CANCER CARE FOR THE WHOLE PATIENT

MEETING PSYCHOSOCIAL HEALTH NEEDS

Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting

Board on Health Care Services

Nancy E. Adler and Ann E. K. Page, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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CANCER CARE FOR THE WHOLE PATIENT MEETING PSYCHOSOCIAL HEALTH NEEDS Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting Board on Health Care Services Nancy E. Adler and Ann E. K. Page, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. N01-OD-4-2139 between the National Academy of Sciences and the National Institutes of Health. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. Library of Congress Cataloging-in-Publication Data Cancer care for the whole patient : meeting psychosocial health needs / Commit- tee on Psychosocial Services to Cancer Patients / Families in a Community Setting, Board on Health Care Services ; Nancy E. Adler and Ann E.K. Page, editors. p. ; cm. Includes bibliographical references and index. ISBN 978-0-309-11107-2 (hardcover) 1. Cancer—Patients—Care—United States. 2. Cancer—Patients—Services for—United States. 3. Cancer—Social aspects—United States. I. Adler, Nancy E. II. Page, Ann (Ann E. K.) III. National Institute of Medicine (U. S.) Committee on Psychosocial Services to Cancer Patients / Families in a Community Setting. [DNLM: 1. Neoplasms--psychology. 2. Neoplasms—therapy. 3. Counseling— methods. 4. Needs Assessment. 5. Psychology, Medical—methods. 6. Stress, Psychological—complications. QZ 200 C2151208 2008] RA645.C3C332 2008 362.196′994—dc22 2008000292 For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2008 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: Institute of Medicine (IOM). 2008. Cancer care for the whole patient: Meeting psychosocial health needs. Nancy E. Adler and Ann E. K. Page, eds. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON PSYCHOSOCIAL SERVICES TO CANCER PATIENTS/FAMILIES IN A COMMUNITY SETTING NANCY E. ADLER (Chair), Professor of Medical Psychology and Vice-Chair, Department of Psychiatry, University of California, San Francisco RHONDA J. ROBINSON-BEALE, Chief Medical Officer, United Behavioral Health, Van Nuys, California DIANE S. BLUM, Executive Director, CancerCare Inc., New York PATRICIA A. GANZ, Professor, UCLA Schools of Medicine and Public Health and Jonsson Comprehensive Cancer Center, Los Angeles SHERRY GLIED, Professor and Chair, Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York JESSIE GRUMAN, President, Center for the Advancement of Health, Washington, DC MICHAEL HOGE, Professor of Psychology (in Psychiatry), Yale University School of Medicine, New Haven JIMMIE C. HOLLAND, Wayne E. Chapman Chair in Psychiatric Oncology, Memorial Sloan-Kettering Cancer Center, New York MELISSA M. HUDSON, Director, After Completion of Therapy Clinic, St. Jude Children’s Research Hospital, Memphis SHERRIE KAPLAN, Associate Dean for Clinical Policy and Health Services Research, University of California at Irvine School of Medicine ALICIA K. MATTHEWS, Associate Professor, University of Illinois, Chicago RUTH MCCORKLE, Florence S. Wald Professor of Nursing and Director, Center for Excellence in Chronic Illness Care, Yale University School of Nursing, New Haven HAROLD ALAN PINCUS, Vice Chair, Department of Psychiatry, College of Physicians and Surgeons, Columbia University and Director of Quality and Outcomes Research, New York-Presbyterian Hospital LEE S. SCHWARTZBERG, Medical Director, The West Clinic, Memphis EDWARD H. WAGNER, Director, Group Health Cooperative W.A. McColl Institute for Healthcare Innovation Center for Health Studies, Seattle TERRIE WETLE, Associate Dean of Medicine for Public Health and Public Policy, Brown Medical School, Providence Study Staff ANN E. K. PAGE, Study Director and Senior Program Officer, Board on Health Care Services 

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JASON F. LEE, Christine Mirzayan Science and Technology Policy Graduate Fellow (9/06–12/06) RYAN PALUGOD, Research Assistant WILLIAM MCLEOD, Senior Research Librarian EVALYNE BRYANT-WARD, Financial Associate Health Care Serices Board MICHELE ORZA, Acting Director CLYDE BEHNEY, Acting Director (5/06–12/06) DANITZA VALDIVIA, Administrative Assistant i

