A proposed systems approach to the evaluation of integrated palliative care

Where are the values in evaluating palliative care? Learning from community-based palliative care provision

Background

The World Health Organization Astana Declaration of 2018 sees primary healthcare as key to universal health coverage and gives further support to the goal of building sustainable models of community palliative care. Yet evaluating the benefits of such models continues to pose methodological and conceptual challenges.

Objective

To explore evaluation issues associated with a community-based palliative care approach in Kerala, India.

Design

An illuminative case study using a rapid evaluation methodology.

Methodology

Qualitative interviews, documentary analysis and observations of home care and community organising.

Results

We appraise a community palliative care programme in Kerala, India, using three linked 'canvases' of enquiry: (1) 'complex' multi-factorial community-based interventions and implications for evaluation; (2) 'axiological' orientations that foreground values in any evaluation process and (3) the status of evaluative evidence in postcolonial contexts. Three values underpinning the care process were significant: heterogeneity, voice and decentralisation. We identify 'objects of interest' related to first-, second- and third-order outcomes: (1) individuals and organisations; (2) unintended targets outside the core domain and (3) indirect, distal effects within and outside the domain.

Conclusion

We show how evaluation of palliative care in complex community circumstances can be successfully accomplished when attending to the significance of community care values.

Assessing Healthcare Integration: An Integrated Palliative Care System in Spain

Introduction

This study explored the Osona palliative care system, recognized internationally for its good results in managing the chronic patient. The literature notices a gap of models that evaluate integration in healthcare systems. This study assesses the degree of integration of the Osona palliative care system, as well it implements a model that evaluates integration.

Methods

This research used a qualitative methodology, involving a case study design with three study phases. The first phase involved reviewing primary sources, followed by conducting interviews. The final phase entailed comparing the findings with a theoretical model to analyse and validate the results.

Results

The study found the integrative elements that the Osona system includes such as: multidisciplinary teams, leadership and a palliative care system that is cost-efficient. It also found aspects to improve including collaboration, continuity of care, early patient identification and lack of funding.

Discussion

Our findings suggest that the Osona system has made significant progress toward integration, even though it continues the path of ongoing development in integrated care.

Conclusion

This research found that the Osona palliative care system includes many integrating aspects such as multidisciplinary teams, leadership and the system's cost-efficiency. Nevertheless, some aspects need changes such as continuity of care, collaboration, enhanced early patient identification and increase funding. Furthermore, this study provides an example of how to assess integration in a system.

Increasing interprofessional collaboration in community-based palliative care: a pilot study of the CAPACITI education program for primary care providers

Interprofessional collaboration in palliative care is essential to ensuring high-quality care for seriously ill patients. Education interventions to increase competency in palliative care should incorporate team-building skills to encourage an interprofessional approach. We developed and piloted a virtual educational program named CAPACITI for interprofessional teams to promote a community palliative approach to care. Primary care teams from across Ontario, Canada, participated in CAPACITI which consisted of 10 facilitated sessions that emphasized how to operationalize a palliative care approach as a team. Pre- and post-study questionnaires were completed by each team, including the AITCS-II, a validated instrument that measures interprofessional collaboration. We analyzed individual paired differences in summary scores and in each of three subdomains of the AITCS-II questionnaire: partnership, cooperation, and coordination. Seventeen teams completed the AITCS-II post survey, representing 133 participants. Teams varied demographically and ranged from 5 to 16 members. After CAPACITI, the overall mean AITCS-II summary score among teams increased to 96.0 (SD = 10.0) for a significant paired mean difference increase of 9.4 (p = .03). There were also significant increases in the partnership (p = .01) and in the cooperation subdomains (p = .04). CAPACITI demonstrated the potential for improving collaboration among primary care teams, which can lead to improved provider and patient outcomes in palliative care.

Regional hospice and palliative care networks worldwide: scoping review

BACKGROUND

Regional hospice and palliative care networks (RHPCNs) are increasingly being established to improve integrative care for patients with life-limiting illnesses. This scoping review aimed at identifying and synthesising international literature on RHPCNs, focusing on structures, outcomes, benefits, success factors and good practices.

METHOD

Following Arksey and O'Malley's (2005) framework, a search of four electronic databases (CINAHL, Google Scholar, PubMed, Web of Science Core Collection) was conducted on 7 July 2023. Additionally, a manual search of reference lists of the identified articles was performed. Original research, qualification theses and descriptive reports on RHPCNs at a structural level were included.

FINDINGS

Two researchers analysed 777 article abstracts, screened 104 full texts and selected 24 articles. The included studies predominantly used qualitative designs. RHPCNs self-identify as local stakeholders, employ coordination offices and steering committees, and actively recruit network partners. Outcomes included improved professional practices, enhanced quality of care, increased patient utilisation of regional care offerings and improved patient transitions between care providers. Success factors included clear coordination, transparent communication, strategic planning and resource-securing strategies.

CONCLUSIONS

The analysis identified key RHPCN success factors such as effective communication and adaptive leadership. Despite the need for further research, the findings emphasise RHPCNs' potential to improve palliative care and encourage policymaker support.

OTHER

This scoping review is part of the research project HOPAN, which aims at assessing and analysing RHPCNs in Germany. The project is funded by the German Innovation Fund of the Federal Joint Committee (G-BA) (Grant N° 01VSF22042; funding period: 01/2023-12/2024).

Implementing palliative care education into primary care practice: a qualitative case study of the CAPACITI pilot program

BACKGROUND

CAPACITI is a virtual education program that teaches primary care teams how to provide an early palliative approach to care. After piloting its implementation, we conducted an in-depth qualitative study with CAPACITI participants to assess the effectiveness of the components and to understand the challenges and enablers to virtual palliative care education.

METHODS

We applied a qualitative case study approach to assess and synthesize three sources of data collected from the teams that participated in CAPACITI: reflection survey data, open text survey data, and focus group transcriptions. We completed a thematic analysis of these responses to gain an understanding of participant experiences with the intervention and its application in practice.

RESULTS

The CAPACITI program was completed by 22 primary care teams consisting of 159 participants across Ontario, Canada. Qualitative data was obtained from all teams, including 15 teams that participated in focus groups and 21 teams that provided reflection survey data on CAPACITI content and how it translated into practice. Three major themes arose from cross-analysis of the data: changes in practice derived from involvement in CAPACITI, utility of specific elements of the program, and barriers and challenges to enacting CAPACITI in practice. Importantly, participants reported that the multifaceted approach of CAPACITI was helpful to them building their confidence and competence in applying a palliative approach to care.

CONCLUSIONS

Primary care teams perceived the CAPACITI facilitated program as effective towards incorporating palliative care into their practices. CAPACITI warrants further study on a national scale using a randomized trial methodology. Future iterations of CAPACITI need to help mitigate barriers identified by respondents, including team fragmentation and system-based challenges to encourage interprofessional collaboration and knowledge translation.

