Rehabilitation Evaluation of Cancer Related Cognitive Dysfunction: The Courage Kenny Rehabilitation Institute STAR ProgramNancy Hutchison, MD

July 30, 2016STAR Connection Conference

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• Describe the MD PMR evaluation for Cancer-Related Cognitive Dysfunction (CRCD)

• Explain the Multifactor Model of cognitive impairment and why it is important for treatment of CRCD

• Describe an Occupational Therapy based CRCD treatment program

• Describe the challenges in reimbursement for therapy services for CRCD

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Course Objectives

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• Focused history– Focal neurologic deficit or high risk for metastatic

disease: imaging– Cancer treatment history– Brain injury/learning history– Nature of impairments

• Attention/multitasking• Unable to complete tasks• Word finding difficulty• Memory• Needing prompts/reminders• Thinking processes slow• Job or functional performance noticeably suffering

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NCCN Survivorship Guidelines Cognition

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• Assessment of Contributing Factors– Medications– Emotional distress

• Depression• Anxiety• Financial• Social

– Symptom burden• Pain• Fatigue• Insomnia

– Comorbidities– Use of alcohol and other substances that alter cognition

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NCCN Guidelines Cognition

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• Memory

• Attention

• Speed of processing

• Word finding

• Executive functioning

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Main Symptoms of CRCD

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• Proinflammatory cytokines produced by the tumor

• Neurotoxic effects of chemotherapy agents– Directly or by inducing cascade of neurotoxic pro-

inflammatory cytokines

• Fatigue• Depression• Stress• Pain• All of the above in some combination

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Possible mechanisms for CRCD

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• Direct training attempting to remediate damaged neurocircuitry

• Psycho-educational approaches to improve self management

• Sometimes in combination with – Cognitive Behavioral Therapy

– Mindfulness Based Stress Reduction

– Exercise interventions

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Strategies for Treatment

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• High-repetition of computer-based exercises over weeks or months.

• Studies on breast cancer patients with computer-based training for – memory (Von Ah et al., 2012)– speed of processing (Von Ah., 2012)– executive functions (Kesler et al., 2013)– multiple cognitive domains (Damholdt et al., 2016)

• Statistically significant improvements on neurocognitive tests and self-reported cognitive function as compared to controls

• Carry over to daily life? Adherence to exercises long term?

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Direct Cognitive Retraining

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• Help cancer survivors improve functioning by expanding their repertoire of cognitive strategies via a limited number of group or individual sessions.

• Studies on cancer survivors with PsychoEducational Interventions:– Memory and Attention Adaptation Training (MAAT; Ferguson et al.,

2012) • improvements in quality of life and verbal memory, but not in self-

reported cognitive complaints, fatigue, depression, or anxiety – Group-based cognitive rehabilitation

• improvements in self-reported cognitive function and neurocognitive measures of attention (Cherrier et al., 2013) or verbal memory (Ercoli et al., 2015).

• Ercoli and colleagues (2015) did not measure treatment effects on fatigue, mood, or stress

• Cherrier and colleagues (2013) found no treatment effect on these domains on fatigue, mood, stress

• Group vs Individual? Motivation for tasks chosen?

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Psychoeducational Approaches to CRCD

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• Developed for individuals with a diagnosis of cancer

• Self Report• 4 areas addressed:

1. Perceived Cognitive Impairments2. Reports of Impairment by others3. Perceived Cognitive Abilities4. Quality of Life

The higher the score the betterCurrently no standardized way to interpret data

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FACT-COG

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Four scales:

• Perceived cognitive impairments: 20 items

• Perceived cognitive abilities: 9 items

• Comments from Others: 4 items

• Impact on quality of life: 4 items

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FACT-COG Version 3

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• The multi-factor model views cognitive changes after cancer treatment as not fixed but varying from moment-to-moment.

• It reflects inefficient cognitive abilities plus adverse effects on functioning from personal factors and situational factors.