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with pro- cedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: TERRY BADGER, College of Nursing, The University of Arizona, Tucson, Arizona BRUCE COMPAS, Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee RONALD EPSTEIN, Rochester Center to Improve Communication in Health Care, University of Rochester School of Medicine and Dentistry, Rochester, New York STEWART FLEISHMAN, Cancer Supportive Services, Continuum Cancer Centers of New York: Beth Israel and St Luke’s- Roosevelt, New York PAUL JACOBSEN, Health Outcomes and Behavior Program, Moffitt Cancer Center, and Departments of Psychology and Interdisciplinary Oncology, University of South Florida, Tampa, Florida ii

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iii REVIEWERS SARAH HOPE KAGAN, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania WAYNE KATON, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington PAULA KIM, Translating Research Across Communities (TRAC), Fallbrook, California BARBARA MURPHY, Hematology/Oncology Division, Vanderbilt University, Nashville, Tennessee LEE NEWCOMER, United HealthCare Corporation, Edina, Minnesota KEVIN OEFFINGER, Program for Adult Survivors of Pediatric Cancer, Departments of Pediatrics and Medicine, Memorial Sloan-Kettering Cancer Center, New York PAUL RUDOLF, Arent Fox LLP, Washington, DC EDWARD SALSBERG, Center for Workforce Studies, Association of American Medical Colleges, Washington, DC LIDIA SCHAPIRA, Gillette Center for Breast Cancer, Massachusetts General Hospital Cancer Center, Boston, Massachusetts JOSEPH SIMONE, Simone Consulting, Atlanta, Georgia KATHRYN SMOLINSKI, Association of Oncology Social Work, Ypsilanti, Michigan SHELLY TAYLOR, Department of Psychology, University of California, Los Angeles Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by JOHANNA T. DWYER, Friedman School of Nutrition Science and Policy, Tufts University School of Medicine and Frances Stern Nutrition Center, Tufts-New England Medi- cal Center and RICHARD G. FRANK, Department of Health Care Policy, Harvard Medical School. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Foreword Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs is an important new addition to a series of Institute of Medicine reports that prescribe actions needed to improve the quality of U.S. health care. Following in the footsteps of Crossing the Quality Chasm: A New Health System for the 21st Century, Improing the Quality of Health Care for Mental and Substance Use Conditions, and other reports in the Quality Chasm series, this report takes another step forward and attends to the psychological/behavioral and social problems that can accompany serious illness. Although the report examines psychosocial health needs from the perspective of individuals with a diagnosis of cancer, the recommendations in this report are also relevant to clinicians, other health care providers, payors, and quality oversight organizations concerned with the care of individuals with other serious and complex medical conditions. Research has amply demonstrated the significance of psychosocial fac- tors to health and health care. Incorporating evidence from studies of psychological and social determinants of health, clinical research on the ef- fectiveness of psychological and behavioral services, health services research on the effective organization and delivery of health care, and biologic re- search in fields such as psychoneuroimmunology, this report documents the consequences of failing to meet psychosocial health needs. Importantly, it translates scientific research findings into practical applications for improv- ing the quality of cancer care. The result is a new standard of care for cancer care, a standard that in- corporates acknowledgement, treatment, and management of psychosocial ix

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x FOREWORD problems. While this report deals specifically with cancer patients, the les- son to improve the quality of care by focusing on the psychosocial needs of the whole patient will apply as well to many other conditions. Harvey V. Fineberg, MD, PhD President, Institute of Medicine

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Preface Americans place a high premium on new technologies to solve our health care needs. However, technology alone is not enough. Health is determined not just by biological processes but by people’s emotions, be- haviors, and social relationships. Sadly, these factors are often ignored or not defined as part of health care. Many doubt their importance and dismiss the evidence as being based on “soft science.” Even when acknowledged, they are often seen as ancillary rather than central to care. High and es- calating health care costs fuel the argument that addressing such concerns is a luxury rather than a necessity. These views fly in the face of evidence of the important role that psychosocial factors play in disease onset and progression, not to mention their impact on people’s ability to function and maintain a positive quality of life. As this report documents, a growing body of scientific evidence demonstrates that psychological and social prob- lems can prevent individuals from receiving needed health care, complying with treatment plans, and managing their illness and recovery. Another recent Institute of Medicine report1 states that the purpose of health care is to “continuously reduce the impact and burden of illness, injury, and dis- ability, and . . . improve . . . health and functioning.” To accomplish this, good quality health care must attend to patients’ psychosocial problems and provide services to enable them to better manage their illnesses and underly- ing health. To ignore these factors while pouring billions of dollars into new 1 IOM. 2006. Performance measurement: Accelerating improement. Washington, DC: The National Academies Press. xi