Effectiveness of Training Programs About a Palliative Care Approach: A Systematic Review of Intervention Trials for Health Care Professionals

Background: Palliative care (PC) training initiatives have proliferated to assist generalist health care providers (HCPs) develop skills for applying an early PC approach. To date, there is little synthesis of high-level evidence to review the content and effectiveness of these programs. To address this gap in knowledge, we conducted a systematic review of trials of training inventions to build PC competency in HCPs, according to PRISMA guidelines (PROSPERO registration no. 271741). Materials and Methods: We searched MEDLINE, Embase, PsycINFO, CINAHL, HealthSTAR, Web of Science, and the Cochrane Database of Systematic Reviews and Clinical Trials for studies published since 2000. Eligible studies were trials assessing PC training for HCPs. Interventions had to address at least two of six PC-related components, adapted from the National Consensus Project: identification or assessment; illness understanding; symptom management; decision making; coping; and referral. Two reviewers independently assessed articles for inclusion, using Rayyan, and extracted relevant data. Risk of bias was assessed using the Cochrane ROB2 or ROBINS-I tools. Results: Of 1209 articles reviewed, 22 studies met the inclusion criteria, with the majority being conducted in the United States (n = 9) or Europe (n = 8). Nearly all studies (n = 19) collected data through self-reported surveys; administrative (n = 4), clinical outcomes (n = 4), or interaction analysis (n = 6) data were also or solely used. Interventions featured didactic, skill-based training followed by role-play and/or individual coaching. Communication around illness understanding was the most taught PC component. Few interventions involved comprehensive PC training, with 12 studies representing 3 or less of the 6 framework components. Most studies (n = 16) reported a significant positive impact on at least one outcome, most often HCP self-reported outcomes. Conclusions: While many of these interventions demonstrated improved confidence among HCPs in the PC components taught, findings were mixed on more objective outcome measures. Further trial-based evidence is required on comprehensive PC training to help inform these interventions.

Building Palliative Care Capacity for Generalist Providers in the Community: Results From the Capaciti Pilot Education Program

Objective: Primary care providers play an important role in providing early palliative care, however they often lack practical supports to operationalize this approach in practice. CAPACITI is a virtual training program aimed at providing practical tips, strategies, and action plans to help primary care providers offer an early palliative approach to care. The CAPACITI pilot program consisted of 10 facilitated, monthly training sessions, covering identification and assessment, communication, and engaging caregivers and specialists. We present the findings of an evaluation of the pilot program. Method: We conducted a single cohort study of primary care providers who participated in CAPACITI. Study outcomes were the change in the percentage of caseload reported as requiring palliative care and improved confidence in competencies measured on a 20-item, study-created survey. Pre and post survey data were analyzed using paired t-tests. Results: Twenty-two teams representing 127 care providers (including 36 physicians and 28 Nurse Practitioners) completed CAPACITI. Paired comparisons showed a moderate improvement in confidence across the competencies covered (.6 to 1.3 mean improvement across items using seven-point scales, all P < .05). Pre-CAPACITI, clinician prescribers (N = 32) identified a mean of 1.2% of their caseload requiring a palliative approach to care, which increased to 1.6% post-program (P = .02). Said differently, the total group of paired clinician prescribers identified 338 patients as requiring palliative care in their caseloads at baseline vs 482 patients following the intervention, for an overall increase of 144 patients in their collective caseloads. Conclusion: CAPACITI improved self-assessed palliative care identification and provider confidence in core competencies. The program demonstrated potential for building palliative care capacity in primary care teams.

[Vulnerable persons, partners or warriors? How relatives perceive their roles in palliative care]

Relatives play a very important role in palliative care. Whilst previous research has investigated this role from the perspective of health professionals, this article focuses on the perspectives of the relatives of palliative patients. The present paper aims to identify relatives' perceptions of their role with respect to their relationship to professionals and to describe their significance for satisfaction with palliative care. Content analysis of 23 guideline-based interviews with relatives in Switzerland identified three main role perceptions of relatives, namely as: "vulnerable persons", as "partners" or "warriors". The results indicate that relatives' satisfaction with palliative care depends on the role assigned to them by specialists in the care process. This article demonstrates that well-trained health personnel in the field of palliative care and a common understanding of the roles within the palliative care team are central to supporting relatives. These findings can help inform good collaboration between relatives and professionals in palliative care (e.g., general practitioners, nurses, specialized doctors, such as oncologists, and specialized nurses) and to encourage families to feel comfortable with the care their loved ones receive.

Synthesis of health promotion concepts in children's palliative care

BACKGROUND

Palliative care improves the health of children with a life-limiting condition and appears to draw implicitly on concepts shared with a model of health promotion. However, to date there has been no scrutiny about how this relationship may shape understanding about children's palliative care.

AIM

To explore the influence of health promoting concepts on children's palliative care models, policies and guidelines.

DATA SOURCES

Health and social care databases were searched for policies, models and guidelines published between 2000-2018. Additional searches of professional national and international healthcare websites, children's palliative care charities and UK and Ireland government websites were conducted.

METHODS

A best fit framework synthesis was used.

FINDINGS

A total of 55 policies and guidelines were reviewed for the framework synthesis. Eight themes were generated: (1) health promoting children's palliative care policy and guidelines; (2) planning ahead; (3) creating a supportive environment; (4) enabling coping and independence; (5) reorienting children's palliative care sectors; (6) the lengthening trajectory of need for support; (7) strengthening community engagement in children's palliative care; and (8) quality of life and value-based ideologies.

CONCLUSION

The best fit framework synthesis confirmed a conceptual relationship between children's palliative care and health promotion. This is captured in a new model that will extend professionals' understanding.

Organizational determinants of information transfer in palliative care teams: A structural equation modeling approach

Several organizational factors facilitate or hinder information transfer in palliative care teams. According to past research, organizational factors that reduce information transfer include the inconsistent use of shared electronic patient files, frequent changes of healthcare staff, a lack of opportunities for personal exchange, and a lack of evaluation of collaborative processes. Insufficient information sharing between professionals can negatively impact patient safety, whereas studies have shown that some organizational factors improve collaboration between professionals and thus contribute to improved patient outcomes. The main purpose of this study is thus to investigate whether, and if so how, organizational factors contribute to successful information exchange in palliative care teams in Switzerland, while also accounting for the different care contexts of primary and specialized palliative care. A nationwide survey was aimed at medical professionals working in palliative care. In total, 379 participants (mean age = 49.8 years, SD = 10.3) were included in this study. Two main outcome variables were examined: healthcare providers' satisfaction with information transfer in their team and their overall satisfaction with communication in their team. Hypotheses were tested by employing structural equation modeling. Findings revealed that the strongest predictors for effective information transfer in palliative care teams were sufficient opportunities for face-to-face meetings and supervision alongside feedback tools to improve collaborative practices and the application of guidelines and standards for collaboration. Face-to-face meetings were an even greater contributor to information transfer in specialized settings, whereas sharing the same work-based values with colleagues was considered more important in primary settings. Results from this study contribute to the existing literature elucidating how information transfer is facilitated in the field of palliative care. If proposed measures are implemented, this could possibly improve patient outcomes in palliative care. Furthermore, the findings can be useful for healthcare organizations and associations to make more efficient resource allocation decisions with the aim to optimize information transfer within the workforce.

