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Building palliative care specialist services and teams

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OSI/WHOCC Introductory Lecture 4 Building palliative care specialist services and teams Xavier G mez-Batiste MD, PhD Director, WHO Collaborating Center for Public ... – PowerPoint PPT presentation

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Title: Building palliative care specialist services and teams


1
Building palliative care specialist services and
teams
OSI/WHOCC Introductory Lecture 4
Xavier Gómez-Batiste MD, PhD Director, WHO
Collaborating Center for Public Health Palliative
Care Programs
2
Building services definitions
  • Definitions service, team, measures in
    conventional services, transitional measures
  • Types of services
  • Indicators, Standards
  • Structure, process, results

3
Definitions
  • Structure What we have
  • Process What we do
  • Outcomes What we achieve
  • Service the organisation
  • Team the professionals working at the service

4
Definitions specialist palliative care services
Palliative care specialist services are the
specific resources devoted to care of advanced
and terminal patients and their families. They
include a well trained multidisciplonary team,
who follows adequate care processes, and who are
clearly identified by patients, families, and
other services. Moreover, such specialists hold
an administrative identity, specific budget, and
leadership. They include support teams, units,
outpatient clinics, days care centers, hopsices,
and comprehensive networks
WHOCC 2009
5
Transitional measures
Transitional measures are models of care
delivering that use some resources (frequently
individuals) such a specific nurse or consultant
not fulfilling the criteria for a specialist
service but devoted to advanced and terminal
patients and families. TM can be the first step
of further development of a specialist service.
WHOCC 2009
6
Specific Resources
  • Specific nurses and/or consultants
  • Monographic teams symptom control ,
    psychosocial, bereavement
  • Support teams (basic, complete) in hospitals,
    community, comprehensive systems
  • Units type, dimension, placement
  • Placement of beds 10-20 acute, 40-60
    sociohealth (mid-term), 10-20 residential,
    10-20 hospices
  • Reference services training and research
  • Comprehensive networks

7
Levels of complexity
Reference complexity training research
Complete teams Units
Basic suport teams (home, hospitals,
comprehensive)
Specialist nurses or consultants
General measures in conventional Services
(Hospitals, Primary care, Nursing homes,
Emergencies, etc)
8
Specific Resources / settings
Hospices
Acute Hospitals
Mid term and long term, RHB, (Sociohealth
Centers)
Nursing homes
Units Support teams Outps / Day care
Community / home
9
Conceptual Transitions
  • From Terminal disease to Advanced progressive
    illnesses
  • From Prognosis of days weeks, lt 6 months to
    Limited life prognosis
  • From Progressive evolution to Evolutive Crisis
  • From Curative/paliative dychotomy to Shared
    synchronic care
  • Specific and palliative treatment can coexist
  • From rigid to flexible intervention
  • From prognosis to complexity as criteria of
    intervention
  • From response to crisis to advance care
    planning
  • From palliative care services to palliative
    measures in all settings

10
  • Building palliative care services and
    teams

11
Services description
Resources and dispositives
Activities Processes
Structure and Setting
Patients and families needs (type, number,
complexity)
Outcomes Clinical, organizational economic, key
Context needs, demands
Outputs
12
Description services elements
Activities Processes, Types of activities
ContextDemográphic, setting, etc.
Institution, Internal and external Clients
Patients / families Númber, typo, complexity,
dependency, prognosis
Team structure, training, activities, process
Quality, research, training
Results
Clínical STAS, ESAS, emotional, experience,
satisfaction, ..
Outputs length stay, mortality, length
intervention,
Other impact, cost, social, society, culture
13
Frequent Process measures and Activities of
Palliative Care Services

Care of Patients (inpatient, outpatients, home, day care, phone/online support) Care of Families and Bereavement Needs assessment (individuals, context) Advance care planning Continuing care and case management Liaison of resources Support of other teams Team work meetings, roles, support, relations, climate Register and documentation Evaluation of results Internal training External training Research and publications Quality assessment and improvement Volunteers Advocacy Links to society
14
Elements of a Strategic Plan
15
Key issues
  • Mission
  • Vision
  • Values
  • Objectives
  • Leadership

16
Mission
  • The reason to exist at the highest level
    with an open, high and wide conception

17
Vision
  • The definition of the ideal development and
    excellence of the service at long term, based in
    existing references

18
Values
  • The principles which preside our actions

19
You matter
Values committment, empathy, compassion,
honesty, congruence, trust, confidence, .
Respect / Spiritual / Dignity / Hope
Clinical
Communication
Ethical /ACP
Continuity
Basic Competencies
Context Team / Atmosphere / Values
Organization oriented to patients and families
20
  • Institutional commitment
  • Context analysis
  • Leadership
  • Defined type of service
  • Target patients and services
  • Mission, vision, principles and values
  • Model of care and intervention
  • Building the team
  • Training
  • Internal consensus model of care, model
    organisation, types of activities
  • External consensus target services, criteria of
    intervention
  • Starting activities
  • Indicators, standards, and quality improvement
  • Follow up and review