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Acknowledgments The Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting thanks the many individuals and organizations who helped with its search for effective psychosocial health services and models for their effective delivery, and provided key information on the health care workforce and a number of policy issues. We gratefully acknowledge Carol L. Alter, MD, at the TEN Project and Georgetown University; M. Brownell Anderson, Robert Eaglen, PhD, and Robby Reynolds at the Association of American Medical Colleges; Neeraj K. Arora, PhD, at the National Cancer Institute; Terry Badger, PhD, RN, FAAN, at the University of Arizona Col- lege of Nursing; Cynthia Belar, Diane M. Pedulla, JD, Kimberley Moore, and Wendy Williams at the American Psychological Association; Thomas P. Beresford, MD, at the Department of Veterans Affairs Medical Center, Uni- versity of Colorado Health Sciences Center; Joyce Bichler, ACSW, of Gilda’s Club Worldwide; Elise J. Bolda, PhD, of The Robert Wood Johnson Foun- dation’s Community Partnerships for Older Adults program at the Univer- sity of Southern Maine; Cheryl Bradley, MSW, and Carson J. Pattillo, MPH, at The Leukemia & Lymphoma Society; William S. Breitbart, MD, and Andrew J. Roth, MD, at Memorial Sloan-Kettering Cancer Center; E. Dale Collins, MD, at Dartmouth Hitchcock Medical Center; Lisa Corchado and Rebecca Yowell at the American Psychiatric Association; Bridget Culhane, RN, MN, MS, CAE, and Gail A. Mallory, PhD, RN, CNAA, at the Oncol- ogy Nursing Society; Charles Darby at the Agency for Healthcare Research and Quality; Kim Day at the Board of Oncology Social Work Certification; Stephen DeMers, EdD, at the Association of State and Provincial Psychol- ogy Boards; Molla S. Donaldson, DrPH, MS, at the American Society of x

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xi ACKNOWLEDGMENTS Clinical Oncology; Patricia Doykos Duquette, PhD, at the Bristol-Myers Squibb Foundation; Peter D. Eisenberg, MD, at California Cancer Care; Ronit Elk, PhD, Katherine Sharpe, Nancy Single, PhD, Michael Stefanek, PhD, and Marcia W. Watts, at the American Cancer Society; Stewart Fleishman, MD, at Continuum Cancer Centers of New York: Beth Israel and St Luke’s-Roosevelt; Barbara Fleming, MD, Paulette Mehta, MD, Thakor G. Patel, MD, MACP, and Shakaib Rehman, MD, FACP, at the Veterans Health Administration; Bill Given at the Charles and Barbara Given Fam- ily Care Program, Michigan State University; Mitch Golant, PhD, at The Wellness Community; Marcia Grant, RN, DNSc, FAAN, and Betty Ferrell, PhD, FAAN, at the City of Hope National Medical Center; Ethan Gray and Kathryn M. Smolinski, MSW, at the Association of Oncology Social Work; David Gustafson at the University of Wisconsin; Karmen Hanson, MA, at the National Conference of State Legislatures; John E. Hennessy, Nancy Washburn, Sandy Simmons, MSN, ARNP-C, AOCN, and Barbara Adkins, MS, ARNP-BC, AOCNP, at Kansas City Cancer Center; Joanne Hilden, MD, at St. Vincent Children’s Hospital in Indianapolis, Beverly Lange, MD, at Children’s Hospital of Philadelphia, and Missy Layfield, Chair of the Patient Advocacy Committee, all of the Children’s Oncology Group; Caroline Huffman, LCSW, MEd, at the Lance Armstrong Foundation; Frits Huyse, MD, PhD, at the University Medical Center Groningen, The Neth- erlands; Paul B. Jacobsen, PhD, Nancy W. Newman, LCSW, and Donna M. Cosenzo at the H. Lee Moffitt Cancer Center and Research Institute; Bar- bara L. Jones, PhD, MSW, at the Association of Pediatric Oncology Social Workers; Nancy Kane, at the Payson Center for Cancer Care; Ernest Katz, Aura Kuperberg, Kathleen Meeske, PhD, Kathleen S. Ruccione, MPH, RN, FAAN, and Octavio Zavala, at the Children’s Hospital Los Angeles; Anne E. Kazak, PhD, ABPP, at the University of Pennsylvania School of Medicine; Emmett B. Keeler, PhD, at the RAND Corporation; Murray Kopelow, MD, at the Accreditation Council for Continuing Medical Education; Wolfgang Linden, PhD, at the University of British Columbia, Canada; Karen Lla- nos at the Center for Health Care Strategies, Inc.; Kate Lorig, RN, DrPH, at Stanford University; Matthew J. Loscalzo, MSW, at the Rebecca and John Moores UCSD Cancer Center; Richard P. McQuellon, PhD, at the Wake Forest University Baptist Medical Center; Stephen Miller, MD, at the American Board of Medical Specialties; Moira A. Mulhern, PhD, at Kansas City Turning Point; Todd Peterson at the American Nurse Credentialing Center; Gail Pfeiffer, RHIA, CCS-P, at the Cleveland Clinic; William Pirl, MD, at the Massachusetts General Hospital Cancer Center; Paul A. Poni- atowski at the American Board of Internal Medicine; Craig Ravesloot, PhD, at the University of Montana; Christopher J. Recklitis, PhD, MPH, at the Dana-Farber Cancer Institute; Karen Robitaille at Yale University School of Medicine; Sarah Rosenbloom, PhD, at Northwestern University Feinberg