Approaches to integrating palliative care into African health systems: a qualitative systematic review

Africa is characterized by a high burden of disease and health system deficits, with an overwhelming and increasing demand for palliative care (PC). Yet only one African country is currently considered to have advanced integration of palliative care into medical services and generalized PC is said to be available in only a handful of others. The integration of PC into all levels of a health system has been called for to increase access to PC and to strengthen health systems. Contextually appropriate evidence to guide integration is vital yet limited. This qualitative systematic review analyses interventions to integrate PC into African health systems to provide insight into the 'how' of PC integration. Forty articles were identified, describing 51 different interventions. This study found that a variety of integration models are being applied, with limited best practices being evaluated and repeated in other contexts. Interventions typically focused on integrating specialized PC services into individual or multiple health facilities, with only a few examples of PC integrated at a population level. Four identified issues could either promote integration (by being present) or block integration (by their absence). These include the provision of PC at all levels of the health system alongside curative care; the development and presence of sustainable partnerships; health systems and workers that can support integration; and lastly, placing the client, their family and community at the centre of integration. These echo the broader literature on integration of health services generally. There is currently a strong suggestion that the integration of PC contributes to health system strengthening; however, this is not well evidenced in the literature and future interventions would benefit from placing health systems strengthening at the forefront, as well as situating their work within the context of integration of health services more generally.

Care Coordination in Palliative Home Care: Who Plays the Key Role?

Background:

Clearly identified professionals who are appointed for care coordination are invaluable for ensuring efficient coordination of health care services. However, challenges to identifying roles in palliative care are well documented in literature. Notably, in order to meet high demands on palliative home care settings, many care practitioners perform tasks that surpass the responsibilities and regulations of their role, including care coordination. Without clearly defined roles, standards of care cannot be guaranteed. Yet, little is understood about who plays the key role in palliative home care.

Aim:

The present study aims to address the gap in the research by identifying who plays a key role in coordination in palliative home care.

Methods:

Interviews with general practitioners (GPs), nurses and relatives of palliative patients were carried out in Swiss cantons (Vaud, Ticino, Luzern and Basel) to identify key coordinators of care. Interviews were analyzed using content analysis and presented using grounded theory.

Results:

Findings indicated that there was considerable ambiguity of the key coordinator role. 1) Causal conditions of this phenomenon were; informality of professional roles and lack of communication between team members, 2) Consequences of this included; conflicting understandings of key coordinator role and family members feeling overburdened, 3) Strategies adopted by interviewees included; adapting or taking control of care coordination. These findings are highly indicative of areas for improvement for care coordination in palliative home care settings. Specifically, they underline a profound need for clear communication between palliative care service providers regarding which professionals assume a key coordative role, or who are delegated a coordinative role at any given time. Crucially, since the findings reveal that relatives are intimately involved in care coordination, the findings point to a lack of adequate financial and psycho-social support for relatives of palliative patients who are burdened with coordination tasks, without the appropriate recompense.

Rethinking palliative care in a public health context: addressing the needs of persons with non-communicable chronic diseases

Non-communicable chronic diseases (NCCDs) are the main cause of morbidity and mortality globally. Demographic aging has resulted in older populations with more complex healthcare needs. This necessitates a multilevel rethinking of healthcare policies, health education and community support systems with digitalization of technologies playing a central role. The European Innovation Partnership on Active and Healthy Aging (A3) working group focuses on well-being for older adults, with an emphasis on quality of life and healthy aging. A subgroup of A3, including multidisciplinary stakeholders in health care across Europe, focuses on the palliative care (PC) model as a paradigm to be modified to meet the needs of older persons with NCCDs. This development paper delineates the key parameters we identified as critical in creating a public health model of PC directed to the needs of persons with NCCDs. This paradigm shift should affect horizontal components of public health models. Furthermore, our model includes vertical components often neglected, such as nutrition, resilience, well-being and leisure activities. The main enablers identified are information and communication technologies, education and training programs, communities of compassion, twinning activities, promoting research and increasing awareness amongst policymakers. We also identified key 'bottlenecks': inequity of access, insufficient research, inadequate development of advance care planning and a lack of co-creation of relevant technologies and shared decision-making. Rethinking PC within a public health context must focus on developing policies, training and technologies to enhance person-centered quality life for those with NCCD, while ensuring that they and those important to them experience death with dignity.

Relationships Among Structures, Team Processes, and Outcomes for Service Users in Quebec Mental Health Service Networks

Background:

Few studies have identified and compared profiles of mental health service networks (MHSN) in terms of structures, processes, and outcomes, based on cluster analyses and perceptions of team managers, MH professionals and service users. This study assessed these associations in Quebec metropolitan, urban and semi-urban MHSN.

Methods:

A framework adapted from the Donabedian model guided data management, and cluster analyses were used to identify categories. Study participants included team managers (n = 45), MH professionals (n = 311) and service users (n = 327).

Results:

For all three MHSN, a common outcome category emerged: service users with complex MH problems and negative outcomes. The Metropolitan network reported two categories for structures (specialized MH teams, primary care MH teams) and processes (senior medical professional, psychosocial professionals), and outcomes (middle-age men with positive outcomes, older women with few MH problems). The Urban and Semi-urban networks revealed one category for structures (all teams) and service user (young service users with drug disorders), but two for processes (psychosocial professionals: urban, all professionals: semi-urban).

Conclusion:

The Metropolitan MHSN showed greater heterogeneity regarding structures and team processes than the other two MHSN. Service user outcomes were largely associated with clinical characteristics, regardless of network configurations for structures and team processes.

The Impact of Measuring Patient-Reported Outcome Measures on Quality of and Access to Palliative Care

BACKGROUND

Measuring performance for palliative care is complex as care is delivered in many sites, over time and jointly to the patient and family. Measures of structural processes do not necessarily capture aspects that are important to patients and families nor reflect holistic multidisciplinary outcomes of care. This article focuses on the question as to whether measurement of patient-reported outcome measures improves the outcomes of quality and access to palliative care.

OBJECTIVES

To review the international evidence that measurement of indicators of desired outcomes improves the quality of and access to palliative care, in order to apply them to the Canadian context.

DESIGN

Rapid review.

SETTING

Canadian context.

FINDINGS

This review identified six systematic reviews and forty-seven studies that describe largely national efforts to arrive at a consensus as to what needs to be measured to assess quality of palliative care. Patient-reported outcome measures (PROMs) are becoming more prevalent, with emerging evidence to suggest that their measurement improves outcomes that are important to patients. Several Canadian initiatives are in place, including the Canadian Partnership Against Cancer's efforts, in conjunction with other partners, to develop common quality measures. Results from Australia's Palliative Care Outcomes Collaborative demonstrate that patient-centered improvements in palliative care can be measured by using patient-reported outcomes derived at the point of care and delivered nationally.

CONCLUSIONS

Measurement of quality palliative and end-of-life care is very complex. It requires that both administrative data and PROMs be assessed to reflect outcomes that are important to patients and families. Australia's national initiative is a promising exemplar for continued work in this area.

An investigation of the challenges to coordination at the interface of primary and specialized palliative care services in Switzerland: A qualitative interview study

Good coordination of healthcare services is vital for ensuring health cost efficiency and high-quality care for patients. It is especially important in the context of palliative care as services are often highly fragmented due to a combination of diverse professional groups, organizations, and approaches to care. However, the coordination of services in this field is often evaluated as insufficient. Little is known about the challenges to coordination in this sector in Switzerland. The present study addresses this gap in research by investigating the challenges to coordination at the interface of palliative care services in Switzerland. Interviews (n = 24) with 38 healthcare practitioners working in palliative care in four cantons (Basel-City, Lucerne, Ticino, and Vaud) form the basis for this investigation. The selected cantons not only represent French, Italian, and German language regions of Switzerland but also represent diverse rural, urban, and historical contexts. Expert interviews are analyzed using structural content analysis. Three clusters of challenges to coordination were identified in the data: (1) organizational challenges to coordination, which relate to explicit forms of coordination; (2) relational challenges to coordination; and (3) structural challenges to coordination, which relate to implicit forms of coordination. The study reveals a need for better financial support for coordination in palliative care and a stronger focus on interprofessional coordination in educating professionals in palliative care. Future research on how to further foster good team coordination practices between primary and specialized palliative services merits further investigation. Since these findings are indicative of areas for improvement for coordination at the interface of Swiss palliative care services, they are of particular interest for healthcare practitioners, policymakers, and researchers involved in the evolution of coordinative practice.