Foundation measures of Palliative Care Services
(elements)
21
  • Context analysis
  • Strategic planning
  • Build leadership
  • Building the team
  • Training
  • Internal consensus
  • External consensus
  • Starting activities
  • Budgeting
  • Designing Evaluation

Aims and actions at short-term
22
  • Demographic and general characteristics of the
    area and care settings
  • Background
  • Maping the existing services and resources
  • Quantitative needs assessment
  • Qualitative analysis
  • Basal surveys
  • Identification of resistances, barriers, and
    possible alliances

Context analysis
23
Objectives 1st year
  1. Build up team
  2. Strategic and action Plan
  3. Start activities clinical, training, research
  4. Internal / external consensus

24
Building leadership
25
Components of leadership
26
Personal competencies of team leaders (Goleman D)
Personal competencies Self-management Emotional self-awareness Self-assessment Self-confidence Self-control
Personal competencies Self-empowerment Achievement Initiative Optimism Adaptability Flexibility Transparency Honesty
Social competencies Social awareness Empathy Organizational Focus on patients
Social competencies Relationships management Empowerment of team members Collaboration and teamwork Inspirational Influence Change catalyst Building bonds Conflict management
27
Building the team
28
Team building
  • Objectives 1st year
  • Select
  • Train
  • Consolidate

29
Personal competencies of team members (Goleman D)
Personal competencies Self-management Emotional self-awareness Self-assessment Self-confidence Self-control
Personal competencies Self-empowerment Initiative Optimism Adaptability Flexibility Transparency
Social competencies Social awareness Empathy Respect Focus on patients
Social competencies Relationships management Collaboration and teamwork Building bonds Conflict management
30
The best (palliative care) professionals
  • Competent
  • Committed
  • Conscious
  • Compassionate
  • Mature
  • Respectful
  • Resilient

31
Professional competencies
  • Palliative care clinical organisation
  • Allied disciplines Oncology, Internal medicine,
    Primary/community Care, Geriatrics,
    Anesthesiology/Pain, etc
  • map of allied competencies ethics, quality,
    research, training,
  • Knowledge of environment
  • The mixed, the best!!!

32
Training The first priority
  • Topics
  • Clinical
  • Organizational
  • Leadership
  • Methods
  • Stages and visits to reference services
  • Mentorship
  • Modelling in place

Online and conventional training based in
lectures do not guarantee the skills and real
changes in practice
33
Evolutive phases
  • 1. Forming
  • 2. Storming
  • 3. Norming
  • 4. Performing
  • 5. Evaluating and reviewing
  • 6. Dissolving or reorientation
  • Tuckmans model

34
Internal consensus
35
  • Leadership
  • Conceptual values
  • Strategic mission, vision
  • Model of care and intervention
  • Therapeutical
  • Organisational timetable, documentation,
  • Team rols, functions, relations, conflict
    prevention
  • Quality and indicators

Areas of internal consensus at the 1st year
36
  1. ILLNESS MANAGEMENT

2. PHYSICAL
3. PSYCHOLOGICAL
8. LOSS, BEREAVEMENT
4. SOCIAL
PATIENT FAMILY
7. CAREAT THE END OF LIFE / DEATH MANEGEMENT
5.SPIRITUAL
6. PRACTICAL
37
Needs patients and families 1. Careful Assessment 2. Sharing information and aims 4. Plan of care 5. Care activities 6. Follow up and results
Disease management
Physical
Psychological
Spiritual
Ethical
Family
Social
Practical
End of Life
Grief and loss
Model of care and intervention
38
  • Care of Patients (inpatient, outpatients, home,
    day care, phone / online support)
  • Care of Families and Bereavement
  • Needs assessment (individual, context)
  • Ethical decission-making and Advance care
    planning
  • Continuing care and case management
  • Liaison of resources
  • Support of other teams
  • Team work meetings, rols, support, relations,
    climate
  • Register and doccumentation
  • Evaluation of results
  • Internal training
  • External training
  • Research and publications
  • Quality assessment and improvement
  • Volonteers
  • Advocacy
  • Links to society

Frequent Processes, measures and Activities of
Palliative Care Services
39
Patients family Needs Principles Quantitative analysis Qualitative strengths and weaknesses Areas of improvement Objectives Actions Indicators
Disease
Physical
Psychological
Spiritual
Ethical
Social
Family
Practical
Last days
Bereavement and loss
Model of self assessment of Care Dimensions
40
Therapeutic consensus
  • Defining and norming the basic therapeutic
    principles.
  • Based on experience and evidence
  • Agreement of team members on the treatment of the
    prevalent conditions of patients and families
  • Built up by investing time and efforts in the
    discussion of cases, and bringing together the
    experience of members