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xii ACKNOWLEDGMENTS School of Medicine; Thomas J. Smith, MD, at Virginia Commonwealth University’s Massey Cancer Center; Joan Stanley at the American Associa- tion of Colleges of Nursing; Annette Stanton, PhD, at the University of California, Los Angeles; James Stockman, MD, and Jean Robillard, MD, at the American Board of Pediatrics; Ellen L. Stovall of the National Coali- tion for Cancer Survivorship; Bonnie Strickland at the Health Resources and Services Administration, Department of Health and Human Services; Thomas B. Strouse, MD, FAPM, DFAPA, at the Samuel Oschin Compre- hensive Cancer Institute, Cedars Sinai Medical Center; Phyllis Torda at the National Committee for Quality Assurance; Douglas Tynan, PhD, at the American Board of Professional Psychology; Ginny Vaitones at the Board of Oncology Social Work Certification; Garry Welch, PhD, at Baystate Medi- cal Center; Pamela R. West, PT, DPT, MPH, at the Centers for Medicare & Medicaid Services; Nancy Whitelaw at the National Council on Aging; Rodger Winn at the National Quality Forum; and James R. Zabora, PhD, of the National Catholic School of Social Service, Catholic University of America. In addition, we thank M. Robin DiMatteo, Kelly B. Haskard, and Summer L. Williams, all at the University of California, Riverside, and Sheldon Cohen and Denise Janicki-Deverts, both at Carnegie Mellon Uni- versity, for their papers, respectively, on “Effects of Distressed Psychological States on Adherence and Health Behavior Change: Cognitive, Motivational, and Social Factors” and “Stress and Disease.” These excellent papers helped the committee think through and quickly review a growing body of evidence documenting the health effects of psychological and social stressors. We also offer many thanks to Maria Hewitt, DrPH, formerly with the National Cancer Policy Board at the Institute of Medicine, for her gener- ous help throughout the initial stages of this study. Rona Briere of Briere Associates, Inc., provided expert copy editing, and Alisa Decatur excel- lent proofreading and manuscript preparation assistance. And as always, Danitza Valdivia, administrative assistant to the Board on Health Care Services, provided ever-ready and gracious assistance regardless of the task or timeline. Finally, we thank our project officers at the National Institutes of Health. Susan D. Solomon, PhD, senior advisor in the Office of Behavioral and Social Sciences Research, and project officer at the beginning of this study, skillfully launched the study and shaped its parameters. Julia H. Rowland, PhD, director of the National Cancer Institute’s Office of Cancer Survivorship, served as project officer for the duration of the study, and provided ongoing support, thoughtful and expert guidance, and generous assistance in identifying and securing needed resources.

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Contents SUMMARY 1 1 THE PSYCHOSOCIAL NEEDS OF CANCER PATIENTS 23 The Reach of Cancer, 24 Cancer-Induced Physical Stressors, 26 Psychosocial Problems, 30 Obstacles to Managing Psychosocial Stressors, 37 Purpose, Scope, and Organization of This Report, 42 2 CONSEQUENCES OF UNMET PSYCHOSOCIAL NEEDS 51 Psychosocial Stressors and Their Effects on Patients, 53 Alterations in Body Functioning Due to Stress, 61 Adverse Effects on Families and the Larger Community, 67 Conclusions, 68 3 PSYCHOSOCIAL HEALTH SERVICES 81 A Diversity of Services, 82 Evidence of Effectiveness, 83 Ready Availability of Key Services, 108 4 A MODEL FOR DELIVERING PSYCHOSOCIAL HEALTH SERVICES 153 Effective Delivery of Psychosocial Health Care, 153 A Unifying Model for Care Delivery, 159 xix

