Integration of the end of life at home

Abstract

Introduction: The Hospital at Home (HaH) department belongs to a Clinical Governance Unit together with Internal Medicine and the Convalescence Unit. Before 2017 the assistance was organized according to geography, so any medical team would attend a mix of patient profiles ( Acute medical patients, decompensated chronic patients, complex postsurgical or palliatives). After 2017 the department was reorganized making assistance teams fit with patient profiles rather than using geographical criteria. Among other things, a team was created to treat palliative patients. Simultaneously, a triage/consultant doctor profile was created for every assistance levels (primary care, nursing homes and hospital) Description of practice change implemented: - Human resource redistribution (doctors and nurses) - Model change to a patient centered assistance - Coordination with all assistance levels in our integrated health organization (Internal Medicine, nursing homes, primary care and other hospital specialties) Aim: 1- Home based care respecting patients’ and families’ will. 2- Advanced Health Directive about treatment intensity and location of care provision 3- Individualised, ongoing, integrated care 4- Knowledge transference to primary care teams and nursing homes. 5- Creation of the Triage/consultant doctor profile for telephonic support Target population: Oncologic palliative patients Non oncologic patient with advanced organ failure in end of life stage Amyotrophic Lateral Sclerosis patients and advanced dementia with clinical instability, with complex or highly complex needs according to the PAL index. Timeline: October 2016 - December 2017: Design of the new organization January 2017: Launch of the new organization February 2017: Professional role change of a doctor, from face-to-face clinician to a triage/consultant doctor to support primary care and nursing homes. 2016 – 2017: Face-to-face training workshops for primary care October 2017 to March 2018: Rotation of primary care physicians in HaH-palliative care team Highlights: Attention to 610 patients and families in 2017 (53% oncologic 47% non-oncologic) with respected will in 97% of the cases. 71% of direct admission to the department avoiding hospital stay from primary care, internal medicine, oncology and case management nurses. 681 calls attended by the new triage/consultant doctor 64% leading to admission to our HaH-palliative team and 36% for helping in the management of the patients by others. Sustainability: Progressive involvement of the primary care in the palliative care provision is likely to improve sustainability Transferability:This scheme for palliative care provision is transferable to the rest of the OSIs (Integrated Health Organizations) in the Basque Country Conclusions: The changes implemented improved the care of palliative patients providing a more specific approach and also improved integration with other stakeholders such as primary care, nursing homes and hospital specialties. Lessons learned: Redistribution of existing resources can lead to a better patient experience in palliative care

Keywords

• end of life care
• home based care
• palliative