International palliative care research priorities: A systematic review

BACKGROUND

There has been increasing evidence and debate on palliative care research priorities and the international research agenda. To date, however, there is a lack of synthesis of this evidence, examining commonalities, differences, and gaps. To identify and synthesize literature on international palliative care research priorities originating from Western countries mapped to a quality assessment framework.

METHODS

A systematic review of several academic and grey databases were searched from January 2008-June 2019 for studies eliciting research priorities in palliative care in English. Two researchers independently reviewed, critically appraised, and conducted data extraction and synthesis.

RESULTS

The search yielded 10,235 articles (academic databases, n = 4108; grey literature, n = 6127), of which ten were included for appraisal and review. Priority areas were identified: service models; continuity of care; training and education; inequality; communication; living well and independently; and recognising family/carer needs and the importance of families. Methodological approaches and process of reporting varied. There was little representation of patient and caregiver driven agendas. The priorities were mapped to the Donabedian framework for assessing quality reflecting structure, process and outcomes and key priority areas.

CONCLUSIONS

Limited evidence exists pertaining to research priorities across palliative care. Whilst a broad range of topics were elicited, approaches and samples varied questioning the credibility of findings. The voice of the care provider dominated, calling for more inclusive means to capture the patient and family voice. The findings of this study may serve as a template to understand the commonalities of research, identify gaps, and extend the palliative care research agenda.

Palliative care in primary care: European Forum for Primary Care position paper

AIM

The aim of this position paper is to assist primary health care (PHC) providers, policymakers, and researchers by discussing the current context in which palliative health care functions within PHC in Europe. The position paper gives examples for improvements to palliative care models from studies and international discussions at European Forum for Primary Care (EFPC) workshops and conferences.

BACKGROUND

Palliative care is a holistic approach that improves the quality of life of patients and their families facing problems associated with terminal illness, through the prevention and relief of suffering by means of early identification and diligent assessment and treatment of pain and other problems, whether physical, psychosocial, or spiritual. Unfortunately, some Europeans, unless they have cancer, still do not have access to generalist or specialist palliative care.

METHODS

A draft of this position paper was distributed electronically through the EFPC network in 2015, 2016, and 2017. Active collaboration with the representatives of the International Primary Palliative Care Network was established from the very beginning and more recently with the EAPC Primary Care Reference Group. Barriers, opportunities, and examples of good and bad practices were discussed at workshops focusing on palliative care at the international conferences of Southeastern European countries in Ljubljana (2015) and Budva (2017), at regular conferences in Amsterdam (2015) and Riga (2016), at the WONCA Europe conferences in Istanbul (2015), Copenhagen (2016), and Prague (2017), and at the EAPC conference in Madrid (2017).

FINDINGS

There is great diversity in the extent and type of palliative care provided in primary care by European countries. Primary care teams (PCTs) are well placed to encourage timely palliative care. We collected examples from different countries. We found numerous barriers influencing PCTs in preparing care plans with patients. We identified many facilitators to improve the organization of palliative care.

Instruments to evaluate complexity in end-of-life care

PURPOSE OF REVIEW

The growing number of patients with terminal and chronic conditions and co-morbidities constitutes a challenge for any healthcare system, to provide effective and efficient patient-centred care at the end of life. Resources are limited, and complexity is rising within patients' situations and healthcare professionals interventions. This review presents the state of art of the role of complexity in specialist palliative care provision.

RECENT FINDINGS

Although studies related to complexity in palliative care are still limited, interesting reviews on complexity frameworks in co-morbidity conditions and palliative care are growing more present in current literature. They identify multidimensional issues, resource utilisation, and the relationship between them as fundamental aspects of complexity constructs, helping to define and understand complexity, and to therefore design validated tools to support healthcare professionals identifying the most complex patients, such as Hui's criteria, PALCOM, INTERMED, and IDC-Pal which is presented in this review.

SUMMARY

There is an urgent need to guarantee quality and equity of care for all the patients eligible for palliative care, from those who need a palliative care approach to those needing specialist intensive palliative care. Implementing complexity theory into practice is paramount. In this review, complexity science, complexity frameworks, as well as tools evaluating complexity in palliative care are described.

Health Care Coordination Theoretical Frameworks: a Systematic Scoping Review to Increase Their Understanding and Use in Practice

BACKGROUND

Care coordination is crucial to avoid potential risks of care fragmentation in people with complex care needs. While there are many empirical and conceptual approaches to measuring and improving care coordination, use of theory is limited by its complexity and the wide variability of available frameworks. We systematically identified and categorized existing care coordination theoretical frameworks in new ways to make the theory-to-practice link more accessible.

METHODS

To identify relevant frameworks, we searched MEDLINE®, Cochrane, CINAHL, PsycINFO, and SocINDEX from 2010 to May 2018, and various other nonbibliographic sources. We summarized framework characteristics and organized them using categories from the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. Based on expert input, we then categorized available frameworks on consideration of whether they addressed contextual factors, what locus they addressed, and their design elements. We used predefined criteria for study selection and data abstraction.

RESULTS

Among 4389 citations, we identified 37 widely diverse frameworks, including 16 recent frameworks unidentified by previous reviews. Few led to development of measures (39%) or initiatives (6%). We identified 5 that are most relevant to primary care. The 2018 framework by Weaver et al., describing relationships between a wide range of primary care-specific domains, may be the most useful to those investigating the effectiveness of primary care coordination approaches. We also identified 3 frameworks focused on locus and design features of implementation that could prove especially useful to those responsible for implementing care coordination.

DISCUSSION

This review identified the most comprehensive frameworks and their main emphases for several general practice-relevant applications. Greater application of these frameworks in the design and evaluation of coordination approaches may increase their consistent implementation and measurement. Future research should emphasize implementation-focused frameworks that better identify factors and mechanisms through which an initiative achieves impact.

Development of empirical recommendations for regional hospice and palliative care networks in Germany: A qualitative study

BACKGROUND

Internationally, efforts are underway to develop coordinated and standardized approaches for palliative care service delivery by improving service quality in hospice and palliative care networks. German legal regulations explicitly demand networking between hospice and palliative care providers. However, there is little research on models of cooperation and the building and development of hospice and palliative care networks. Research-based recommendations for network building and advancement are lacking.

OBJECTIVE

The study aim was to develop empirical recommendations for the building of new and advancement of existing hospice and palliative care networks in Bavaria, Germany.