• As people see little successes toward their own goals, they are motivated to continue to change

• Reinforces principles of successful behavior change– “The Why” transforms a chore ("extrinsic motivation")

into a gift ("intrinsic motivation") that individuals want to keep giving themselves.” Michelle Segar, PhD

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Multifactor Model

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• One group, pre-post intervention

• 28 women at least 3-18 months post chemo and rad (completion treatment) for breast cancer

• Measurements– Canadian Occupational Performance Measure

(function in everyday life)

– FACT Cog (self report measure of cognitive function)

– Other measures of anxiety, depression, fatigue, neuropsychologic tests, self efficacy

– Satisfaction Survey

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CKRI Focus Forward Study: Method

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• Statistically significant pre-post improvements in occupational performance and self-efficacy– largest effect sizes for tasks participants identified as important to them.

• Statistically significant improvements in interfering factors (anxiety, stress, depression, fatigue). – Of the 8 participants whose Beck Depression Inventory-II score was in the

moderate/severe range at pretest (>19), 5 were in the normal/mild range at posttest.

– Composite Fatigue Symptom Inventory (FSI) score was not significant but the amount of change in the FSI interference score was significant.

• Participants improved in all dimensions FACT-Cog • Statistically significant improvements pre-post in 3 neurocognitive

measures – Trails A– Word fluency– Total recall domain of the Hopkin Verbal Learning Test-Revised (HVLT-R).

• Participants were very satisfied with Focus Forward– mean overall satisfaction score of 9.4 out of 10.

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Focus Forward study: Submitted for publication

Occupational Therapy based Cognitive Rehabilitation Program

Joette Zola, OTR/L, STAR/T

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• Ensures that Star Cognitive Cancer Program is provided in a consistent manner across sites

• Evidenced-Based or guided protocol– Ongoing literature review

• Recommendations for treatment frequency and duration

• Billing Guidelines

• Reviewed and updated/ adapted annually to bi-annually if indicated

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Best Practice Guidelines

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• Fact Cog is the program outcome measure– Completed at initial assessment– Again towards the end of treatment when majority of

progress has been achieved

• Structured interview using the COPM and the philosophy of MI– What their life was like prior to diagnosis– How they experienced their brains prior to diagnosis– Top 5 challenges in life roles or symptoms they would like to

work on at this point in their acute care– Factors; both personal and situational that are affecting

thinking and life role performance

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Assessment

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I just couldn’t figure out how to organize my

daughter’s scrapbook

I drove home and wondered how many

stop signs I went through

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• Multi Factor Model

• Awareness

• Human Information Processing Theory

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3 Core Concepts

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When individuals have cancer and/ cancer treatment,

a person’s disability is determined by:

– Brain factors

– The effects of problematic factors both personal and situational

• Montgomery, 1995

• An individuals cognitive function varies from moment to moment & from situation to situation.

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Multi-factor Model of Function

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PERSONAL FACTORS:– Fatigue

– Arousal/Tension

– Physical symptoms • (i.e. headaches, nausea)

– Negative thoughts

SITUATIONAL FACTORS:– External environmental

distracters

– Multi-task demands

– Information processing demands

• Montgomery 1995

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Multi Factor Model of Function

Client Worksheet

My Brain Factors:StrengthsInefficiencies

My Personal Factors

My Situational Factors

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Distractions from physical

symptoms (fatigue & pain)

Distractions from emotional

symptoms (stress, fear, depression)

Situational demands of everyday life

Pathophysiology

Thinking abilities

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Crosson’s Awareness Hierarchy(Crosson, et.al. 1989)

There are 3 levels:

• Intellectual: Aware there is a change but feel it is not in your control (This cancer has ruined my memory)

• Emergent: Recognizing problems when they occur

(“There I go again, I am too tired and nauseous to remember anything.”)

• Anticipatory: Anticipates a potential problem and has a

strategy they can use to avoid problems

(“I know that on weeks I have chemo I am more fatigued and apt to forget

things so I only schedule important meetings on non-chemo weeks.”)

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Awareness is a Process

• Some people are limited in their ability to develop awareness at an organic level

– (consider the type of cancer, tumor location, prognosis and impairment level)

– Sometimes the client is the family

• Some people are limited in their ability to develop awareness at a psychological level

• It is very important to be aware of what your client’s barriers are and normalize resistance to change.

