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Building palliative care specialist services and
teams
OSI/WHOCC Introductory Lecture 4OSI/WHOCC Introductory Lecture 4
Xavier Gómez-Batiste MD, PhDDirector, WHO Collaborating Center
for Public Health Palliative Care Programs
Institut Català d’Oncologia
Building services: definitions
• Definitions: service, team, measures in conventional services, transitional measures
• Types of services• Indicators, Standards• Structure, process, results
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Definitions
• Structure: What we have• Process: What we do• Outcomes: What we achieve• Service: the organisation• Team: the professionals working
at the service
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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
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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
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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
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Levels of complexity
General measures in conventional Services (Hospitals, Primary care, Nursing homes, Emergencies, etc)
Basic suport teams (home, hospitals, comprehensive)
Reference:
complexity+ training+ research
Complete teams Units
Specialist nurses or consultants
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Specific Resources / settings
Units
Support teams
Outp’s / Day care
Acute Hospitals
Nursing homes
Mid term and long term, RHB, (Sociohealth Centers)
Hospices
Community / home
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Conceptual Transitions• From “Terminal disease” to “Advanced
progressive illnesses”• From “Prognosis of days weeks, < 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”
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Building palliative care services
and teams
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Service’s description
Outputs
Patients and families needs(type, number, complexity)
Structure and Setting
Resources and dispositives
Activities
Processes
Outcomes:
Clinical, organizational economic, key
Context: needs, demands
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Description services: Description services: elementselements
Patients / families: Númber, typo,
complexity, dependency,
prognosis
Team: structure, training,
activities, process
Clínical: STAS, ESAS, emotional, experience,
satisfaction, ..
Outputs: length stay, mortality,
length intervention,
Other :impact, cost,
social, society, culture
Quality, research, training
Context:Demográphic, setting, etc.
Activities: Processes,
Types of activities
Institution, Internal and
external Clients
Results
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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
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Context
Quantitativeand qualitativeanalisys
Visions, scenarios, tendencies, strategies
Care, training, research qualityimprovementón
Qualitative:
Strong Points
Weaknesses
Threats
Opportunities
Persons , team, institution, clients, stakeholders,
Doctors, nurses, social workers, psychologists, administration, volonteers, chaplains, others
Mision, VisionValues, Principles, Objectives
Aims and actionsat short, mid, long
term
Patients & families
Elements of a Strategic Plan
Elements of a Strategic Plan
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Key issues
• Mission• Vision• Values• Objectives• Leadership
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Mission
“The reason to exist at the highest level” with an open, high and wide conception
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Vision
“The definition of the ideal development and excellence of the service at long term”, based in existing references
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Values
“The principles which preside our actions”
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Clinical Communication
Ethical /ACP
Continuity
Context: Team / Atmosphere / Values Organization oriented to patients and
families
Respect / Spiritual / Dignity / Hope
Values: committment, empathy, compassion, honesty, congruence, trust, confidence, ….
Basic Competencies
“You matter”“You matter”
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•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)
Foundation measures of Palliative Care Services (elements)
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•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
Aims and actions at short-term
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•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 analysisContext analysis
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Objectives 1st year
1.Build up team
2.Strategic and action Plan
3.Start activities: clinical, training, research
4.Internal / external consensus
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Building leadership
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Components of leadership
Knowledge
Organization
Persons
Vision and strategy
StakeholdersAdvocacyQuality
Values: patient’s centered, commitment, respect, honesty, trust, compassion
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Personal competencies of team leaders (Goleman D)
Personal competencies
Self-management
Emotional self-awarenessSelf-assessmentSelf-confidenceSelf-control
Self-empowerment
AchievementInitiativeOptimismAdaptabilityFlexibilityTransparencyHonesty
Social competencies
Social awarenessEmpathyOrganizationalFocus on patients
Relationships management
Empowerment of team membersCollaboration and teamworkInspirationalInfluenceChange catalystBuilding bondsConflict management
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Building the team
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Team building
Objectives 1st year:
1.Select
2.Train
3.Consolidate
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Personal competencies of team members (Goleman D)
Personal competencies
Self-management
Emotional self-awarenessSelf-assessmentSelf-confidenceSelf-control
Self-empowerment
InitiativeOptimismAdaptabilityFlexibilityTransparency
Social competencies
Social awarenessEmpathyRespectFocus on patients
Relationships management
Collaboration and teamworkBuilding bondsConflict management
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The best (palliative care) professionals
• Competent• Committed• Conscious• Compassionate + • Mature• Respectful• Resilient
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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!!!
