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Table 1 Description of the core services and core processes of the isPO care program

From: Integrated, cross-sectoral psycho-oncology (isPO): a new form of care for newly diagnosed cancer patients in Germany

Domain of services (care area) Care step/ allocation criteriaa Calculated number of services within 12 months Core service functions/
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
  1. aThe allocation criteria are described in the paragraph: patient allocation and follow up within the isPO care program
  2. Abbreviations: HADS Hospital Anxiety and Depression Scale (HADS) [64PSR Psychosocial Risk questionnaire (German: Psychosozialer Risikofragebogen) [65]