• Realize the hierarchy is not rigid, we go back and forth depending on the focus and our personal/ situational factors

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CROSSON’S AWARENESS

ANTICIPATORY

EMERGENT

INTELLECTUAL

ACCEPTANCE

RESISTANCE

DENIAL/ UNAWARE

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Anticipatory Awareness helps clients learn how to manage themselves via behavior changes and strategies

Area of concern Times this occurs Strategy that could

help

Forgetting to take

medications

Good in the am but

forget at noon

Post a sign in kitchen

Set a cell phone

alarm

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Human Information Processing 1001

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Pain

To do FatigueShort-term sensory

registers

Working memory Long term memory

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Implications for cancer**ADD REFERENCE FOR ENCODING ARTICLE

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Pain

To do FatigueShort-term sensory

registers

Working memory Long term memory

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Main Modules in Program

• Energy Management (modified since the study)

• Time Management

• Information Management

• Attention

• Communication (added since the study)

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Energy Management

• Budget

• Taking breaks

• Activity template

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Know their current minimum balance

Recognize that they will get hit with penalties if they go below that balance

Practice putting “deposits” in through out the day

Increase their budget through exercise

If they decide to “blow the budget”; Be ready to pay the fees

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Energy Budget

Checking Account

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Taking Breaks Intentionally

• Reflect on 3 types of Fatigue:– Physical– Cognitive– Emotional

• Generate a list of 10 possible breaks

• Identify times of day that they need to pause and consider their status

• Use stop notes and / timers

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Activity Template

Can be used to:

1. Re-establish lost routines

2. Re-evaluate routines to ensure they are realistic and sustainable

3. Plan a routine that paces tasks throughout the day/ week

Task Sun Mon Tues Wed Thurs Fri Sat

Self-care

Home

Others

Social

Medical

Work

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Time Management

• Task Categorization:– To Do’s– Projects – Problems

• Prioritization– Including self care

• Divide and Conquer– Help them identify roles or tasks that someone else

can manage for a while.

• Structured Problem-solving

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Time Management

Key is understanding what the task requires:

Determine the type of task

TO DO Single item that needs to be completed

Project Multiple tasks that need to be completed to

reach an end goal

Problem Need to determine a solution and then

complete the TO Do or Project.

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To Do’s = Prioritization

Franklin Covey

A: Urgent & Important

Just Do It , Delegate to

Someone you Trust

B: Not Urgent but Important

Plan for it

C: Urgent but Not Important

Do it, Delegate it, Delete it

D: Not Urgent or Important

Do it, Delegate it, Delete it,

\Choose to Ignore it until it

becomes urgent

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Projects = Divide and Conquer

Break the Project up into categories of tasks

Add single tasks below each heading

Assign due dates as needed

Identify the order the tasks need to be completed in

Project Name:

Order: Category: Deadline:

Category:

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Problems = Structured Solving

1. Notice the Problem

2. Identify main goal

3. List alternate solutions

4. Write down the pro’s/ con’s of each

5. Make your decision

6. Complete the To Do

or

Divide & Conquer

7. Reflect back on your

choices/ plan

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Information Management

• Review and assess effectiveness of current system/ systems

• Planning routines– Monthly– Weekly – Daily updates: morning or evening before

• Other options **will add more in this area d/t recent research

– Memory strategies – Structured lists– Momentary Intentions– Etc.

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Choose a memory up that works for them

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Attention Levels Defined:

Focused attention - preparedness of an individual to respond

Sustained attention - the duration of time over which a given level of performance may be maintained

Selective attention - the ability to focus on relevant stimuli in the presence of distracting stimuli

Alternating attention – the ability to shift focus from one task to another and back again

Divided attention: the ability to either process more than one kind of stimuli or simultaneously carry out more than 1 activity at a time

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Intentional Task Choosing:

Identify the Consequence level of the task?

Low: You can afford mistakes or errors

High: can not afford mistakes or errors

Identify their capabilities?

Hardphysically, cognitively,

emotionally

Easyphysically, cognitively and/

emotionally

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ATTENTIONLimit the demands on your attention

HIGH CONSEQUENCE AND/ OR HARD FOR YOU:

LOW CONSEQUENCE

AND/ EASY:

Limit distracters

Limit interruptions

Best time of day

Do one thing at a time

Use strategies

Use Stop Notes

Take breaks

Distracters are allowed

Perform tasks when you are not at your best

Ok to multi-task or handle interruptions

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Pausing

Thumb:

STOP

1ST finger:

What am I

doing?

