1. Introduction

Interdisciplinary team-based care, incorporating psychosocial clinicians, seeks to address mental health, health behaviors and psychosocial factors including distress that contribute to disease. While this burgeoning field may be most established in chronic pain management [1], interdisciplinary collaborative care model (CoCM) in oncology is an evidence-based approach [2] with reliable data indicating enhanced quality of life and improved treatment adherence [3]. One health psychology team at Veterans Affairs (VA) offers broad and adaptive integrated services to medical teams across its healthcare system for Veterans [4,5]. With recognition from leadership and additional funding for oncology, one dedicated health psychology position has co-located and specialized further in psycho-oncology with some preliminary enhancements [6]. For example, the interdisciplinary oncology team demonstrated increased utilization of health psychology, and new availability of same-day services, engaging Veterans in behavioral health as a component of their cancer care. This paper describes a service delivery model implemented in one VA healthcare system, outlining broad and adaptive health psychology services in oncology that include Veteran-centered, co-located direct care, assessment of utility, and healthcare team well-being.

The Veteran population is particularly deserving of attention to enhance its interdisciplinary cancer care. First, compared to civilian counterparts, Veteran populations have a higher burden of risk factors associated with cancer such as obesity, diabetes and exposure to agent orange [7,8]. Moreover, prostate cancer is the most common solid tumor malignancy among Veterans, and Veterans are twice as likely to be diagnosed with prostate cancer compared to age-matched civilians [9,10]. Second, the Veteran population is increasingly diverse and unique health inequities need attention. Data reveal non-White racial/ethnic minority Veterans represent a steadily increasing proportion of those accessing healthcare [11], and challenges to providing culturally-informed care remain. Furthermore, among the comprehensive data across cancer types and particular non-White populations, African Americans disproportionately bear the cancer burden including the highest death rates for lung, prostate and breast cancers [12]. It is therefore important for all interdisciplinary healthcare teams, including cancer providers, to adapt continually to shifting demographics and health disparities.

Third, the prevalence of co-occurring mental health conditions is imperative to understand and address in Veteran populations. As one example, a higher rate of suicide risk has been demonstrated around the time of a cancer diagnosis among Veterans [13] compared to civilians. There are other data indicating a later diagnosis of small cell lung cancer among Veterans with a psychiatric history who are not engaging in mental health services [14] in contrast to those established with mental health. Such co-occurring mental health conditions may negatively impact accessing cancer screening, as well as cancer treatment initiation, adherence an/or completion. At the intersection of Veteran status, racial/ethnic and cultural factors and mental health is a complex healthcare landscape for oncology in particular. An interdisciplinary and adaptive healthcare team is foundational to understand and strive to meet the needs of all Veterans coping with cancer.

2. Broad and Adaptive Psychology Services in Oncology

Integrated and co-located psychosocial clinicians offer a broad range of services that are adaptive, contextualized and distinct from specialty mental health treatment. One central aim is to reach a broader segment of the Veteran population who may not otherwise engage with psychosocial or mental health services. Another crucial goal is to enhance overall healthcare, its quality, processes and outcomes. Initiation of integrated psycho-oncology services may be at any phase of the cancer trajectory. And while co-located in oncology, this VA integrated health psychology service welcomes referrals from across its healthcare system (e.g., primary care, or a related cancer service such as pulmonary or urology, etc.). Outreach for the services occurs naturally with its visibility and co-location. Moreover, integrated clinicians participate with individual discipline and team huddles, meetings and/or on-line communications to increase awareness.

The National Comprehensive Cancer Network (NCCN) distress thermometer [15] is utilized at this VA, and also may serve as the impetus for integrating psychosocial services. This VA’s Radiation Oncology clinic has incorporated the NCCN screening into its clinic flow with noteworthy support from nursing. Per guidance, a screen of 4 or higher is offered a referral for health psychology or other indicated services. Yet, as part of our broad, adaptive approach, health psychology services are offered to all Veterans in the clinic. Our team has noted Veterans may express interest to meet with health psychology even if they report mild to no distress symptoms at the time of screening. The NCCN screening is expanding to General Surgery and Medical Oncology clinics as well. Collectively, with co-location and both informal publicity and formalized NCCN distress screening, as much as 10% of the Veteran population receiving cancer care at the VA has engaged with the health psychology service. This reach or “penetration rate” into a service population is a performance indicator and suggests progress that VA more broadly evaluates for primary care mental health integration [16].

