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

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

• Shirley Otis-Green, MSW, ACSW, LCSW, OSW-C
• Founder Consultant
• CollaborativeCaring
• Shirley_at_CollaborativeCaring.net

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Presentation Goals

• To 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

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Shared Perspective

• Whats in the best interests of the patients and
  families that we serve?

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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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5 -10
1IOM, 2008 2Zabora, et al., 20033Loscalzo
Clark, 2007 4Zabora, et al., 2001
Psychiatric or mental health disorders1
Need Referral Counseling1
Distress varies by cancer site4
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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 Data

• To document the extent of patient/family
  challenges
• To provide your institution with data for
  enhancing care (Quality Improvement/Quality
  Assurance)
• To inform development and implementation of
  practice, institutional programs, and policies
• To demonstrate impact and raise profile of
  oncology social work
• Make a case for additional staffing, based on
  home-based data

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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.

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What are your questions, concerns, challenges
around distress screening? How have you addressed
these challenges?

• Instrument selection?
• Implementation?
• Turf Battles?
• Social Works Competing Priorities? Other
  Obligations? Unclear Responsibility?
  Accountability? Limited Resources?

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Screen to Intervene

• Normalizes need for help and support
• Establishes social workers professional role
• Increases knowledge research base on psychosocial
  impacts of cancer
• Efficacy 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

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Evidence-Based Medicine (EBM)

• Why do we do what we do when we do for whom we
  do? (Too often because thats they way its
  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)

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Five Steps of Evidence-Informed Care

1. Ask focused questions Convert uncertainty into
   answerable questions
2. Systematically retrieve the best evidence with
   which to answer the questions
3. 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.as
   px?o1914)

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Goal Evidence-Informed Practice

• Critical thinking is key
• Curiosity regarding outcomes
• Commitment to explore options compare outcomes
• Intentionality in selecting interventions
• Professionalism requires contribution to build a
  strong evidence base

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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 TheoryChanging anythingchanges
  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
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• What are some of the major challenges encountered
  with family conferences?
• Lack of space to accommodate family
• Difficulty establishing preconference meeting
  with the health care providers
• Difficulty establishing off-hour meetings
  (weekends, outside 9am-5pm)
• Difficulty communicating with family due to
  language barriers, lack of a translator
• Lack of clear team to facilitate family
  meetings

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Key Elements of a Highly Functioning Team

• Consensual Goals (clarity of purpose)
• Tendency to default on the side of trust vs.
  mistrust (dont assume the worst about others)
• Willingness to roll up ones sleeves and do what
  needs to be done (functional nimbleness
  role flexibility)
• Perspective of were all in this together
  (shared credit shared responsibility)
• Conscious playing off peoples strengths and
  supporting others weaknesses (without focus on
  fault finding or blaming)
• Informal dept. survey (2007) of what makes a team
  work

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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.

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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 Helpers
  Journey, Research Press.

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1. What is Medically Appropriate
10 Steps of the Family Conference

• Based 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 patients current
  condition in terms of function/quality/time

(Adapted from EPERC Fast Facts Medical College
of Wisconsin, 2006)
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Pre-Meeting with Patient/Family To Ensure
Culturally Congruent Decision-Making

• Conducted by Social Worker? Chaplain? Nurse?
• Obtain history assess the patient and familys
  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?

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• Culture/Spirituality Provides the Lens Through
  Which We View Our Experiences

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2. Pre-Meeting Planning

• Coordinate medical opinions between consultants
  and primary MD
• Obtain patient/family psychosocial data
• Review Advance Care Planning Documents
• Is patient decisional
• Is there a power of attorney
• Review medical history/treatment
  options/prognostic information

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3. Environment

• Choose a proper environment
• Quiet, comfortable, chairs in a circle
• Invite participants to sit down
• Check your appearance, turn off pagers,

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4. Introductions

• Identify legal decision maker or family
  designated decision maker
• Introduce self and have others introduce
  themselves and relationship to patient
• Review your goals ask family if these are the
  same or different than their goals
• Establish ground rules
• Everyone can talk, but only one at a time
• No interruptions

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Build Rapport

• Build a relationship
• Ask the family to tell you something about the
  patient
• I know about the patients illness but I was
  wondering if you could tell me something about
  her as a person, her hobbies or interests?

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5. What does the patient know?

• Make no assumptions Find out what the
  patient/family already knows
• What 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?

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6. Medical Review

• Physician presents medical information succinctly
• Present the Big Picture
• Current condition Expected Course
• Speak slowly, deliberately, clearly
• No medical jargon

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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 water
• Do 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, Questions

• Allow silence, give patient/family time to react
  and ask questions
• Acknowledge and validate reactions prior to any
  further discussion
• Invite 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 medicines 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)

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8. Review Care Options

• Allow for pushback from patient and family
• Consider that recommendations for treatment might
  be on a trial basis
• Check again for clarity and consensus
• Ask for more questions
• Confirm 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.

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9. Confirm Plan of Care

• Based on the decision what do they want/need in
  the time remaining
• Confirm Goals- so what you are saying is
• Establish a Plan
• Decide on steps to achieve plans
• Usually involves discussion of CPR, ICU,
  artificial nutrition/hydration, home hospice
• If test or treatment wont meet goals its best
  not to start it
• Confirm plan summarize to ensure that everyone
  shares understanding of plan

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10. Conclusion

• Summarize areas of consensus and any
  disagreements
• Caution against unexpected outcomes
• Provide continuity
• Document in the medical record provide summary
  documents to family
• Who was present, what was decided, next steps
• Discuss results with other concerned healthcare
  professionals not present

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Implications for Your Institution?
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Summary

• A 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