4. action plan€¦ · develop an individual intervention plan (iip) in an interdisciplinary...

Strategy

4. Action Plan

Mission Unit for Integrated Continuous Care. Lisbon, December of 2010

LONG TERM CARE Health and Social Support

Fall

2010

Strategy for the Development of the National Palliative Care

Programme

2 Mission Unit for Integrated Continuous Care Strategy for the Development of the National Palliative Care Programme

4.1 Action Lines

The Action Plan for the next triennium, here presented, takes into

account the goals defined in NPCP, the diagnosis of the current

situation for the PC and also the priorities presented in the previous

chapter. In this sense the action lines are:

1. Consolidate NPCP: NPCP incorporates the NHS as a public health

policy, developed using an integrated form, sustainable and

adequately resourced to meet existing needs;

2. Improving the quality of care: ensuring quality in the organization

and delivery of care throughout the continuum of care according to

the best practices and organizational assistance;

3. Promote the expertise of teams and scientific research: to ensure

that all staff who coordinates the NPCP and those who provide direct

care to patients with advanced and progressive disease have the

necessary skills according to the type of service where they are and

their professional profile. Distinguish clinical from organizational skills.

Integrate scientific knowledge production as a measure for the model

adequacy and qualifications of the teams;

4. Developing critical mass and to disseminate the results: promoting

the creation of a pool of actors (politicians, providers, professionals,

civil society) committed to the development of NPCP.

Mission Unit for Integrated Continuous Care Strategy for the Development of the National Palliative Care Programme

3

4.1.1 Consolidate NPCP

DESCRIPTION: NPCP incorporates the NHS in an integrated, sustainable

way and adequately resourced to meet existing needs.

4.1.1.1 Ensuring Leadership

Actions:

1. Formally appoint the referring technicians in each region to

coordinate the implementation of NPCP;

2. Develop mechanisms for coordination and communication between

the national and regional coordination;

3. Set a training plan aimed at national and regional leaders;

4. Create strategic partnerships at national and regional levels that

may add value to NPCP;

5. Develop an annual action plan for each region;

6. Develop a National Action Plan for the triennium 2013-2016 and

ensure its implementation.


4.1.1.2 Assess needs and plan care provision in a phased manner

Actions:

1. Develop Palliative Care Programs integrated into regional plans in

late 2013;

2. Set the answers based on the needs of population coverage

encompassing various organizational models for demographic area

(urban, semi-urban, rural) and including all types of service (specific

and conventional);

3. Adjust annually the planning to the needs of population coverage

and implementation capacity;

4. Prepare regional annual implementation plans identifying:

• The possibilities of optimization / exploitation of existing resources;

• New resources;

• The existence of teams with the necessary technical skills to ensure

the provision of care;

• Areas of reference that meet specifications in order to be constituted

as example areas / excellence of care ;

• Award of merit to the units considered as "Excellence of Care".

4.1.1.3 Implementation

Actions:


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1. Implement annual regional and national action plans in line with the

NPCP;

4.1.1.4 Set the necessary resources and ensure their availability and

sustainability

Actions:

1. Define and allocate annual budgets for implementation of NPCP;

2. Assess the total cost (direct and indirect) for each type of team;

3. Define minimum human , physical and material resources required

for each specific type of Palliative Care;

4. Include in procurement all the requirements for human, material and

physical resources, for each specific type of Palliative Care;

5. Ensure the availability of opioid medications listed in vademecum;

6. Ensure the availability of assisted devices and social support services;

4.1.1.5 Promoting the integration of care and coordination of resources

Actions:

1. Create awareness and information actions about the value of the

provision of early palliative care and integrated with the provision of

other health care;


2. Define and develop joint NPCP with other health related areas,

notably the National Programme for Disease Control and Prevention

and the National Oncological Control of Pain;

3. Define and develop mechanisms for coordination and linkage with

social support services, ensuring their availability especially for patients

receiving palliative home care.

4.1.1.6 Develop and manage all necessary procedures for the proper

services functioning

Actions:

1. Include the admission criteria defined in the system of registration

and referral of the Integrated Continuous Care National Network;

2. Define the minimum set of information to appear on referral;

3. Define the minimum set of information for the registration system and

monitoring and frequency of registration by the providing teams;

4. Provide access to aggregated information at a regional level by

regional team coordination;

5. Define management information available to the national / regional

Coordination and its periodicity;

6. Elaborate a Plan and develop training actions within the functional

organization and utilization of instruments of NPCP.