2nd finger:

Is this what I

should be

doing?

3rd finger:

Do I have

what I need?

4th

finger:

GO

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• Take a moment to align their brain and their body

• Think calmly regarding what they are doing at the present time

• If we ask our brains a question it will try to answer it

• We get in trouble when we are too distracted, stressed or tired to ask

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Pause to focus attention

simply taking a moment to align your brain and

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• Understand the inefficiency:– Word retrieval

– Attention

– Memory

• Correlation to the personal and situational factors

• Strategies to match the concern

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Communication

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Highlight the importance of exercise for thinking, fatigue and overall health.

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•6 treatments + an assessment

•3 months

•Start weekly and decrease to every other with an optional 1 month follow up

•This is suggested not mandated

• Inform referring provider if falling significantly outside of best practice

Frequency and Duration

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•PM&R Doctors

•Care Coordinators

•Social Workers

•Psychologists/ Healing Coaches

•Nutritionists

•Other therapists from different impairment groups

•Only own what is ours

Work with a Team to meet Client needs

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Therapy Operations and Reimbursement Challenges

Lori Froehling, PT, STAR/T

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• CRCD as an impairment is well documented in the literature

• Assessment of CRCD and Occupational Therapytreatments have been identified

• Many patient tools and activities to address impairments

• Team Approach

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Quick Review

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• Billing for Evaluation– Initial Evaluation Occupational Therapy 97002

• Billing for Treatment– Development of Cognitive Skills 97532

– Self care/Home Management Training 97535

– Community/Work Reintegration Training 97537

*** Bill according to intent of the outcome of treatment

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Beyond Providing Care - Billing

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• Comprehensive Evaluation– Objective self-report and performance based assessments– Clearly identify functional (ADL/IADL) impairments and

expectation of improvement– Interventions – document to support the skilled and medically

necessary skills of the therapist– Objective and measurable goals– Planned interventions appropriate for identified impairment

• Subsequent visits– Non-repetitive, progressive– Skilled and medically necessary– Re-assessment of progress toward goals (objective measures)

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Beyond Providing Care -Documentation

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Understanding Coverage Limitations

• Accurately identify the patient insurance coverage before the patient attends the first visit

• Workflow to communicate information to therapist

• Coding - Coverage determination may be dependent on accurate coding of primary and secondary diagnosis

• Billing – Timely notification of denials

• Knowledgeable in Medicare / Medicaid, and private insurance coverage

• Partner with Payer Relations department –access to plan representatives

• Assist with staff education – billing, documentation, waivers, ABN

• Understand the diagnosis and interventions being performed

• Staff education

• Advocate for change in payer coverage –requires outcome data and measure of value

Rehab Manager

Quality & Regulatory

Staff

Registration Staff

Coding & Billing Staff

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Therapist

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• Payer Plan and Policy specific – keep track

• Educate patients on services available, your understanding of coverage, and their responsibility to contact their insurance company to confirm (provide dx and CPT codes)

• Follow ABN and Waiver guidelines of your organization

• Utilize facility discounts or subsidy programs

• Establish self-pay guidelines for non-covered or excluded services

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Non-Covered Service

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• As clinicians read the literature and use it to develop best practice guidelines

• Challenge our current models of care delivery (1:1 visit) and evaluate options: – group sessions as part of survivorship– Reinforce cognitive strategies as part of care coordination– Therapist phone visit (billable – not yet)

• Advocate for cognitive rehabilitation as part of bundled payment for cancer care

• Collect outcome measures – initial and discharge, measure impact of services provided and overall value (return to work, caregiver burden, etc.) – use to influence payer policy and payment

• We have so much to offer !

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Future Considerations

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Questions & Discussion

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• Nancy Hutchison, MD, STAR/T– Medical Director for Cancer Rehabilitation,

Survivorship and Lymphedema– Nancy.hutchison@allina.com

• Joette Zola, OTR/L, STAR/T– Lead for Cancer Rehabilitation Cognitive Impairment

team– Joette.zola@allina.com

• Lori Froehling, PT, STAR/T– Director of Therapy Operations– Lori.froehling@allina.com

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Presenters