WHO Public Health approach in the planning and implementation of Palliative care: Experience and evi

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WHO Public Health approach in the planning and
implementation of Palliative care Experience
and evidence from CataloniaXavier
Gomez-BatistePal Care , Institut Catala
dOncologiaSocio-Health, Catalan Department of
HealthSpanish Society for Pall care (SECPAL)
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CATALONIA

• 6.7 milion habitants
• gt 16 gt 65
• 1 million gt 65 ys
• 100.000 elderly with pluripathology and
  dependency
• Dementia 90.000
• Cancer mortality 13.000
• Aids 300

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Catalonia Public Health Care system (universal
coverage, free access)
Hospitals 14.000 beds
Regional Cancer Institute
Sociohealth Centers 5.000
Residential 45.000
Primary care network
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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

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PCPC global results 2004

• Nº total resources 162
• Interventions/year gt 20.000
• Coverage cancer 75
• Cancer vs noncancer 60/40
• Coverage, geographical 100
• Total beds 550
• Beds /milion hab 85
• Full time doctors 140

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Units 2001 placement
Hosp Univ 6
Hosp Gen 4
ICO 1
CSS 38
MEP 11

• Nº total 60
• Beds 550 (9.5/UCP)
• Length stay 22.8 days
• Mortality 69.7
• Discharges home 23.0

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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
• 
  

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CP levels of complexity
Complete teams Units
Reference complexity training research
Basic Support Teams
General Measures in Conventional Services
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Complex metropolitan systems (300-500.000 hab)
levels, coordination
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ICO Palliative Care Service

• Unit 16 beds
• Outpats/DC
• Support team

CSUB
ICO
PADES UCPSS
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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

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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

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ICO 1998 the ping-pong model
CIR
HMT
ONC
ORL
PAIN
PAL CARE
RDT
URG
Cuidados Paliativos
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ICO 2005 interphase Oncology-Pal care
UFP
PACMAC
UFM
Palliative Care Service clinic, unit, support
team
Case management Continuing care Emergencies Coordi
nation
UFORL
UFGINE
USAC
From competition to cooperation
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Death
Diagnosys
Bereavement
Specific Treatment
Suportive care
Palliative care
Terminal care
Complexity vs prognosis
Definitions and trams
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PVAA 166,8 million 3 of total CHS budget
PCPC 23,7 million 0,43 total CHS budget
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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

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Spain 2002 by Regions
Fuente Directorio SECPAL
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Spain 1984-2002
Fuente Directorio SECPAL
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Results on the use and cost of reources
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COMPARISON 1992-2002 USE/COST OF RESOURCES INGR
malalts / ESTMITJ dies / URGENC malalts
COST euros x 100

(XGB et al, 2002)
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Hospital Costs 1992 vs 2001(Cost /
process-patient / 6 weeks at 2001 prices)
TESISTAULESTEXTCAPVI1

• 1992 4.987 euros
• 2001 1.701 euros
• Difference 3.286 euros / patient

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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

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Principles

• Measures in all places
• Sectorized
• Insertion in preexisting services, including
  sociohealth
• Gradual implementation
• Public Planning
• Public Financement

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Aims

• Coverage for all in everywhere
• Equity and accesibility
• Quality effectiveness, efficiency, satisfaction
• Reference WHO

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Initial key procesess

• Clear ideas
• Clear definition of clients and services
• Leadership
• Training
• References/experiences
• Institutional support

pva20
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Leadership

• Joint venture between
• Ministry of health and financing agency
• Professionals well trained and highly committed
• Organisations (Providers) public, profit,
  nonprofit
• Academic (Universities)

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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

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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

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Types of processes (always combined)

• Implementation of new specific resources
• Adaptation of conventional resources (general
  measures)
• Reallocation of resources (reconversion)
• Catalythic implementation or investment

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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

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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....

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Expected results

• Enormous improvement of the quality of care
• Effectiveness
• Efficiency saving more than the structrural cost
• Satisfaction patients, families, professionals,
  and politicians

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Palliative Care added values

• Care and organisation models useful in all the
  system
• Model of care appliable to other conditions
  earlier
• Emphasis in quality of life
• Impact on the global efficiency
• High patients and families satisfaction
• Ethical approach