Broad and adaptive health psychology services are exemplified by a greater focus on the bio-psychosocial conceptualization [4,17] and a shared decision-making approach [18], and are less diagnostically-driven. The health psychologist aims to collaborate and integrate with existing nursing and provider appointments, often as same-day “warm hand-offs” or “check-ins”. Appointments may also be scheduled, and formats for all appointments or sessions are flexible, namely telephone, VA Video Connect and in-person. With shared decision-making, the health psychology interventions are tailored to each individual Veteran. A brief description of services is offered and if indicated, a brief functional assessment can address emergent or urgent, or situational or more chronic mental or behavioral health concerns. Of note, a standard “intake” is not routinely implemented given the tailoring or contextualized approach. For example, if a Veteran is experiencing significant distress in the context of a new diagnosis or learning of disease progression or recurrence, the health psychologist may meet with the Veteran, and/or family, and focus on patient-centered communication [19,20]. This encounter creates an opportunity to pause from the medical discussion to a more person-centered or meaning-focused interaction [21]. While standardized mood and/or functioning assessments may be indicated, the integrated health psychologist functions as a component of the interdisciplinary cancer team, and not a separate provider to meet with as a result of a referral to a circumscribed service.

In addition to the adaptive initiation and format of the services, health psychology interventions are broad as well as nimble in nature. The services may be one or two sessions that are consultative; or, briefer interventions may serve as linkages to other services (another discipline on the cancer team, or another service including specialty therapies, integrative modalities or specialty mental health). Services may also function as a briefer model of psychotherapy, approximately 6 sessions, conducting brief cognitive-behavioral therapy for insomnia or chronic pain, and constitute an episode of behavioral health care. Or interventions may be longer-term and draw from acceptance-based, meaning-centered or interpersonal psychotherapies in addition to cognitive-behavioral psychotherapy traditions. Interventions may focus more on behavioral health themes with goal setting or solution-focused coping, or suicide assessment and prevention. Other episodes of care may begin with a short-term focus, but evolve into longer-term cognitive behavioral, acceptance-based and/or meaning centered psychotherapies.

3. Measuring Value for Broad and Adaptive Psycho-Oncology Services

With the broad and adaptive approach employed with this VA oncology service, demonstrating value is challenging yet necessary. As mentioned in the Introduction, initial increased utilization of services has been demonstrated [6]. To elaborate, the authors reviewed the utilization of services with administrative clinic data for a 4-month period prior to the new health psychology position, and the for the first 4 months the position was integrated into the oncology clinics. Descriptive statistics revealed an increase in the number of Veterans engaging in health psychology, the number of sessions offered to each Veteran and total number of sessions. Furthermore, same-day services which previously were not available were utilized 4-9 times per week [6].

Table 1: Utilization of health psychology services

As the authors describe, the broad range of services aims to include Veterans who experience ambivalence about receiving behavioral or mental health, or they may experience significant side effects of cancer treatment or disease progression. Thus, symptom reduction, increased quality of life or other traditional measurement-based care may not be as applicable to these integrated services. With this in mind, a “perceptions of referring providers” survey was developed when these broad and adaptive health psychology services were initiated across the healthcare system [4,22]. This provider survey was conducted a second time during the first 4-month time-period of having the integrated, co-located health psychologist in oncology, assessing Utility, Quality and Overall Satisfaction of the health psychology services. An independent samples t-test was conducted and statistically significant increases in both service Utility and Overall Satisfaction were observed (see Figure 1: t=2.76, p=.0076 and t=2.17, p=.033). This was of particular value, given that initial perceptions were “quite satisfied”.

Figure 1: Perceptions of referring providers as a measure of value.