7

4.1.1.7 Design and implement tools for outcomes monitoring and

control

Actions:

1. Define and include indicators in the contracts of Palliative Care

team providers;

2. Periodically disclose the results.

4.1.1.8 Ensure continuous assessment

Actions:

1. Monitor and evaluate the development of National Action Plan;

2. Monitor and evaluate the development of regional action plans;

3. Using the results of evaluations propose measures for improvement

and continuous development in order to establish it as the WHO

Demonstration Project, according to NPCP;

4. Periodically and systematically evaluate the outcomes of providers’

contracts;

5. Periodically analyze the indicators - key specific results for Palliative

Care, contained in a futurely elaborated document;

6. Comparative studies of national and international levels;


7. Monitor the financial execution of plans;

8. Verify compliance with the requirements of human, material and

physical resources set for delivering teams .

4.1.2 Improving the quality of care

DESCRIPTION: Ensuring quality in the organization and delivery of care

throughout the continuum of care according to organizational and

care best practices.

4.1.2.1 Ensure care in the adequate service and time

Actions:

1. Train professionals in signaling and referral of patients in need of

palliative care;

2. Develop a communication plan that will:

• Inform professionals of the positive value of palliative care;

• Extend the knowledge that they are not opposed to curative (can

coexist) and that the earlier the need of Palliative Care is detected the

more effective it is, which is not exclusive to patients with cancer;

• Raise awareness of the importance of providing local care and, if


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possible, at home where conditions are met to ensure the quality of

care and patient safety;

4.1.2.2 Ensure the provision of holistic care

Actions:

1. Evaluate patients and their family background in a multi and

interdisciplinary way, ensuring that the physical, social, emotional and

spiritual needs are properly assessed and answered;

2. Develop an Individual Intervention Plan (IIP) in an interdisciplinary

context, for each patient;

3. Implement and periodically evaluate the individual intervention plan

for each patient;

4. Define for each case the frequency of communication with the

patient and family and identify a contact point for the team;

5. Include the degree of knowledge of the patient and family /

informal caregivers of their health status and prognosis in the medical

history chart ;

6. Integrate the user's preferences regarding the process of care and

expectations of the place of death in the medical history, information,

dischargement and referral charts;

7. Identify and provide specific support in the process of Grief;


8. Develop guidelines for action on the patient’s privacy and comfort;

9. Establish committees of ethics and bioethics.

4.1.2.3 Ensure continuity in care providance

Actions:

1. Identify and prepare the expected date of dischargement from the

time of admission of the patient, if applicable;

2. Include in the referral record/ dischargement the identification of

the preceding service, doctor / nurse in charge, direct contacts and

availability;

3. Promote the development and preparation of protocols and clinical

cross guidelines involving professionals of different levels of care and

types of services in each area;

4. Facilitate communication and coordination through the

implementation of information technology and communication.

4.1.2.4 Fostering health literacy for patients and support for informal

caregivers

Actions:

1. Inform the patient of every therapeutic goal defined by the team

and review them together;


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2. Maintain appropriate and personalized communication with intensity

and resources in line with the needs of each case;

3. Educating the caregiver / family and the patient in care / self-care;

4. Support decision-making from the patient and family / informal

caregiver, through clarification of the care process;

5. Develop guides for information on palliative care for patients and

carers / family members.

4.1.2.5 Develop mechanisms to support the caregiver

Actions:

1. Define methodologies for identifying early symptoms of burnout in

team professionals;

2. Provide support to practitioners suffering from exhaustion.

4.1.2.6 Promote good practice in care providance

Actions:

1. Develop guidelines for good care practice in accordance with the

principles and recommendations elaborated by organizations of

recognized scientific value ;


2. Disclose forms containing the most widely used drugs in palliative

care, according to international principles and recommendations.

