Background: While distress is prevalent among individuals living with cancer, distress management has not been optimized across cancer care delivery despite standards for screening. This manuscript describes the development of an enhanced Distress Thermometer(eDT) and shares the process for implementing the (eDT) across a cancer institute by highlighting process changes and improvements at the provider, system, and clinic levels. Methods: Focus groups and surveys were used at the provider-level to outline the problem space and to identify solutions to improve distress screening and management. Through stakeholder engagement, an eDT was developed and rolled out across the cancer institute. The eDT included pull down menus for each of the DT problem areas to provide detailed context of the specific issue. EHR infrastructure changes were implemented at the system-level to improve the use of the distress screening findings and generate automated referrals for specialty services. Clinic-level workflows were adapted to improve screening and distress management using the eDT. Patient-level data was collected to examine severity of distress and referral pathway utilization comparisons between original DT and eDT. Results: Stakeholder focus group participants (n = 17) and survey respondents (n = 13) found the eDT to be feasible and acceptable for distress identification and management. System-level technical EHR changes resulted in high accuracy with patient identification for distress management and 100% of patients with moderate to severe distress were connected directly to an appropriate specialty provider. Clinic-level workflow changes to expand eDT use improved compliance rates with distress screening from 86% to 98% over a 1 year period. We are currently analyzing utilization data based on distress screening at the patient level and will provide these results in the final presentation. Conclusions: An eDT that provides more context to patient-reported problems improved identification of referral pathways for patients experiencing moderate to high distress during cancer treatment and enhanced overall clinical use of the eDT. Combining process improvement interventions across multiple levels in the cancer care delivery system enhanced the success of this project. These processes and tools could support improved distress screening and management across cancer care delivery settings.