With the aim to sustain and continue enhancing these integrated psychosocial services in oncology, the authors continue to explore ways to demonstrate value. A small clinical dataset from Veterans engaging in a discrete episode of integrated care, who have been willing to complete a pre-post brief measure as part of clinical care has been conducted. An 8-item measure, with responses anchored in a 5-point Likert scale was drafted, drawing from several PROMIS [23] subscales. Six items represent physical, social and emotional functioning concepts, as well as two items focused on purpose-in-life and meaning. The items were selected based on face-validity while upholding brevity for Veterans so as to maintain the focus on clinical care [24]. A paired t-test for dependent samples was conducted and revealed a statistically significant change in scores (see Figure 2: t(8)=6.94, p<.001) with average pre-measure m=28.22, SD=4.71) and the average post-measure m=34.56, SD=3.05). This suggests enhanced reports of mood, functioning and purpose in life over the course of an episode of integrated psycho-oncology care. The authors reviewed the change scores (m=6.33, SD=2.74) with broader PROMIS data norms and these can be interpreted as clinically meaningful as well as statistically significant. That is, change scores of >=3, >=5 and >=10 have been viewed as clinically meaningful [23].

Figure 2: Pre and post PROMIS scores as a measure of value.

4. Clinician and Interdisciplinary Team Wellness in Oncology

The breadth of services described in this approach includes consultation for team functioning and clinician and staff wellness. Some Veterans decline services with a mental health provider, and these cases may call for a consultative role with the referring provider. The integrated psychologist may review medical records and consult with oncology nurses, physicians and other providers to clarify why a Veteran may be presenting in a particular manner. Or, Veterans may have co-occurring conditions that may not benefit from psychotherapeutic interventions such as dementia. Other consultations may explore communication and how a provider can engage more effectively with the Veteran. Importantly the Office of Mental Health and Suicide Prevention in VA has conceptualized mental health integration roles to include consultation, training and other non-direct care functions. Furthermore, this conceptualization and approach have been outlined in scholarly literature as well [5,25].

For oncology, there may be higher levels of clinician burnout historically [26] and pandemic-related strain on the healthcare workforce [27] has increased clinician well-being relevancy. Literature suggests interdisciplinary team-based care is associated positively with outcomes including patient safety, health status, patient and clinician satisfaction, as well as clinician well-being [28]. While some responses to workforce strain focus more narrowly on a single discipline or building clinician resiliency, there are other factors that deserve attention. As one research team declared, “healthcare clinicians do not have a resiliency problem”, rather, healthcare leaders can improve systems, settings, and mechanisms in which clinicians deliver care [29]. Interdisciplinary team-based care has potential to improve simultaneously patient outcomes and clinician well-being [30].

A whole health approach recognizes that members of healthcare teams need to be healthy. It further acknowledges that addressing clinician burnout or enhancing wellness on an individual level only will not be effective. Interdisciplinary teams thus need to experience whole health themselves and have system-level and leadership support to deliver care effectively. (National Academies of Sciences Engineering Medicine [31]. The VA “whole health” initiative aligns with amassing healthcare wellness literature. For example, Welp and Manser [28] provide one framework which inter-relates three foundational concepts of effective teamwork, clinician occupational well-being, and patient-safety. Smith et al. [32] employ this framework and describe evidence-based elements that serve as facilitators and barriers to implementing effective interdisciplinary teams. Given discipline-specific training and approaches, Winder et al. [33] posit interdisciplinary team-based care including psychosocial clinicians may be well-positioned to address clinician well-being, with the example of organ transplant healthcare teams.

Literature is emerging on why and how interdisciplinary team-based care can enhance both patient and clinician outcomes, although it is not yet clear whether psychosocial clinicians are a fundamental component of the teams. With the VA oncology team described here, it is noted that some wellness efforts have emerged organically among physician and nursing team members. Such informal, naturally occurring efforts need to be supported and encouraged in addition to more systematic, formalized efforts. Ethical and pro-active leadership that encourages informal as well as formal wellness efforts is also key [34]. The Table 2 below summarizes both the formal and informal wellness efforts of the authors’ oncology team.

Table 2: Oncology employee well-being.

Moving forward, the VA interdisciplinary oncology team described here plans to sustain and improve upon these wellness-related efforts, with hopes to display measurable outcomes. The integrated health psychologist in oncology serves on a wellness advocates network at this VA’s university-affiliated academic institution. This Well-Being Office similarly conceptualizes wellness broadly, at the individual, team and system levels [31]. This comprehensive approach to wellness has a goal to move beyond assessment of burnout or job satisfaction towards deployment of interventions and resources that aim to enhance well-being. For our oncology teams, we aim to continue and expand upon the well-being efforts outlined in Table 2 above, and to assess utility. Our team can continue to share best practices and information when we engage in efforts, and potentially provide descriptive statistics such as number of workshops or consultations, and numbers of participants or proportion of the oncology staff engaging. Also of interest to our interdisciplinary team is more systematic evaluation that explores clinician and staff awareness, knowledge and perceptions of wellness over time as we continue to implement well-being efforts. We aim to nurture workforce wellness in order to continue improving adaptive, bio-psychosocially-driven care to all Veterans coping with cancer.