4.1.2.7 Promote and evaluate the quality of care

Actions:

1. Define the core of core indicators and quality targets;

2. Include the core indicators and targets in contracts with the teams

providing palliative care;

3. Perform annual satisfaction survey for professionals, patients and

carers in all types of care;

4. Encourage / support the creation of "forums" of participatory

discussion with national and international providers of palliative care,

as well as the involvement of patients, relatives and representatives of

civil society;

5. Conduct external audits on all types of services (inpatient,

outpatient, home) with more than one year of operation;

6. Include conducting internal audits as a mandatory requirement in

the contracts and determine their frequency.


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4.1.3 Promote the expertise of teams and scientific research

DESCRIPTION: Ensure that all professionals who take care of patients

with advanced and progressive disease have the skills identified as

necessary in accordance with the type of service they are in and their

professional profile.

Support the qualification of services in the organization and delivery of

palliative care through the generation of scientific knowledge.

4.1.3.1 Training

Actions:

1. Undertake a survey of all theoretical and practical skills of each

professional, by type and professional profile;

2. Prepare and develop annual training plans based on identified

training needs. The plans should include:

• Lectures;

• Practical component: training;

3. Prepare and develop a training plan specific to conventional

services professionals (general practitioners and nursing) which

includes:

• Identification of patients in need of palliative care;

• Management of the main symptoms;


4. Elaborate and develop a joint Workshop in PC, for the national

coordination team and regional teams;

5. Prepare and develop a training plan aimed at patients, family /

primary caregiver and volunteers;

6. Prepare and develop a training plan for the integration of new

professionals in specific palliative care teams;

7. Prepare and develop a training plan to support the delivery of

palliative care to specific groups of diseases (eg, rapidly progressive

neurological diseases, AIDS);

8. Defining the training plan and developing specific training in the use

of opioids;

9. Conduct and disseminate program / training evaluations;

10. Create reference centers to provide theoretical training of

undergraduate, postgraduate and practical training at regional and

national level.

11. Sensitize the authorities to the importance of integration of palliative

care in medical and nursing curricula, both in undergraduate courses

and in graduate ones;

12. Sensitize the authorities to the importance of including the Palliative

Care program in practical classes / internship courses;


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13. Sensitize related fields such as psychology, social welfare officers,

physiotherapy and others to formulate a plan of specific training in

palliative care.

4.1.3.2 Research

Actions:

1. Start / strengthen lines of research for all palliative care services.

(Hospitals, RNCCI, Primary Care), scientific societies, professional

associations, universities and others.

4.1.4 Develop critical mass

DESCRIPTION: Fostering the creation of a pool of actors (politicians,

providers, professionals, civil society) committed to the development of

NPCP.

4.1.4.1 Encourage wide participation and commitment in implementing

the action plan by regional coordination teams, RNCCI providers,

professionals and civil society

Actions:

1. Prepare and develop a communication plan to disseminate the

NPCP and the Action Plan and its progress;


2. Schedule and conduct workshops for critical thinking with several

agents (eg, providers, professionals, associations, ....)

3. Develop volunteer incorporating programs for the teams: develop

selection criteria , training program, conditions of participation;

4. Conduct a population survey to ascertain what each individual

thinks about dignified death and what their expectations are regarding

their own death;

5. Inform the authorities of the need to support informal caregivers in

order to facilitate the effective availability of care provision.

4.1.4.2 Ensure the social and scientific visibility

Actions:

1. Prepare and develop a communication plan to inform the civil

society, technicians and politicians about:

• What is Palliative Care;

• Its Goals;

• Who should be referenced and how it should be referenced;

• What are the services provided;

• Number of existing providers.

2. Plan and implement actions to sensitize the media to create valid

information and not sensationalist, preserving the rights of families and

patients;


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3. Planning and carrying out internal and external benchmarking;

4. Conduct studies of results and publish them in recognized scientific

journals;

5. Define and develop actions to implement the NPCP in order to

achieve recognition as a WHO Demonstration Project.


