coverage Matters: Insurance and Health Care. Washington, DC: National Academy Press.
OCR for page 197
Meeting Psychosocial Needs of Women with Breast Cancer Institute of Medicine. 2002. Care Without Coverage: Too Little, Too Late. Washington, DC: National Academy Press. Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Healthcare Quality. Washington, DC: The National Academies Press. Institute of Medicine and National Research Council. 2000. Enhancing Data Systems to Improve the Quality of Cancer Care. Washington, DC: National Academy Press. Landerman LR, Burns BJ, Swartz MS, Wagner HR, George LK. 1994. The relationship between insurance coverage and psychiatric disorder in predicting use of mental health services. Am J Psychiatry 151(12):1785–1790. Lee-Feldstein A, Feldstein PJ, Buchmueller T, Katterhagen G. 2000. The relationship of HMOs, health insurance, and delivery systems to breast cancer outcomes. Med Care 38(7):705–718. Lerman C, Daly M, Walsh WP, Resch N, Seay J, Barsevick A, Birenbaum L, Heggan T, Martin G. 1993. Communication between patients with breast cancer and health care providers. Determinants and implications. Cancer 72(9):2612–2620. Levy MH, Weinstein SM, Carducci MA. 2001. NCCN: Palliative care. Cancer Control 8(6 Suppl 2):66–71. Liang W, Burnett CB, Rowland JH, Meropol NJ, Eggert L, Hwang YT, Silliman RA, Weeks JC, Mandelblatt JS. 2002. Communication between physicians and older women with localized breast cancer: Implications for treatment and patient satisfaction. J Clin Oncol 20(4):1008–1016. Maguire P, Tait A, Brooke M, et at. 1980. Effect of counseling on the psychiatric morbidity associated with mastectomy. Br Med J. 281(6253):1454-1456. Mandelblatt JS, Ganz PA, Kahn KL. 1999. Proposed agenda for the measurement of quality-of-care outcomes in oncology practice. J Clin Oncol 17(8):2614–2622. Matthews AK, Sellergren SA, Manfredi C, Williams M. 2002a. Factors influencing medical information seeking among African American cancer patients. J Health Commun 7(3):205–219. Matthews BA, Baker F, Spillers RL. 2002b. Healthcare professionals’ awareness of cancer support services. Cancer Pract 10(1):36–44. McGivney WT, McGinnis L, Gansler TS. 2000. The NCCN/American Cancer Society partnership. Oncology (Huntingt) 14(11A):213–216. Mock V, Atkinson A, Barsevick A, Cella D, Cimprich B, Cleeland C, Donnelly J, Eisenberger MA, Escalante C, Hinds P, Jacobsen PB, Kaldor P, Knight SJ, Peterman A, Piper BF, Rugo H, Sabbatini P, Stahl C. 2000. NCCN Practice Guidelines for Cancer-Related Fatigue. Oncology (Huntingt) 14(11A):151–161. National Breast Cancer Coalition. 2002. Guide to Quality Breast Cancer Care. 2nd edition. Washington, DC: National Breast Cancer Coalition. National Comprehensive Cancer Network. 1999. NCCN practice guidelines for the management of psychosocial distress. Oncology (Huntingt) 13(5A):113–147. NCCN. 2003. Clinical Practice Guidelines for Management of Distress. Journal of the NCCN. National Coalition for Cancer Survivorship. 1995. Imperatives for Quality Cancer Care: Access, Advocacy, Action, and Accountability. Silver Spring, MD. National Mental Health Association. 2001. Americans Say Depression Is a Disease “Not a State of Mind,” but Stigma and Policy Impede Treatment. Alexandria, VA. Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. 2002. National trends in the outpatient treatment of depression. JAMA 287(2):203–209. Parle M, Gallagher J, Gray C, Akers G, Liebert B. 2001. From evidence to practice: factors affecting the specialist breast nurse’s detection of psychological morbidity in women with breast cancer. Psycho-Oncology 10(6):503–510.
OCR for page 198
Meeting Psychosocial Needs of Women with Breast Cancer Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S. 1998. Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol 16(4):1594–1600. Payne DK, Hoffman RG, Theodoulou M, Dosik M, Massie MJ. 1999. Screening for anxiety and depression in women with breast cancer. Psychosomatics 40(1):64–69. Pignone MP, Gaynes BN, Rushton JL, Burchell CM, Orleans CT, Mulrow CD, Lohr KN. 2002. Screening for depression in adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 136(10):765–776. Redman S, Turner J, Davis C. 2003. Improving supportive care for women with breast cancer in Australia: The challenge of modifying health systems. Psycho-Oncology 12(6):521–531. Roetzheim RG, Gonzalez EC, Ferrante JM, Pal N, Van Durme DJ, Krischer JP. 2000. Effects of health insurance and race on breast carcinoma treatments and outcomes. Cancer 89(11):2202–2213. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A, Krischer JP. 1999. Effects of health insurance and race on early detection of cancer. J Natl Cancer Inst 91(16):1409–1415. Roter DL, Hall JA, Kern DE, et al. 1995. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med 155(17):1877–1884. Schapira, L. 2003. Communication skills training in clinical oncology: The ASCO position reviewed and an optimistic personal perspective. Crit Rev Oncol Hematol 46(1):25–31. Sellers T. 2000. A model of collaborative healthcare in outpatient medical oncology. Families, Systems & Health 18(1):19–33. Smith TJ, Hillner BE. 2001. Ensuring quality cancer care by the use of clinical practice guidelines and critical pathways. J Clin Oncol 19(11):2886–2897. Sofaer S, Davidson BN, Goodwan RD, et al. 1990. Helping Medicare beneficiaries choose health insurance: The illness episode approach. Gerontologist 30(3):308–315. Sorensen, M, Liu, ET. 1995. With a different voice: Integrating the psychosocial perspective into routine oncology care. Breast Cancer Res Treat 35(1):39–42. U.S. Census Bureau. 2002. Health Insurance Coverage: 2001. Washington DC: U.S. Department of Commerce, Economics and Statistics Administration. U.S. Department of Health and Human Services. 2000. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. Von Korff M, Gruman J, Schaefer JK, Curry SJ, Wagner EH. 1997. Collaborative management of chronic illness. Ann Intern Med 127:1097–1102. Wagner EH, Austin BT, Von Korff M. 1996. Organizing care for patients with chronic illness. Millbank Quarterly 74:511–544. Williams JW Jr, Pignone M, Ramirez G, Perez Stellato C. 2002. Identifying depression in primary care: A literature synthesis of case-finding instruments. Gen Hosp Psychiatry 24(4):225–237. Zabora JR. 1998. Screening Procedures for Psychosocial Distress. In: Holland JC, Breitbart W, eds. Psycho-Oncology. New York: Oxford University Press. Pp. 653–661. Zabora JR, Smith-Wilson R, Fetting SH, et al. 1990. An efficient method for psychosocial screening of cancer patients. Psychosomatics 31(2):192–196.
Representative terms from entire chapter: