Domain of services (care area) | Care step/ allocation criteriaa | Calculated number of services within 12 months | Core service functions/ criteria | Description of the core service, responsibilities and performances |
---|---|---|---|---|
Overall objective of the isPO care program | Empowerment of patients to actively participate in their cancer therapy and aftercare while maintaining the highest possible quality of life | |||
Case-management | step 0 / all enrolled patients | up to 20 | coordination | Coordination and organization (care and case management: scheduling, correspondence, meetings, reporting, quality assurance, service accounting etc. at patient and organizational level) Contact person for disease-related and/or treatment-related psychosocial questions in the cancer continuum, especially for patients who are not treated at levels 2 and 3 |
intake | Ensuring the first contact with the patient shortly after the medical referral, in-depth information and enrolment of the patient | |||
assessment | Collection of all necessary information (among other things implementation of the screening) at intake | |||
planning/linking | Documentation of test results in CAPSYS-docu and assignment of the patient to the care providers according to the automated criteria-based data evaluation within CAPSYS-docu (see Fig. 4 and 5) | |||
monitoring | Monitoring of the path-guided course of care using CAPSYS-assist, information from the treating physicians as well as the patients on the screening results by means of automatically generated CAPSYS-reports, documentation for service billing, contact person for patients and the service provider team on organizational questions | |||
re-/evaluation | Data collection and documentation in CAPSYS-docu on T2 (4th month of treatment) and T3 (12th month, end of treatment); information from the treating physicians as well as the patients on the screening results by means of automatically generated CAPSYS reports | |||
isPO-oncoguide | step 1 / all enrolled patients | up to two | orient | Provision of information and explanations to promote patient self-help resources by a trained volunteering person previously ill with cancer |
inform | Information on community-based psychosocial support services, contacts to non-profit self-help groups, services offered by statutory health insurance companies and internet addresses of non-profit cancer societies and other independent and evidence-based sources of information and support, including the delivery of written information material to the patient | |||
explain | Provision of patient information on the basis of a self-commitment declaration signed by the trained person (in particular: empathetic and sympathetic attitude, listening to the patient, no medical or therapy-related or legal advice, restraint should the patient request personal advice, not holding their own medical history as a standard, complying with the head of the psycho-oncological care unit) | |||
agree | Documentation on whether the patient agrees to having experienced the information received as helpful | |||
document | Assessment of the personally felt quality of the information meeting with indication of a possible further need for care on the part of the patient (note: the documentation in CAPSYS-docu is done by a case manager) | |||
Psychosocial care | step 2 / HADS-G ≥ 15/ PSR ≤ 3 | up to six | orient | Accompaniment of the patient during their cancer disease and cancer therapy with the aim of improving their individual skills in coping with symptoms and treatment, as well as their short and longer-term physical and psychosocial consequences, including the life changes necessary to live with the protracted disease |
assessment | Assessment of the severity of the patient’s psychosocial problems, based on the results of a questionnaire and a half-structured interview and creation of a psychosocial self-help plan | |||
advice | Consultation on necessary care needs based on the psychosocial self-help plan and preparation of a priority list of psychosocial care needs | |||
agree | Joint prioritization of the psychosocial issues that need to be dealt with first | |||
assist | Determination of the professional support needs of a patient based on the assessed severity of the problem Low need of support: the patient receives information or advice on how to independently carry out the interventions defined in the help plan High need of support: The patient is actively supported and guided by the psychosocial expert or the service provider implements aspects of the help plan for instead of with the patient | |||
arrange | Accompanying support of the patient in the implementation of their self-help goals (e.g. internet research, discussions with treating physicians or other persons, provision of documents for applications to authorities) | |||
Psycho-oncological care | step 3a / HADS-G ≥ 15 | up to 14 | orient | Accompaniment of the patient during their cancer disease and cancer therapy with the aim of the following: reduction of psychological burden; emotional stabilization; improvement of self-management in coping with acute physical symptoms, treatment related or acute states of emotional dysregulation; coping with the short and longer-term physical and psychological consequences of cancer, including the life changes necessary for living with a protracted disease |
diagnose | Assessment and classification of the severity of the patient's psychological burdens based on the results of the screening assessment at intake and an initial psycho-oncological examination. In particular, specification of the nature and severity of the emotional distress or mental disorder on the basis of available information | |||
indicate | Selection of a suitable psychotherapeutic intervention for the current problem of a patient. In the continuum of a bio-medical cancer therapy, psychotherapeutic diagnostic and therapeutic decisions may repeatedly become necessary. In the care area on step 3a/3b CAPSYS-assist offers decision support for finding a possible indication based on questionnaire data, anamnesis data, protocol data etc | |||
intervene | Selection and implementation of one of 25 treatment modules described in the isPO manual for the care areas at step 3a/b | |||
evaluate | Continuous evaluation of the achievement of psychotherapeutic goals | |||
Complex care | step 3b / HADS-G ≥ 15/ PSR ≥ 6 | up to 14 as in step 3a and up to 4 as in step 2 | orientate | Accompaniment of the patient during their cancer disease and cancer therapy as in 3a Psycho-oncological treatment as in care area of step 3a; psychosocial care as in care area of step 2, following a regulation by the psychotherapist |