4.2 Schedule of implementation

Goal 1: Consolidating the NPCP

SCHEDULE OF IMPLEMENTATION

STRATEGIES

3 YEAR ACTIONS (2011-2013) 1st

YEAR 2nd YEAR

3rd YEAR

1. Formally appoint the referring technicians in each region to coordinate the implementation of NPCP

2. Define and develop mechanisms for coordination and communication between the national and regional coordination.

3. Develop a plan for continuing education aimed at national and regional leaders.

4. Create strategic partnerships at national and regional levels that add value to NPCP.

5. Prepare the Annual Action Plan by region.

1.1. Providing leadership

6. Review and validate Regional Annual Action Plans by the national coordination.

1.2. Study the needs and plan care provision in a phased manner

1. Set answers based on the needs of population coverage, encompassing various organizational models for each demographic area (urban, semi-urban, rural) and all types of service (specific and conventional).


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STRATEGIES 3 YEAR ACTIONS (2011-2013) RESPONSIBLE

1st YEAR

2nd YEAR

3rd YEAR

2. Annually adjust the planning to the needs of population and implementation capacity.

RNCCI/ECR

1.2. Study the needs and plan care provision in a phased manner (cont.)

3. Prepare annual plans / regional and national implementation plan, identifying opportunities of: optimization / utilization of existing resources, new resources, teams with the necessary technical skills; reference areas (gather characteristics of example areas).

RNCCI/ECR

1.3. Implement

1. Implement annual, regional and national plans of action

RNCCI/ECR

1. Annually define and allocate the funds for implementation of PNCP.

Funds transferred to each ARS/ predicted funds

1.4. Define the necessary resources and ensure their availability 2. 2. Assess the total cost (direct

and indirect) for each typology of team;

RNCCI



STRATEGIES

3 YEAR ACTIONS (2011-2013)

1st YEAR

2nd YEAR

3rd YEAR

3. Define minimum human, physical and material resources required for specific typology of Palliative Care.

4. Include in the program-contracts the requirements for human, physical and material resources for each specific type of Palliative Care.

5. Ensure the availability of opioid medications listed in vademecum.

1.4. Define the necessary resources and ensure their availability (cont.)

6. Ensure the availability of assisted devices and social support services

1. Create awareness raising and information about the value of early palliative care and integrated with other services.

2. Define and implement activities to coordinate the plan with other activities related to health plans.

1.5. Integrate and coordinate care resources

Social Support


21


STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

1. Include the admission criteria defined in the system for recording and monitoring.

2. Define the minimum set of information to appear on referral

3. Define the minimum set of information for the registration system and monitoring and frequency of registration by the providing teams.

4. Provide access to aggregated information at the regional level by regional team coordination.

5. Define management information to provide the coordination national / regional level and their frequency.

1.6. Develop and manage the necessary means for developing the National Palliative Care Programme

6. Develop a training plan and develop training within the organization and functional use of the instruments of the Programme.

1. Define and include indicators and targets of CP on the program-contracts from providing teams.

1.7. Define indicators and outcome targets

Outcomes



STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

1. Monitor and evaluate the development of National Action Plan.

2. Monitor and evaluate the development of Regional Action Plans.

3. Using the results of evaluations to propose measures for improvement and continuous development, aiming to establish itself as a demonstration project of WHO.

4. Periodically and systematically evaluate the outcomes of providers’ contracts.

5. Comparative studies of national and international levels.

6. Monitor the financial execution of the plans.

1.8. Ensure continuous assessment: decisions should be based on evidence in order to improve outcomes

7. Verify compliance with the requirements of human, material and physical resources set for providers teams.


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Goal 2: Improving quality of assistance


STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

1. Training professionals in signaling and referral of patients in need of PC.

2.1. Ensure care in the adequate service and time

2. Develop a comunication plan.

1. Evaluate in an interdisciplinary context and ensure that the needs are answered. 2. Develop an interdisciplinary IIP for each user. 3. Implement the IIP 4. Define for each patient the frequency of communication with the patient / family and identify a caller.

2.2. Ensure the provision of holistic care 5. Include medical history, the

degree of knowledge of the patient and family / caregiver of their health status and prognosis.

ONGOING ACTIVITIES AND ATTACHED TO CARE



STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

6. Include medical history, and note the referral of patient dischargement preferences and family / caregiver and expectations of the care process. 7. Identify and provide specific support in the process of pathological mourning.