METHODS

The project utilized a qualitative approach. The research project was structured in six sequential phases: 1) semi-structured individual interviews on status quo of networks, 2) a workshop including a focus group to develop definitions of key terms and prioritize major network themes, 3) semi-structured face-to-face interviews on factors enabling and inhibiting cooperation, 4) drafting of a recommendation for regional hospice and palliative care networks, 5) an online consensus survey questionnaire to rate relevance and feasibility of the draft recommendation and an internal consensus meeting to revise the draft, and 6) an expert workshop to develop examples of realization. Coordinators and chairpersons of 12 hospice and palliative care networks constitute the study population for study phases 1 to 3, 5, and 6. Network representatives partook in one (n=6), two (n=6), three (n=4), four (n=2), or all five (n=1) of the study phases 1, 2, 3, 5, and 6. Further experts participated in one (n=10) or both (n=1) of the phases 5 and 6.

RESULTS

Recommendations were drafted for six thematic fields: (i) missions and aims, (ii) roles and responsibilities, (iii) coordination, (iv) communication and information channels, (v) public visibility, and (vi) funding. The whole set of recommendations was rated by 90% of the participants to be fully or somewhat important for network building and development. A total of 22 recommendations was approved.

CONCLUSIONS

The call for establishing and developing standards for hospice and palliative care networks was situated within the current policy climate of Germany and the broader international community. The present recommendations can aid implementation of this request and have a strong relevance for practice.

Evaluating Program Integration and the Rise in Collaboration: Case study of A Palliative Care Network

Introduction: There is increasing global interest in using regional palliative care networks (PCNs) to integrate care and create systems that are more cost-effective and responsive. We examined a PCN that used a community development approach to build capacity for palliative care in each distinct community in a region of southern Ontario, Canada, with the goal of achieving a competent integrated system. Methods: Using a case study methodology, we examined a PCN at the structural level through a document review, a survey of 20 organizational administrators, and an interview with the network director. Results: The PCN identified 14 distinct communities at different stages of development within the region. Despite the lack of some key features that would facilitate efficient palliative care delivery across these communities, administrators largely viewed the network partnership as beneficial and collaborative. Conclusion: The PCN has attempted to recognize specific needs in each local area. Change is gradual but participatory. There remain structural issues that may negatively affect the functioning of the PCN.

The development of specialized palliative care in the community: A qualitative study of the evolution of 15 teams

BACKGROUND

Interprofessional specialized palliative care teams at home improve patient outcomes, reduce healthcare costs, and support many patients to die at home. However, practical details about how to develop home-based teams in different regions and health systems are scarce.

AIM

To examine how a variety of home-based specialized palliative care teams created and grew their team over time and to identify critical steps in their evolution.

DESIGN

A qualitative study was designed based on a grounded theory approach, using semi-structured interviews and other documentation.

SETTING/PARTICIPANTS

In all, 15 specialized palliative care teams from Ontario, Canada, representing rural and urban areas. Data were collected from core members of the teams, including nurses, physicians, personal support workers, spiritual counselors, and administrators.

RESULTS

In all, 122 individuals where interviewed, ranging from 4 to 10 per team. The analysis revealed four stages in team evolution: Inception, Start-up (n = 4 teams), Growth (n = 5), and Mature (n = 6). In the Inception stage, a champion provider was required to leverage existing resources to form the team. Start-up teams were testing and adjusting care processes to solidify their presence in the community. Growth teams had core expertise, relationships with fellow providers, and 24/7 support. Mature teams were fully integrated in the community, but still engaged in continuous quality improvement.

CONCLUSION

Understanding the developmental stages of teams can help to inform the progress of other community-based teams. Appropriate outcome measures at each stage are also critical for team motivation and steady progress.

An Instrument to Measure Maturity of Integrated Care: A First Validation Study

INTRODUCTION

Lessons captured from interviews with 12 European regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions reflecting the various aspects that need to be managed in order to deliver integrated care. The objective of the study was to test the content validity of B3-MM as part of SCIROCCO (Scaling Integrated Care into Context), a European Union funded project.

METHODS

A literature review was conducted to compare B3-MM's 12 dimensions and their measurement scales with existing measures and instruments that focus on assessing the development of integrated care. Subsequently, a three-round survey conducted through a Delphi study with international experts in the field of integrated care was performed to test the relevance of: 1) the dimensions, 2) the maturity indicators and 3) the assessment scale used in B3-MM.

RESULTS

The 11 articles included in the literature review confirmed all the dimensions described in the original version of B3-MM. The Delphi study rounds resulted in various phrasing amendments of indicators and assessment scale. Full agreement among the experts on the relevance of the 12 B3-MM dimensions, their indicators, and assessment scale was reached after the third Delphi round.

CONCLUSION AND DISCUSSION

The B3-MM dimensions, maturity indicators and assessment scale showed satisfactory content validity. While the B3-MM is a unique instrument based on existing knowledge and experiences of regions in integrated care, further testing is needed to explore other measurement properties of B3-MM.

A Review of the Essential Components of Quality Palliative Care in the Home

OBJECTIVE

The home is an important and often preferable setting of palliative care. While much research has demonstrated the benefits of specialized palliative homecare on patient and system outcomes, there has been little delineation of the underlying components of these efficacious programs. We synthesized the essential elements of palliative homecare from a combined review of successful programs, perspectives of patients and caregivers, and views of healthcare providers in palliative care.

METHODS

Five unique palliative homecare studies were included in the rapid review and synthesis-(1) systematic review of the components of efficacious programs; (2) in-depth analysis of 11 effective community-based teams; (3) survey of bereaved caregivers; (4) survey of the general public; and (5) interviews of providers and administrators. A qualitative approach was used to identify transcending themes across the studies.

RESULTS

Six essential elements of quality palliative homecare were common across the studies: (1) Integrated teamwork; (2) Management of pain and physical symptoms; (3) Holistic care; (4) Caring, compassionate, and skilled providers; (5) Timely and responsive care; and (6) Patient and family preparedness.

CONCLUSIONS

Our metasynthesis of effective palliative homecare models, as well as, the values of those who use and provide these services, illuminates the underpinning elements of quality home-based care for patients with a life-limiting illness. However, the application of these elements must be relevant to the local community context. To create impactful, sustainable homecare programs, it is critical to capitalize on existing processes, partnerships, and assets.

Is the content of guidelines/pathways a barrier for the integration of palliative Care in Chronic Heart Failure (CHF) and chronic pulmonary obstructive disease (COPD)? A comparison with the case of cancer in Europe

BACKGROUND

There is a notable inequity in access to palliative care (PC) services between cancer and Chronic Heart Failure (CHF)/Chronic Obstructive Pulmonary Disease (COPD) patients which also translates into discrepancies in the level of integration of PC. By cross-examining the levels of PC integration in published guidelines/pathways for CHF/COPD and cancer in Europe, this study examines whether these discrepancies may be attributed to the content of the guidelines.

DESIGN

A quantitative evaluation was made between integrated PC in published guidelines for cancer and CHF/COPD in Europe. The content of integrated PC in guidelines/pathways was measured using an 11 point integrated PC criteria tool (IPC criteria). A statistical analysis was carried out to detect similarities and differences in the level of integrated PC between the two groups.

RESULTS

The levels of integration between CHF/COPD and cancer guidelines/pathways have been shown to be statistically similar. Moreover, the quality of evidence utilized and the date of development of the guidelines/pathways appear not to impact upon the PC integration in the guidelines.

CONCLUSION

In Europe, the empirically observed imbalance in integration of PC for patients with cancer and CHF/COPD may only partially be attributed to the content of the guidelines/pathways that are utilized for the PC implementation. Given the similarities detected between cancer and CHF/COPD, other barriers appear to play a more prominent role.

