Screening tool helps Ascension identify outpatients with pressing spiritual care needs

August 15, 2019

St. Louis-based Ascension has made it a strategic priority to ensure that patients receiving care outside of the hospital walls get access to spiritual care.

To identify outpatients who may benefit from — and be receptive to — a spiritual care consult, the system is beginning to screen for unmet spiritual care needs in its broader patient intake assessments. Ascension began this initiative last summer, by asking patients in its remote care monitoring program three screening questions to gauge their level of spiritual distress and referring those with pressing needs to remote chaplaincy services. Ascension currently is piloting the screening tool in some inpatient and ambulatory care settings as well.

The Rev. Cathy Chang, Ascension's director of on demand spiritual care and mission integration, and Mary M. Heintzkill, Ascension director of spiritual care and mission integration, talked with Catholic Health World about the spiritual assessment tool.

How did you land on three questions that would be a valid barometer of spiritual health?

Heintzkill: We knew patients would be overwhelmed if we asked too many questions. We ask questions that get at a patient's level of concern when it comes to loss of meaning and/or joy, spiritual or religious issues and end-of-life issues. Depending on their response, there is a referral made to a chaplain. We are finding that about 20 percent of the patients in our remote care monitoring program (for patients with serious chronic illness) are experiencing spiritual distress and that chaplain intervention is appropriate in these cases.

How was the tool developed?

Chang: This screening tool was based off the study, "Determining the best methods to screen for religious/spiritual distress," by Stephen King and other authors. It is from the Supportive Care in Cancer journal, from 2016.

How is the tool administered?

Heintzkill: The three questions are part of a larger assessment that a nurse completes with each patient when the patient is brought into the remote care monitoring program. This larger assessment covers the patient's physical, emotional and spiritual health and other topics. Depending on the score, referrals are made.

Our remote care monitoring involves a multidisciplinary team — that could include a doctor, nurse, social worker and others. That team is monitoring patients with cardiac and chronic disease to help them get to the level of optimal functioning. The chaplain is really integral to our multidisciplinary teams.

What is the interplay between spiritual and behavioral health, when it comes to the assessments?

Chang: Our tool is designed to screen for spiritual distress. The behavioral health teams have their own screener to catch behavioral health needs, and those trigger a social worker, or a behavioral health expert being added to the team. As always, we do refer back and forth, so if a social worker sees something that is a spiritual need, they will refer to a chaplain, or vice versa if the chaplain sees a possible behavioral health need.

Alina Masavage, a nurse case manager with Ascension St. Vincent Indiana, conducts an intake assessment with a patient. Spiritual care questions on the assessment are intended to flag patients who would benefit from a referral to a chaplain.

What happens when a patient is referred to a chaplain?

Heintzkill: An Ascension chaplain does a more thorough assessment of what is causing the distress and identifies resources to help the patient get to a place of more meaning. Currently the chaplains who respond (to the patients in the remote monitoring program) do so by phone or over the web. Our remote care team chaplains are working out of Florida, Indiana and Texas.

What are some of the ways chaplains help patients get to a place of more meaning?

Chang: The chaplains help the patient find meaning in light of their current circumstances. For instance, we've heard several stories about patients who are isolated, or even self-isolating, because they don't feel they can their share their circumstances with their loved ones. But after working with the chaplain, they've often found ways to open up to their loved ones, which has given the patients a lot of peace, because they have more support.

The chaplain can help the patient find their own internal spiritual strengths or reconnect with God or the spiritual.

How much contact does a chaplain have with remote monitoring patients who have expressed spiritual needs?

Chang: Typically, the chaplain is spending about an hour per patient per week, but that includes time trying to reach the patient, which is often challenging even when meetings are scheduled for a virtual or telephone visit. Also, not every patient needs to talk every week. Depending on the patient and the patient's 
circumstances — medical, spiritual and emotional — they may need to talk every few weeks rather than every week. Services from a chaplain end when either the patient is discharged from the remote patient monitoring service — typically 90 to 120 days — or earlier if the patient's spiritual needs have been addressed.

Heintzkill: We're in the process of developing more and more connections with community resources that a patient can tap for ongoing spiritual support.

What are some of the challenges of connecting patients to such resources?

Chang: The majority of patients who are referred to us are in very remote rural areas — or the patient is often homebound for physical and/or financial reasons. Even telephone resources for support groups can be a financial burden, as many can only afford limited minutes per month. Connecting patients with resources often means helping the patient figure out what resources they have locally, in their families, and internally, as well as having the patient identify what is important to them.

What feedback have you received about this spiritual assessment?

Heintzkill: We're hearing good things from the teams using the assessment. When a team realizes a patient is in spiritual distress, it's so much better to have a chaplain respond — the chaplain has the expertise.

What advice would you offer others considering using a similar approach?

Heintzkill: There is a lot of integration needed. For instance, you need to work with IT to embed the tool's questions into the larger assessment, you need nurses administering the tool who will understand the importance of the questions. And you need other team members like social workers and physicians who are on board. So my best advice is to not work in a silo.

What are the main benefits of this approach?

Heintzkill: It helps zero in with the patient on what is important to them. We're developing new competencies for chaplains as we enter new areas of service like this one. And it's been great fun and an adventure to move into this next era of spiritual care. We're reimagining how we can empower people to live with cardiac disease and chronic illness.

Questions to assess spiritual health needs

When a patient enrolls in Ascension's remote monitoring program, a nurse conducts an assessment with the patient in person, by phone or via a web-based survey instrument. As part of that assessment, the nurse asks questions related to the patient's spiritual health. The nurse begins by saying: "At Ascension Health … we're committed to caring for the whole person: body, mind, and spirit. Because of this commitment to holistic care, I'd like to ask you a few questions to determine any level of concern you might have in a few areas."

The nurse then walks the patient through the assessment, which includes three questions used to assess spiritual health. Patients are asked to assess the following measures:

Level of concern related to loss of meaning and/or joy in life

-- Not at all

-- Somewhat

-- Quite a bit

-- A great deal

Level of concern related to spiritual or religious issues

-- Not at all

-- Somewhat

-- Quite a bit

-- A great deal

Level of concern related to end-of-life issues

-- Not at all

-- Somewhat

-- Quite a bit

-- A great deal

If the patient answers "somewhat" to two or more questions, or "quite a bit" or "a great deal" to any questions, then a referral for spiritual care is made.


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