ONGOING ACTIVITIES AND INHERENT TO CARE

8. Develop guidelines for action concerning privacy and comfort of the patient.

2.2. Ensure the provision of holistic care (cont.)

9. Establish committees of ethics and bioethics.

1. Identify and prepare the dischargement from the time of admission of the patient, if applicable.


2. Include in the referral record / dischargement the identification of the preceding service, doctor / nurse in charge, direct contacts and availability.

3. Promote the development and preparation of protocols and crossed clinical guidelines involving staff at different levels of care and types of services in each area.

2.3. Ensuring continuity of care

4. Facilitate communication and coordination through the implementation momentum of ITC.


25


STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

1. Inform the patient of every therapeutic goal defined by the team and review them together 2. Maintain appropriate and personalized communication with intensity and resources in line with the needs of each case.


3. Educating the caregiver / family in care / self-care.

4. Support decision-making from the patient and family / informal caregiver through clarification on the process of care.

2.4. Promote the empowerment of patients and informal caregiver support

5. Develop guides for information on palliative care aimed at patients and caregivers / family members.

1. Define methodologies for early symptoms of burnout in professionals.

2.5. Develop mechanisms to support the caregiver formal

2. Provide support to professional exhaustion.


2.6. Develop good practice guides

1. Develop guidelines for good practice in providing care in accordance with the principles and recommendations from organizations of recognized scientific value.


Internationals.


STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

1. Set a core of core indicators and quality targets.

2. Include the core indicators and targets in contracts with the teams providing palliative care.

3. Perform annual satisfaction survey for professionals, patients and carers in all types of care.

4. Conduct external audits on all typologies over 1 year of operation.

2.7. Develop and monitor indicators and quality standards of care

Periodicity.


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Goal 3: Promote skills and techniques of research teams


STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

1. Make a diagnosis on the theoretical and practical skills of professionals by type and profile.

2. Prepare and develop annual training plans, based on the diagnosis made, including: theoretical and internships.

3. Prepare and develop a training plan specific to conventional services professionals (general practitioners and nursing) which includes: the identification of patients in need of PC and management of the main symptoms.

4. Prepare and develop a continuous plan for the national coordination team and regional teams.

5. Develop a training plan aimed at patients, families / primary caregivers and volunteers.

3.1. Training

6. Prepare and develop a training plan for the integration of new professionals in specific Palliative Care teams.



STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

7. Prepare and develop a training program to support the care of specific collective (eg, neurological diseases, AIDS and children).

8. Prepare and develop specific training in the use of opioid medications.

9. Define criteria for selection of faculty.

10. Conduct and disseminate program / training evaluations.

11. Create a referral center with theoretical training (under and post-graduate) and corporate practice as an activity center.

12. Sensitize the authorities to the importance of integrating palliative care into the curricula of medicine and nursing, both in undergraduate courses and in postgraduate courses.

3.1. Training (cont.)

13. Sensitize the authorities to the importance of including the PC in trainning / practical classes / internship.

3.2. Research

1. Start / strengthen lines of research especially in the specialized services of PC level 3 (high complexity).


29

Goal 4: Develop critical mass and disseminate results


STRATEGIES


1st YEAR

2nd YEAR

3rd YEAR

1. Prepare and develop a communication plan to disseminate the NPCP and Action Plan and its progress.

2. Schedule and conduct seminars for critical reflection with the participation of several agents.

3. Develop and incorporate volunteer programs for the teams: developing criteria for selection, training program type and conditions of participation.

4. Conduct a population survey to ascertain what each individual thinks about dignified death and what their expectations are regarding their own death.

4.1. Encourage wide participation and commitment in implementing the action plan by regional coordination teams, RNCCI providers, professionals and civil society

5. Inform the authorities of the need to support informal caregivers in order to facilitate the effective availability of care provision.

Outcomes

4.2. Ensure social and scientific visibility


References


31

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DGS - Programa de Prevenção e Controle das Doenças

Oncológicas 2007/2010 – Development Program.

DGS - Plano Nacional de Saúde 2004 – 2010, vol.I e II.

EAPC: Radbruch L., Payne S, the Board of Directors of the

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norms for hospice and palliative care in Europe (EAPC): The

EAPC white paper. 2009.

Estrategia en Cuidados Paliativos del Sistema Nacional de Salud

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Xavier Gomez-Batiste, Jose Espinosa, Porta-Sales J, Benedito E.

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