Research Priorities in Subspecialty Palliative Care: Policy Initiatives

Palliative care demonstrably improves quality of life for the seriously ill in a manner that averts preventable health crises and their associated costs. Because of these outcomes, palliative care is now broadening its reach beyond hospitals, and hospice care for those near death, to patients and their families living in the community with chronic multimorbidities that have uncertain or long expected survival. In this article, we address research needed to enable policies supportive of palliative care access and quality, including changes in regulatory, accreditation, financing, and training approaches in the purview of policy makers. Mr. K. is an 86-year-old male with multimorbidities, including severe chronic obstructive pulmonary disease, congestive heart failure, peripheral vascular disease, and atrial fibrillation requiring anticoagulation therapy. He fell in his mobile home and was unable to reach the telephone to call for help. Six hours later, his neighbor found him lying on the bedroom floor in pain and confused, and called 911. On examination, he was found to have a cold blue foot complicated by a large hematoma. The vascular surgery service was consulted to evaluate Mr. K. for revascularization or amputation. Although Mr. K. had several risk factors complicating his candidacy for general anesthesia, the team thought the benefits of surgery would outweigh the risks. Mr. K's daughter agreed to surgery telling her father "the doctors know best." Mr. K. replied "I just want to be out of pain." Six months later, Mr. K. remains in a skilled nursing facility due to post-op complications, including pneumonia, worsened confusion, and the inability to recover to enough function to live safely at home. He now suffers from depression, cognitive deficits, and social isolation. His daughter has had to take on a second job because she is struggling to pay for his continued long-term care, which costs $6000 per month. Money she had saved for her own retirement and her daughter's college tuition is already gone. In retrospect, she realizes the surgical team did not discuss the possibility of his survival with chronic debility and long-term functional dependency, nor the fact that Medicare would not pay for the care he now requires.

Common care practices among effective community-based specialist palliative care teams: a qualitative study

Objective

Evidence has shown that, despite wide variation in models of care, community-based specialist palliative care teams can improve outcomes and reduce acute care use at end of life. The goal of this study was to explore similarities in care practices among effective and diverse specialist teams to inform the development of other community-based teams.

Methods

Interviews with 78 providers and administrators from 11 distinct community-based specialist palliative care teams from Ontario, Canada were conducted. Interviews were audio-recorded, transcribed and analysed using an inductive approach to identify common themes.

Results

3 key themes across all teams emerged. First, the distinct models of care were generally summarised into 3 models: primary care and specialist providers either collaborated by transferring, sharing or consulting in care. Second, teams explicitly or implicitly followed 7 common care practices related to: specialised expertise 24/7; intrateam communication; timeliness; physical symptom and psychosocial–spiritual management; education; peace and fulfilment; and advocacy for patient preferences. Third, all teams emphasised the importance of team building, even more than using clinical tools and processes.

Conclusions

Despite wide variation in models of care among community-based specialist palliative care teams, this large qualitative study identified several common themes in care practices that can guide the development of other teams.

Organizational Capabilities for Integrating Care: A Review of Measurement Tools

The success of integrated care interventions is highly dependent on the internal and collective capabilities of the organizations in which they are implemented. Yet, organizational capabilities are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. Assessing these capabilities can contribute to understanding why some integrated care interventions are more effective than others. We identified, organized, and assessed survey instruments that measure the internal and collective organizational capabilities required for integrated care delivery. We conducted an expert consultation and searched Medline and Google Scholar databases for survey instruments measuring factors outlined in the Context and Capabilities for Integrating Care Framework. A total of 58 instruments were included in the review and assessed based on their psychometric properties, practical considerations, and applicability to integrated care efforts. This study provides a bank of psychometrically sound instruments for describing and comparing organizational capabilities. Greater use of these instruments across integrated care interventions and studies can enhance standardized comparative analyses and inform change management. Further research is needed to build an evidence base for these instruments and to explore the associations between organizational capabilities and integrated care processes and outcomes.

Communicating prognostic uncertainty in potential end-of-life contexts: experiences of family members

BACKGROUND

This article reports on the concept of "communicating prognostic uncertainty" which emerged from a mixed methods survey asking family members to rank their satisfaction in seven domains of hospital end-of-life care.

METHODS

Open-ended questions were embedded within a previously validated survey asking family members about satisfaction with end-of-life care. The purpose was to understand, in the participants' own words, the connection between their numerical rankings of satisfaction and the experience of care.

RESULTS

Our study found that nearly half of all family members wanted more information about possible outcomes of care, including knowledge that the patient was "sick enough to die". Prognostic uncertainty was often poorly communicated, if at all. Inappropriate techniques included information being cloaked in confusing euphemisms, providing unwanted false hope, and incongruence between message and the aggressive level of care being provided. In extreme cases, these techniques left a legacy of uncertainty and suspicion. Family members expressed an awareness of both the challenges and benefits of communicating prognostic uncertainty. Most importantly, respondents who acknowledged that they would have resisted (or did) knowing that the patient was sick enough to die also expressed a retrospective understanding that they would have liked, and benefitted, from more prognostic information that death was a possible or probable outcome of the patient's admission. Family members who reported discussion of prognostic uncertainty also reported high levels of effective communication and satisfaction with care. They also reported long-term benefits of knowing the patient was sick enough to die.

CONCLUSION

While a patient who is sick enough to die may survive to discharge, foretelling with family members in potential end of life contexts facilitates the development of a shared and desired prognostic awareness that the patient is nearing end of life.

Generalist palliative care in hospital - Cultural and organisational interactions. Results of a mixed-methods study

BACKGROUND

It can be challenging to provide generalist palliative care in hospitals, owing to difficulties in integrating disease-oriented treatment with palliative care and the influences of cultural and organisational conditions. However, knowledge on the interactions that occur is sparse.

AIM

To investigate the interactions between organisation and culture as conditions for integrated palliative care in hospital and, if possible, to suggest workable solutions for the provision of generalist palliative care.

DESIGN

A convergent parallel mixed-methods design was chosen using two independent studies: a quantitative study, in which three independent datasets were triangulated to study the organisation and evaluation of generalist palliative care, and a qualitative, ethnographic study exploring the culture of generalist palliative nursing care in medical departments.

SETTING/PARTICIPANTS

A Danish regional hospital with 29 department managements and one hospital management.

RESULTS

Two overall themes emerged: (1) 'generalist palliative care as a priority at the hospital', suggesting contrasting issues regarding prioritisation of palliative care at different organisational levels, and (2) 'knowledge and use of generalist palliative care clinical guideline', suggesting that the guideline had not reached all levels of the organisation.

CONCLUSION

Contrasting issues in the hospital's provision of generalist palliative care at different organisational levels seem to hamper the interactions between organisation and culture - interactions that appear to be necessary for the provision of integrated palliative care in the hospital. The implementation of palliative care is also hindered by the main focus being on disease-oriented treatment, which is reflected at all the organisational levels.

Measuring healthcare integration: Operationalization of a framework for a systems evaluation of palliative care structures, processes, and outcomes

BACKGROUND

Healthcare integration is a priority in many countries, yet there remains little direction on how to systematically evaluate this construct to inform further development. The examination of community-based palliative care networks provides an ideal opportunity for the advancement of integration measures, in consideration of how fundamental provider cohesion is to effective care at end of life.

AIM

This article presents a variable-oriented analysis from a theory-based case study of a palliative care network to help bridge the knowledge gap in integration measurement.