5. Declarations

Ethics approval and consent to participate - The service delivery model approach described in this report is not a research endeavor. This report describes a clinical service that supports the VA mission and is not for the purpose of generalizable knowledge.

Consent for publication - Each author, L.Bloor, P.Tsao, S.Yentz, A.Radhakrishnan, E.Choi, and N.Ramnath respectfully provide consent for publication if this paper is accepted.

Availability of data and material - The clinical data and material described in the paper are reported in full and can be made available separately from the manuscript upon request.

Funding - As a clinical endeavor, there is no funding for the clinical service delivery model approach that is described.

Competing interests - The authors have no commercial relationships relevant to the content of this manuscript, and no conflicts of interest.

Authors’ contributions -

L.B. Wrote the main manuscript and prepared/drafted Tables 1-2, and Figures 1-2.

P.T. and S. Y. Contributed to the Introduction of manuscript, reviewed the entire manuscript, and assisted with preparing Table 1 and Figure 1.

S.Y. , E.C. and N.R. Contributed to the Team Well-Being section of the manuscript, assisted with preparing Table 2, and reviewed the entire manuscript.

A.R. reviewed the entire manuscript.

Acknowledgements

The authors would like to thank the Office of Mental Health and Suicide Prevention’s (OMHSP) initiative “Mental Health Integration into Medical Settings” in Veterans’ Affairs (VA). In addition, we would like to acknowledge the Office of Patient Centered Care & Cultural Transformation’s (OPCC&CT) support for Employee Whole Health at VA.

Clinical trial number:

Not applicable

Funding Declaration:

This service delivery model report describes clinical care and there is no Funding.