41
WHOCC Basic Indicators of PCSs
  • Process
  • Multidimensional evaluation of needs of patients
    and families
  • Systematic elaborated multidisciplinar plan of
    care
  • Systematic approach of process of care (square
    of care)
  • Systematic monitoring and review of clinical
    outcomes and organisational outputs
  • Team approach meetings, plan, assessment,
    doccumentation
  • Continuing care and accesibility
  • Links with other services
  • Documentation and tools complimented
  • Activities training / quality improvement
  • Bereavement process
  • Structure
  • Multidiscilinary team
  • Advanced specialist training
  • Documentation
  • Unit / office / setting / access
  • Policies

Adapted from SCBCP 1993 and SECPAL 2006
42
Square of evaluation and improvement services
Dimensions of organization Principlesmodel care Quantitative anallysis Strong points Weak points Areas for improvement Objectives priorities Actions short, mid, long Indicators Responsables
Care patients (Dimensions)
Care families (Dimensions)
Team (dimensions)
Decission making
Evaluation and monitoring
Coordination/ liaison/accesibility/continuity
Training, research
Other
43
Action plan 1st year clinical
  • 1. Select Clinical activities and number
  • Support team?
  • Outpatients clinic?
  • Unit?
  • Day care?
  • Home care?
  • 2. Select target patients and services
  • 3. Define criteria (and limits) of admission and
    intervention

Coverage never a priority first year
44
Action plan 1st year training
  1. Internal training 1st priority
  2. Target services
  3. Key topics
  4. Key protocols

Coverage never a priority first year
45
Starting clinical activities
  • Start gradually (inpatient care or home care,
    support of other teams, outpatients clinics, day
    care and others) based on feasibility and
    available resources.
  • Respect time and spaces to the tasks of building
    the team.
  • Gradual approaches to focus in few target
    services and only inpatients. In home care
    services, select the most accessible area and
    primary care.
  • It is also frequent to select target patients
    initially (mostly, cancer) and expand gradually
    into others.
  • Frequent limitations in the early stages Late
    intervention, Difficulty of offering 24hrs
    coverage, Absence of other resources (specialist
    beds, or home care services, or both)

Start low and go slow, but do so!!!!
46
Action plan 1st year research
  • Select parameters () of success
  • Symptom control
  • Use of resources
  • Use of opioids
  • Satisfaction
  • 2. Improve description
  • Prevalence, surveys, etc
  • () easy to change, to measure and to find

47
External consensus
  • Institution / stakeholders
  • Target services (our clients!!)
  • Criteria admission
  • Criteria intervention
  • Rol of the service in the followup and continuing
    care

48
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49
3
Crisis prevention and intervention
Murray, S. A et al. BMJ 2008336958-959
50
Death
Diagnosis
Bereavement
One way, late intervention, terminal care, lack
of influence
Dissociated/dichotomic model
51
Death
Diagnosis
Bereavement
Specific cancer treatment
Supportive Care
Palliative care
Terminal care
Complexity vs prognosis Flexible, shared,
cooperative
Integrated model
52
The earliest, the best!!!
53
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54
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55
Measure progress at short-term
  • Select the easiest, simplest, fastest indicators
    and results
  • Oriented to show results to different targets
  • Describe experience, generate evidence, and
    promote development

56
Structure Process Outcomes
Multidisciplinary team Advanced training and competencies Leadership Office Documentation Protocols/ policies Criteria for intervention Multidimensional evaluation of patients needs Multidimensional Therapeutic Plans for patients Identifying and supporting primary career Advance care planning Register and Monitorising needs, demands, expectations Evaluation of results Case management and Continuing care Coordination other services Bereavement Efficacy Effectiveness Cost Efficiency Cost/effectiveness Satisfaction patients, families, services Social Ethical
Basic Indicators of PCServices
57
Advocacy
  • Select targets managers, politicians,
    policymakers, funders, academics, NGOs, public
    awareness, media, ..
  • Select messages (adapted to targets)
    effectiveness, efficiency, satisfaction, ethical
    issues, values, innovation, stories, ..
  • Select key results at short / mid / long times
  • Prevent and treat conflicts, threats,
    misunderstandings

58
Resistances and barriers
  • Individual / personal
  • Corporative
  • Denial
  • Values
  • Interests
  • Misconceptions
  • Unrealistic expectations or demands
  • Some are based in our own attitudes and behaviours

Identify, prevent, treat
59
Conceptual Transitions
  • From Terminal disease to Advanced progressive
    illnesses
  • From Prognosis of days weeks, lt 6 months to
    Limited life prognosis
  • From Progressive evolution to Evolutive Crisis
  • From Curative/paliative dychotomy to Shared
    synchronic care
  • Specific and palliative treatment can coexist
  • From rigid to flexible intervention
  • From prognosis to complexity as criteria of
    intervention
  • From response to crisis to advance care
    planning
  • From palliative care services to palliative
    measures in all settings

60
Expected results
  • Enormous improvement of the quality of care
  • Effectiveness
  • Efficiency saving more than the structural cost
  • Satisfaction patients, families, professionals
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