DESIGN

Data from a mixed-methods case study were mapped to a conceptual framework for evaluating integrated palliative care and a visual array depicting the extent of key factors in the represented palliative care network was formulated.

SETTING/PARTICIPANTS

The study included data from 21 palliative care network administrators, 86 healthcare professionals, and 111 family caregivers, all from an established palliative care network in Ontario, Canada.

RESULTS

The framework used to guide this research proved useful in assessing qualities of integration and functioning in the palliative care network. The resulting visual array of elements illustrates that while this network performed relatively well at the multiple levels considered, room for improvement exists, particularly in terms of interventions that could facilitate the sharing of information.

CONCLUSION

This study, along with the other evaluative examples mentioned, represents important initial attempts at empirically and comprehensively examining network-integrated palliative care and healthcare integration in general.

Evaluating a pilot paediatric hospice-at-home service: a literature review

Background: This literature review aims to offer practitioners an overview of the key components involved in designing the evaluation of a paediatric hospice-at-home pilot that will assess the effectiveness, efficiency and sustainability of the programme. The literature was reviewed in two stages: the first examined existing literature in the area of paediatric palliative care. The second looked at the wider field of adult palliative care to gain further insights into evaluation tool design. The findings are presented as a conceptual model to highlight each component of the pilot development stage as identified for evaluation purposes, emphasising their role and impact on the resultant delivery of integrated care. The clarity and transparency of this model offers a comprehensive overview of the evaluation process to all involved in the pilot.

Indicators of integration of oncology and palliative care programs: an international consensus

BACKGROUND

Recently, the concept of integrating oncology and palliative care has gained wide professional and scientific support; however, a global consensus on what constitutes integration is unavailable. We conducted a Delphi Survey to develop a consensus list of indicators on integration of specialty palliative care and oncology programs for advanced cancer patients in hospitals with ≥100 beds.

METHODS

International experts on integration rated a list of indicators on integration over three iterative rounds under five categories: clinical structure, processes, outcomes, education, and research. Consensus was defined a priori by an agreement of ≥70%. Major criteria (i.e. most relevant and important indicators) were subsequently identified.

RESULTS

Among 47 experts surveyed, 46 (98%), 45 (96%), and 45 (96%) responded over the three rounds. Nineteen (40%) were female, 24 (51%) were from North America, and 14 (30%) were from Europe. Sixteen (34%), 7 (15%), and 25 (53%) practiced palliative care, oncology, and both specialties, respectively. After three rounds of deliberation, the panelists reached consensus on 13 major and 30 minor indicators. Major indicators included two related to structure (consensus 95%-98%), four on processes (88%-98%), three on outcomes (88%-91%), and four on education (93%-100%). The major indicators were considered to be clearly stated (9.8/10), objective (9.4/10), amenable to accurate coding (9.5/10), and applicable to their own countries (9.4/10).

CONCLUSIONS

Our international experts reached broad consensus on a list of indicators of integration, which may be used to identify centers with a high level of integration, and facilitate benchmarking, quality improvement, and research.

Towards a taxonomy for integrated care: a mixed-methods study

INTRODUCTION

Building integrated services in a primary care setting is considered an essential important strategy for establishing a high-quality and affordable health care system. The theoretical foundations of such integrated service models are described by the Rainbow Model of Integrated Care, which distinguishes six integration dimensions (clinical, professional, organisational, system, functional and normative integration). The aim of the present study is to refine the Rainbow Model of Integrated Care by developing a taxonomy that specifies the underlying key features of the six dimensions.

METHODS

First, a literature review was conducted to identify features for achieving integrated service delivery. Second, a thematic analysis method was used to develop a taxonomy of key features organised into the dimensions of the Rainbow Model of Integrated Care. Finally, the appropriateness of the key features was tested in a Delphi study among Dutch experts.

RESULTS

The taxonomy consists of 59 key features distributed across the six integration dimensions of the Rainbow Model of Integrated Care. Key features associated with the clinical, professional, organisational and normative dimensions were considered appropriate by the experts. Key features linked to the functional and system dimensions were considered less appropriate.

DISCUSSION

This study contributes to the ongoing debate of defining the concept and typology of integrated care. This taxonomy provides a development agenda for establishing an accepted scientific framework of integrated care from an end-user, professional, managerial and policy perspective.

Measuring horizontal integration among health care providers in the community: an examination of a collaborative process within a palliative care network

In many countries formal or informal palliative care networks (PCNs) have evolved to better integrate community-based services for individuals with a life-limiting illness. We conducted a cross-sectional survey using a customized tool to determine the perceptions of the processes of palliative care delivery reflective of horizontal integration from the perspective of nurses, physicians and allied health professionals working in a PCN, as well as to assess the utility of this tool. The process elements examined were part of a conceptual framework for evaluating integration of a system of care and centred on interprofessional collaboration. We used the Index of Interdisciplinary Collaboration (IIC) as a basis of measurement. The 86 respondents (85% response rate) placed high value on working collaboratively and most reported being part of an interprofessional team. The survey tool showed utility in identifying strengths and gaps in integration across the network and in detecting variability in some factors according to respondent agency affiliation and profession. Specifically, support for interprofessional communication and evaluative activities were viewed as insufficient. Impediments to these aspects of horizontal integration may be reflective of workload constraints, differences in agency operations or an absence of key structural features.

Bridging between professionals in perinatal care: towards shared care in the Netherlands

Relatively high perinatal mortality rates in the Netherlands have required a critical assessment of the national obstetric system. Policy evaluations emphasized the need for organizational improvement, in particular closer collaboration between community midwives and obstetric caregivers in hospitals. The leveled care system that is currently in place, in which professionals in midwifery and obstetrics work autonomously, does not fully meet the needs of pregnant women, especially women with an accumulation of non-medical risk factors. This article provides an overview of the advantages of greater interdisciplinary collaboration and the current policy developments in obstetric care in the Netherlands. In line with these developments we present a model for shared care embedded in local 'obstetric collaborations'. These collaborations are formed by obstetric caregivers of a single hospital and all surrounding community midwives. Through a broad literature search, practical elements from shared care approaches in other fields of medicine that would suit the Dutch obstetric system were selected. These elements, focusing on continuity of care, patient centeredness and interprofessional teamwork form a comprehensive model for a shared care approach. By means of this overview paper and the presented model, we add direction to the current policy debate on the development of obstetrics in the Netherlands. This model will be used as a starting point for the pilot-implementation of a shared care approach in the 'obstetric collaborations', using feedback from the field to further improve it.

Pediatric palliative care: a reflection on terminology

The definition of palliative care is the cornerstone of a medical subspecialty that plays a particular role for all who need it, for all who practice it, and increasingly for those who try to understand it.

The difficulties around the definition and terminology arise from problems in separating it from other concepts such as supportive care, constructs such as “palliative care is only about dying”, or, in children, the rather vague use of terms like life-threatening and life-limiting diseases. These weaknesses have been recognized and important steps have been taken. This review discusses current definitions as well as efforts to overcome their weaknesses and make the term palliative care—for both children and adults—more intelligible.