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xx CONTENTS A Recommended Standard for Care, 199 ANNEX 4-1: Empirically Validated Models of and Clinical Practice Guidelines for the Effective Delivery of Psychosocial Health Services, 201 5 IMPLEMENTING THE STANDARD OF CARE 219 Approaches to the Delivery of Psychosocial Health Services, 220 Recommendations, 237 6 PUBLIC- AND PRIVATE-SECTOR POLICY SUPPORT 241 Supports for and Constraints on Interventions to Deliver Psychosocial Services, 242 Supports for and Constraints on Service Availability, 260 Use of Performance Measurement to Improve the Quality of Psychosocial Health Care, 269 Conclusions and Recommendations, 274 7 PREPARING THE WORKFORCE 283 A Large and Diverse Workforce, 284 Workforce Education in Biopsychosocial Approaches to Care, 288 Educational Barriers to Psychosocial Health Care, 309 Conclusions and Recommendation, 319 8 A RESEARCH AGENDA 329 A Taxonomy and Nomenclature for Psychosocial Health Services, 329 Effectiveness and Health Services Research, 330 Report Evaluation, 338 APPENDIXES A COMMITTEE MEMBER BIOGRAPHIES 343 B STUDY METHODS 353 C RECOMMENDATIONS FROM PRIOR SELECTED REPORTS 379 INDEX 409

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Tables, Figures, and Boxes TABLES S-1 Psychosocial Needs and Formal Services to Address Them, 10 3-1 Psychosocial Needs and Formal Services to Address Them, 82 3-2 Selected Nationwide Sources of Free Patient Information on Cancer and Cancer-Related Services, 109 3-3 Selected Psychosocial Services (Other Than Information) Available at No Cost to Individuals/Families with Cancer, 118 4-1 Models for Delivering Psychosocial Health Services and Their Com- mon Components, 155 4-2 Comparison of Needs Assessment Instruments, 174 4-3 Comparison of Domain Item Distribution Across Needs Assessment Instruments, 188 5-1 Distribution of Adult Ambulatory Cancer Care Visits by Site of Visit, Physician Specialty, and Clinic Type, United States, 2001– 2002, 221 6-1 Examples of Policy Support for Interventions to Deliver Psychosocial Health Care, 244 6-2 Psychologist Claims Paid by Medicare, 2003–2005, by Type of Intervention, and Comparison 2005 Claims Paid for All Provider Types, 253 6-3 Some Availability of Psychosocial Services in Health and Human Services Sectors and from Informal Supports, 262 6-4 Performance Measures of Psychosocial Health Care Adopted/ Endorsed by Leading Performance Measurement Initiatives as of July 2007, 271 xxi

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xxii TABLES, FIGURES, AND BOXES 7-1 Estimates of the Supply of Selected Physician Types Available to Pro- vide or Ensure the Provision of Psychosocial Health Services, 285 7-2 Estimates of the U.S. Supply of Selected Nonphysician Providers Available to Provide or Ensure the Provision of Psychosocial Health Services, 286 B-1 Serial Search Strategies, 362 B-2 Psychosocial Needs and Formal Services to Address Them, 364 C-1 Recommendations Addressing Psychosocial Services, 379 C-2 Other Recommendations of Potential Relevance, 394 FIGURES S-1 Model for the delivery of psychosocial health services, 8 1-1 Cancer care trajectories, 25 4-1 Model for the delivery of psychosocial health services, 158 BOXES 5-1 A Letter to My Patients, 231 5-2 Example of Patient Handout on Sources of Help in Managing Cancer and Its Treatment, 233 5-3 Patient Comments on the Usefulness of CancerCare’s Telephone Edu- cation Workshops, 234 6-1 Medicare Care Coordination Demonstration Projects, 259 7-1 LCME Undergraduate Medical Education Accreditation Standards That Address Psychosocial Health Services, 290 7-2 General Principles of Gender, Ethnic, and Behavioral Considerations for USMLE Step 1, 292 7-3 General Competencies of the ACGME Outcome Project, 293 7-4 Selected NLNAC Core Competencies Addressing Psychosocial Health Services, 298 7-5 Selected Core Competencies from The Essentials of Baccalaureate Education, 299 7-6 Selected C-Change Psychosocial Core Competencies, 314 B-1 Key Factors Associated with Successful Dissemination and Adoption of Innovations, 368

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CANCER CARE FOR THE WHOLE PATIENT MEETING PSYCHOSOCIAL HEALTH NEEDS

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