References

1. DeBar L, Benes L, Bonifay A, et al. Interdisciplinary team-based care for patients with chronic pain on long-term opioid treatment in primary care (PPACT) - Protocol for a pragmatic cluster randomized trial. Contemporary Clinical Trials 67 (2018): 91-99.
2. Li M, Kennedy EB, Byrne N, et al. Systematic review and meta-analysis of collaborative care interventions for depression in patients with cancer. Psycho-oncology 26 (2017): 573-587.
3. Faller H, Schuler M, Richard M, et al. Effects of psycho-oncologic interventions on emotional distress and quality of life in adult patients with cancer: Systematic review and meta-analysis. J Clin Oncol 31 (2013): 782-93.
4. Bloor L, Grix BE, Fisher C. Towards a better understanding of clinical health psychology services: Exploring referring clinicians’ perceptions of value. EC Psychology and Psychiatry 4 (2017): 51-60.
5. Bloor LE, Jendrusina AA, Rexer K. Broad and adaptive integrated health psychology services: Engaging BIPOC veterans in VA healthcare. Journal of Clinical Psychology in Medical Settings (2023a).
6. Bloor L, Gustitus D, Yentz S, et al. Enhancing integrated health psychology services for oncology. Association for Veterans Affairs Hematology Oncology. Poster (2023b).
7. Ansbaugh N, Shannon J, Mori M, et al. Agent Orange as a risk factor for high-grade prostate cancer. Cancer 119 (2013): 2399-404.
8. Minas TZ, Kiely M, Ajao A, et al. An overview of cancer health disparities: new approaches and insights and why they matter. Carcinogenesis 42 (2021): 2-13.
9. Kensler KH, Rebbeck TR. Cancer Progress and Priorities: Prostate Cancer. Cancer Epidemiol Biomarkers Prev 29 (2020): 267-277.
10. Chang ET, Boffetta P, Adami HO, et al. A critical review of the epidemiology of Agent Orange/TCDD and prostate cancer. European Journal of Epidemiology 29 (2014): 667-723.
11. Peterson K, Anderson J, Boundy E, et al. Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map. Am J Public Health 108 (2018): e1-e11.
12. Lawrence WR, McGee-Avila JK, Vo JB, et al. Trends in cancer mortality among black individuals in the US from 1999 to 2019. JAMA Oncol 8 (2022): 1184-9.
13. Dent KR, Szymanski BR, Kelley MJ, et al. Suicide risk following a new cancer diagnosis among Veterans in Veterans Health Administration care. Cancer Med 12 (2023): 3520-3531.
14. Berchuck JE, Meyer CS, Zhang N, et al. Association of mental health treatment with outcomes for US Veterans diagnosed with non-small cell lung cancer. JAMA Oncol 6 (2020): 1055-1062.
15. Donovan KA, Grassi L, DeShields TL, et al. Advancing the science of distress screening and management in cancer care. Epidemiology and Psychiatric Sciences. 29 (2020): e85,1-5.
16. Leung LB, Post EP, Jaske E, et al. Quality of mental health care in integrated Veterans Affairs patient-centered medical homes: A national observational study. J Gen Intern Med 34 (2019): 2700-2701.
17. Borrell-Carrio F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: Principles, practice and scientific inquiry. Ann Fam Med 2 (2004): 576-82.
18. Slade M. Implementing shared decision making in routine mental health care. World Psychiatry 16 (2017): 146-153.
19. Epstein RN, Street RL. The values and value of patient-centered care. Ann Fam Med 9 (2011): 100-103.
20. Bergerot CD, Phillip EJ, Bergerot PG, et al. Fear of cancer recurrence: What is it and what can we do about it. Amer Society of Clinical Oncology 42 (2022).
21. Winger A, Fruh EA, Holman H, et al. Making room for life and death at the same time - A qualitative study of health and social care professionals’ understanding of the concept of pediatric palliative care. BMC Palliative Care 21 (2020).
22. Alfaro A, Carlson C, Trivedi R, et al. Referring providers’ perceptions of a tele-geropsychiatry consult model of care. Geriatric Psychiatry 30 (2022): S77.
23. Cella D, Choi SW, Condon DM, et al. PROMIS® Adult health profiles: Efficient short-form measures of several health domains. Value in Health 22 (2019): 537-544.
24. Samuels S, Abrams R, Shengelia R, et al. Integration of geriatric mental health screening into a primary care practice: A patient satisfaction survey. Int J Geriatr Psychiatry 30 (2015): 539-546.
25. Stelmokas J, Cigolle C, Rochette A, et al. Integration of neuropsychological assessment and intervention services into a specialty geriatric medicine clinic. Professional Psychology: Research and Practice 53 (2022): 483-493.
26. Penson RT, Dignan FL, Canellos GP, et al. Burnout: Caring for the caregivers. The Oncologist 5 (2000): 425-434.
27. Limoges J, Mclean J, Anzola D, et al. Effects of the COVID-19 pandemic on healthcare providers: Policy implications for pandemic recovery. Health Policy 17 (2022): 49-64.
28. Shanafelt TD, Larson D, Bohman B, et al. Organization-wide approaches to foster effective unit-level efforts to improve clinician well-being. Mayo Clin Proc 98 (2023): 163-180.
29. Bloor L, Stelmokas J, Chrouser K, et al. Prioritizing the integration of biological and psychological healthcare to improve both patient outcomes and clinician well-being. Gen Hosp Psychiatry 85 (2023c): 245-246.
30. National Academies of Sciences Engineering Medicine. (NASEM). Taking action against clinician burnout; A systems approach to professional well-being. The National Academies Press. Washington DC. Committee on systems approaches to improve patient by supporting clinician well-being (2019).
31. Smith CD, Balatbat C, Cobridge S, et al. Implementing optimal team-based care to reduce clinician burnout. National Academy of Medicine. Perspectives. September 17 (2018): 2-10.
32. Welp A, Manser T. Integrating teamwork, clinician occupational well-being and patient safety: Development of a conceptual framework based on a systematic review. BMC Health Services Research 16 (2016): 281.
33. Winder GS, Clifton EG, Fernandez AC, et al. Interprofessional teamwork is the foundation of effective psychosocial work in organ transplant. Gen Hosp Psychiatry 69 (2021): 76-80.
34. Gillet N, Fouquereau E, Coillot H, et al. The effects of work factors on nurses’ job satisfaction, quality of care and turnover intensions in oncology. Journal of Advanced Nursing 74 (2018): 1208-1219.