WHO Public Health approach in the planning and implementation of Palliative care: Experience and...
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Transcript of WHO Public Health approach in the planning and implementation of Palliative care: Experience and...
WHO Public Health approach in the planning and
implementation of Palliative care:
Experience and evidence from Catalonia
Xavier Gomez-BatistePal Care , Institut Catala d’Oncologia
Socio-Health, Catalan Department of HealthSpanish Society for Pall care (SECPAL)
CATALONIA
• 6.7 milion habitants• > 16% > 65• 1 million > 65 ys• 100.000 elderly with pluripathology
and dependency• Dementia: 90.000• Cancer mortality: 13.000• Aids: 300
Catalonia: Public Health Care system (universal coverage, free access)
Hospitals: 14.000 beds
Sociohealth Centers: 5.000 Residential:
45.000
Regional Cancer Institute
Primary care network
Background
• British experience on Hospices: model of care and internal organisation, but outside the NHS
• The Public Health approach: E. Wilkes (1985) + Jan Stjernsward (WHO) + V Ventafridda
PCPC: global results 2004
• Nº total resources: 162• Interventions/year: > 20.000• Coverage cancer: 75%• Cancer vs noncancer: 60/40%• Coverage, geographical: 100%• Total beds: 550• Beds /milion hab: 85• Full time doctors: 140
Units 2001: placement
Hosp Univ: 6Hosp Gen: 4
CSS: 38
MEP: 11
ICO: 1
Nº total: 60Beds: 550 (9.5/UCP)Length stay: 22.8 daysMortality: 69.7%Discharges home: 23.0%
Home Care Support Teams
• Nº total: 62• Nº new patients/year: 250• Cancer (46%), geriatrics (46%), chronic• Prevalents: 30-40• Time intervention: 6 weeks• Place of death: 61% home, 19% CSS, 12% HA• Nº total professionals (2003): 318• Cost: savings of 1.000 euros/patient
CP: levels of complexity
General Measures in Conventional Services
Basic Support Teams
Reference:
complexity+ training+ research
Complete teams
Units
PCS at ICO: basic outputs
• New patients/year: 1.000 (Cancer 100%)
• Median survival 1st visit: 3.5 months
• Mean age: 60 years
• Length of stay (Unit) : 9 days
• Mortality (Unit): 50%
• Cost: 30% of Medical Oncology
PCS at ICO: other aspects
• Reference for training (Master, Intermediate, Basic): more than 5.000 profesionals trained
• Research: CATPAL cooperative group (more than 17 studies)
• Quality improvement: EFQM model
Cuidados PaliativosCuidados Paliativos
ICO 1998: the “ping-pong” modelICO 1998: the “ping-pong” model
ONCONC
RDTRDTURGURG
HMTHMT
PAL CAREPAL CARE
PAINPAIN
CIRCIR
ORLORL
ICO 2005: interphase Oncology-Pal careICO 2005: interphase Oncology-Pal care
“From competition to cooperation”
UFP
UFM
UFORL
UFGINE
USAC
Palliative Care Service: clinic, unit,support team
PACMAC PACMAC Case Case managementmanagement
Continuing careContinuing care
EmergenciesEmergencies
CoordinationCoordination
Definitions and trams
Diagnosys Death
Specific Treatment
Suportive care
Palliative care
Terminal care
Bereavement
Complexity vs prognosis
SOCIOHEALTH ACTIVITY IN CATALONIAProgress 1990-2002
28.000
39464
53884
7772082000
14.99118.390
23.143
6.70012.285
650025824
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
1990 1993 1995 1997 2001 2003
SOURCE: Information system "Programa Vida als Anys"
Nº Users
PVAA Budget (million Ptas)
PVAA 166,8 million €3% of total CHS budgetPVAA 166,8 million €
3% of total CHS budget
PCPC: 23,7 million € 0,43 % total CHS
budget
PCPC: 23,7 million € 0,43 % total CHS
budget
Legislation and standards
•Decret Catalunya 1990•Recomendaciones de la SECPAL, Ministerio de Sanidad (1993)•Estàndards de cures pal.liatives, SCS, SCBCP (1993)•Decreto/orden 1993 (Opioides) Ministerio•Plan Nacional de Cuidados Paliativos (2001)•Guía de criterios de calidad en cuidados paliativos: SECPAL, Ministerio Sanidad (2002)•Indicadores de calidad en cuidados paliativos: SECPAL, Ministerio de Sanidad
0
50
100
150
200
250
300
350
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01
Recursos HospitalariosRecursos DomiciliariosOtros RecursosTotal Recursos
Spain 1984-2002
Fuente: Directorio SECPAL
0
10
20
30
40
50
60
70
80
INGRÉS ESTMITJ URGENC DOMI COST
1992
2002
COMPARISON 1992-2002: USE/COST OF RESOURCESINGR: % malalts / ESTMITJ: dies / URGENC: %malalts COST: euros x 100 (XGB et al, 2002)
Hospital Costs: 1992 vs 2001(Cost / process-patient / 6 weeks at 2001 prices)
•1992: 4.987 euros
•2001: 1.701 euros
Difference: 3.286 euros / patient
National Policy: Elements• Evaluation of needs• Defined targets, aims and principles• Leadership• Implementation of specific services• General measures in conventional services• Opioid availability• Education and training• Standards, legislation, definition of services• Financing model• Evaluation• Implementation plan with specific budget
Principles
• Measures in all places• Sectorized • Insertion in preexisting services,
including sociohealth• Gradual implementation• Public Planning• Public Financement
Aims
• Coverage: for all in everywhere
• Equity and accesibility• Quality: effectiveness,
efficiency, satisfaction
• Reference WHO
Initial key procesess• Clear ideas• Clear definition of clients
and services• Leadership• Training• References/experiences• Institutional support
pva20
LeadershipJoint venture between
• Ministry of health and financing agency
• Professionals: well trained and highly committed
• Organisations (Providers): public, profit, nonprofit
• Academic (Universities)
General measures
• Targets: Hospitals (oncology, internal medicine, geriatrics, emergencies), mid-term and long-term resources (nursing homes), primary care teams
• Training: policies, sessions, formal training, local references
• Change of organisation: teamwork, presence and support of the family
• Liaison of resources
Specific Resources
• Specific nurses
• Support teams: in hospitals, community, both, systems
• Units: type, dimension, placement
• Nº beds: 80-100/milion
• Placement: 10-20% acute, 40-60% sociohealth (mid-term), 10-20% residential, 10-20% hospices
Types of processes (always combined)
• Implementation of new specific resources
• Adaptation of conventional resources (general measures)
• Reallocation of resources (reconversion)
• “Catalythic” implementation or investment
Palliative care and geriatrics and cancer
• Links with geriatrics in Sociohealth centers, nursing homes, and community
• Links with cancer in hospitals, cancer centers, and the community
• Both necessary
Common Resistances• “We are already doing so...”
• “There is no need of specific services, we will do a lot of training....”
• “Palliative care services will be seen as places to die....”
• “This is good for England, USA, or Catalonia, but it will not work in our country....”
Expected results• Enormous improvement of the quality
of care
• Effectiveness
• Efficiency: saving more than the structrural cost
• Satisfaction: patients, families, professionals, and politicians