The role of the keyworker in breaking down professional culture barriers to providing high-quality palliative care: a literature review

Background

Palliative cancer care is by definition multi-professional in nature. An interdisciplinary approach to disease management emphasising continuity of care results in increased quality of life for patients and families. Complex disease management demands the provision of a full spectrum of high-quality care; requiring both specialist and generalist services. Appointed keyworkers are knowledgeable about patient preferences enabling effective coordination of care and promotes collaborative team-working. The need for diversity in the provision of palliative care is recommended but can challenge effective interdisciplinary collaboration by creating tension and limiting the interdisciplinary team (IDT) from reaching its full potential resulting in adverse outcomes.

Purpose

The purpose of this paper is to review the literature available regarding how IDTs and keyworkers influence high-quality palliative care; evaluate how professional culture barriers can influence team collaboration; discuss the keyworker role in minimising these barriers and clinical implications.

Methodology

A review of the English literature from 2003 to 2013 was performed using the databases PubMed (NML), OVID Medline and Google Scholar.

Results and conclusion

Keyworkers can help overcome professional culture barriers that result from ineffective team communication. Facilitating improved communication regarding professional roles fosters mutual understanding among team members. The dissemination of relevant and timely information minimises fragmentation, prompting team decision-making and promotes continuity of high-quality palliative care.

Evidence-based planning and costing palliative care services for children: novel multi-method epidemiological and economic exemplar

Background

Children’s palliative care is a relatively new clinical specialty. Its nature is multi-dimensional and its delivery necessarily multi-professional. Numerous diverse public and not-for-profit organisations typically provide services and support. Because services are not centrally coordinated, they are provided in a manner that is inconsistent and incoherent. Since the first children’s hospice opened in 1982, the epidemiology of life-limiting conditions has changed with more children living longer, and many requiring transfer to adult services. Very little is known about the number of children living within any given geographical locality, costs of care, or experiences of children with ongoing palliative care needs and their families. We integrated evidence, and undertook and used novel methodological epidemiological work to develop the first evidence-based and costed commissioning exemplar.

Methods

Multi-method epidemiological and economic exemplar from a health and not-for-profit organisation perspective, to estimate numbers of children under 19 years with life-limiting conditions, cost current services, determine child/parent care preferences, and cost choice of end-of-life care at home.

Results

The exemplar locality (North Wales) had important gaps in service provision and the clinical network. The estimated annual total cost of current children’s palliative care was about £5.5 million; average annual care cost per child was £22,771 using 2007 prevalence estimates and £2,437- £11,045 using new 2012/13 population-based prevalence estimates. Using population-based prevalence, we estimate 2271 children with a life-limiting condition in the general exemplar population and around 501 children per year with ongoing palliative care needs in contact with hospital services. Around 24 children with a wide range of life-limiting conditions require end-of-life care per year. Choice of end-of-life care at home was requested, which is not currently universally available. We estimated a minimum (based on 1 week of end-of-life care) additional cost of £336,000 per year to provide end-of-life support at home. Were end-of-life care to span 4 weeks, the total annual additional costs increases to £536,500 (2010/11 prices).

Conclusions

Findings make a significant contribution to population-based needs assessment and commissioning methodology in children’s palliative care. Further work is needed to determine with greater precision which children in the total population require access to services and when. Half of children who died 2002-7 did not have conditions that met the globally used children's palliative care condition categories, which need revision in light of findings.

Planning ahead with children with life-limiting conditions and their families: development, implementation and evaluation of 'My Choices'

Background

The United Kingdom has led the world in the development of children’s palliative care. Over the past two decades, the illness trajectories of children with life-limiting conditions have extended with new treatments and better home-based care. Future planning is a critically under-researched aspect of children’s palliative care globally. This paper describes the development, implementation and evaluation of innovative child and parent-held palliative care planning resources. The resources were designed to facilitate parent and child thinking and engagement in future planning, and to determine care preferences and preferred locations of care for children with life-limiting conditions from diagnosis onwards. These resources fill a significant gap in palliative care planning before the end-of-life phase.

Methods

Drawing on contemporaneous research on producing evidence-based children’s health information, we collaborated with leading children’s not-for-profit organisations, parents, children, and professionals. A set of resources (My Choices booklets) were developed for parents and children and evaluated using interviews (parents, children, professionals) and questionnaires (professionals) and an open web-based consultation.

Results

Parents and children responded in three ways: Some used the booklets to produce detailed written plans with clear outcomes and ideas about how best to achieve desired outcomes. Others preferred to use the booklet to help them think about potential options. Remaining parents found it difficult to think about the future and felt there was no point because they perceived there to be no suitable local services. Professionals varied in confidence in their ability to engage with families to plan ahead and identified many challenges that prevented them from doing so. Few families shared their plans with professionals. Parents and children have far stronger preferences for home-care than professionals.

Conclusion

The My Choices booklets were revised in light of findings, have been endorsed by Together for Short Lives, and are free to download in English and Welsh for use by parents and young people globally. More work needs to be done to support families who are not yet receptive to planning ahead. Professionals would benefit from more training in person-centred approaches to future planning and additional communications skills to increase confidence and ability to engage with families to deliver sensitive palliative care planning.

Health system characteristics of quality care delivery: a comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada

BACKGROUND

A number of palliative care delivery models have been proposed to address the structural and process gaps in this care. However, the specific elements required to form competent systems are often vaguely described.

AIM

The purpose of this study was to explore whether a set of modifiable health system factors could be identified that are associated with population palliative care outcomes, including less acute care use and more home deaths.

DESIGN

A comparative case study evaluation was conducted of 'palliative care' in four health regions in Ontario, Canada. Regions were selected as exemplars of high and low acute care utilization patterns, representing both urban and rural settings. A theory-based approach to data collection was taken using the System Competency Model, comprised of structural features known to be essential indicators of palliative care system performance. Key informants in each region completed study instruments. Data were summarized using qualitative techniques and an exploratory factor pattern analysis was completed.

RESULTS

43 participants (10+ from each region) were recruited, representing clinical and administrative perspectives. Pattern analysis revealed six factors that discriminated between regions: overall palliative care planning and needs assessment; a common chart; standardized patient assessments; 24/7 palliative care team access; advanced practice nursing presence; and designated roles for the provision of palliative care services.

CONCLUSIONS

The four palliative care regional 'systems' examined using our model were found to be in different stages of development. This research further informs health system planners on important features to incorporate into evolving palliative care systems.

Developing a national quality register in end-of-life care: the Swedish experience

BACKGROUND

The complexity of end-of-life care, represented by a large number of units caring for dying patients, different types of organizations and difficulties in identification and prognostication, signifies the importance of finding ways to measure the quality of end-of-life care.

AIM

To establish, test and manage a national quality register for end-of-life care.

DESIGN

Two questionnaires were developed with an attempt to retrospectively identify important aspects of the care delivered during the last week in life. An internet-based IT platform was created, enabling the physician and/or nurse responsible for the care during the last week in life to register answers online.

SETTING

Units caring for dying people, such as hospital wards, home care units, palliative in-patient care units and nursing facilities.

RESULTS

The register received status as a National Quality Register in 2006. More than 30,000 deaths in nursing facilities, hospital wards, palliative in-patient units and private homes were registered during 2010, representing 34% of all deaths in Sweden and 58% of the cancer deaths.

CONCLUSIONS

We have shown that it is feasible to establish a national quality register in end-of-life care and collect data through a web-based system. Ongoing data analyses will show in what way this initiative can lead to improved quality of life for patients and their families. There is an ongoing process internationally to define relevant outcome measures for quality of care at the end-of-life in different care settings; the registry has a potentially important role in this development.