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Training: The first priority
Topics• Clinical• Organizational• LeadershipMethods:• 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”
“Online and conventional training based in lectures do not guarantee the skills and real changes in practice”
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Evolutive phases1. Forming2. Storming3. Norming4. Performing5. Evaluating and reviewing 6. Dissolving or reorientation
Tuckman’s model
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Internal consensus
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•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
Areas of internal consensus at the 1st year
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1.ILLNESS MANAGEMENT
1.ILLNESS MANAGEMENT 2. PHYSICAL2. PHYSICAL 3.
PSYCHOLOGICAL
3. PSYCHOLOGICAL
8. LOSS, BEREAVEMENT
8. LOSS, BEREAVEMENT
7. CAREAT THE END OF LIFE / DEATH MANEGEMENT
7. CAREAT THE END OF LIFE / DEATH MANEGEMENT
4. SOCIAL4. SOCIAL
5.SPIRITUAL5.SPIRITUAL6. PRACTICAL6. PRACTICAL
PATIENT & FAMILY
PATIENT & FAMILY
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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
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•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
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Patients & family Needs
Principles
Quantitative analysis
Qualitative: strengths and weaknesses
Areas of improvement
Objectives
Actions
Indicators
Disease
Physical
PsychologicalSpiritual
Ethical
Social
Family
Practical
Last daysBereavement and loss
Model of self assessment of Care Dimensions
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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
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WHOCC Basic Indicators of PCSs
Structure:
• Multidiscilinary team
• Advanced specialist training
• Documentation
• Unit / office / setting / access
• Policies
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 Adapted from SCBCP 1993 and SECPAL 2006
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Dimensions of organization
Principlesmodel care
Quantitative anallysis
Strong points
Weak points
Areas for improvement
Objectivespriorities
Actions short, mid, long
IndicatorsResponsables
Care patients(Dimensions)
Care families(Dimensions)
Team(dimensions)
Decission making
Evaluation and monitoring
Coordination/ liaison/accesibility/continuity
Training, research
Other
Square of evaluation and improvement: services
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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 services3. Define criteria (and limits) of admission
and intervention
Coverage never a priority first year
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Action plan 1st year: training
1. Internal training 1st priority
2. Target services3. Key topics4. Key protocols
Coverage never a priority first year
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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!!!!
Start low and go slow, but do so!!!!
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Action plan 1st year: research
1. Select parameters (*) of success:- Symptom control- Use of resources- Use of opioids- Satisfaction2. Improve description: - Prevalence, surveys, etc(*): easy to change, to measure and to
find
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External consensus
1.Institution / stakeholders
2.Target services (our clients!!)
• Criteria admission
• Criteria intervention
• Rol of the service in the followup and continuing care
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Figure 5: Criteria for interventionofspecialistservices
Needsanddemandsattheconventionalservice
Multidimensional Assessment: complexity
TherapeuticPlan andindicationofresources
Rol in thecare: - Shared / Exclusive - Case management– Advancecareplanning - Continuity- Emergency
+ Supportofthe referentteam
Back toconventional service ifstable
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3
Murray, S. A et al. BMJ 2008;336:958-959
Crisis prevention and intervention
Crisis prevention and intervention
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Dissociated/dichotomic model
Diagnosis Death
Bereavement
One way, late intervention, terminal care, lack of influence
Institut Català d’OncologiaIntegrated model
Diagnosis Death
Specific cancer treatmentSupportive Care
Palliative care
Terminal care
Bereavement
Complexity vs prognosis Flexible, shared, cooperative
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The earliest, the best!!!
The earliest, the best!!!
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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
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Structure Process Outcomes Multidiscipli
nary team Advanced
training and competencies
Leadership Office Documentati
on 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 Effectivene
ss Cost Efficiency Cost/
effectiveness
Satisfaction: patients, families, services
Social Ethical
Basic Indicators of PCServices
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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
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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
Identify, prevent, treat
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Conceptual Transitions• From “Terminal disease” to “Advanced
progressive illnesses”• From “Prognosis of days weeks, < 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”
Institut Català d’Oncologia
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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