6/29/11. Training proactive palliative care by general practitioners ; clinical use and evaluation two years after introduction.

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1 Training proactive palliative care by general practitioners ; clinical use and evaluation two years after introduction Aletta Moeland, MD Eric van Rijswijk, MD, PhD Dept of Primary Health Care Dept of Pain and Palliative Care UMC St Radboud Nijmegen The Netherlands Research Group : Bregje Thoonsen, Kris Vissers, Chris van Weel, Yvonne Engels, Marieke Groot, Eric van Rijswijk, Stans Verhagen, Judith Prins, Cilia Galesloot, Koby van de Knaap Dept. of Anesthesiology, Pain and Palliative medicine Dept. of Primary Care Radboud University Nijmegen Medical Centre Comprehensive cancer centre East/South Next 20 minutes Background and aim overall project Training Method evaluation Results Strenghts and weaknesses Conclusions and recommendations 1

2 Background Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual Primary care 80% of patients want to die at home 32% patients die at home (Nivel, 2006) General practitioner: central medical care provider 8-12 patients die per year of a non-acute illness in avarage practice Palliative care focus on cancer Stimulating palliative care in primary care (Ministry of Health, 2007) Generalist palliative care 2

3 Early identification!? Early indentification high function palliative care intensity interference follow up care informal carer GP low death time stable fase terminal fase? Fig 1. Modification figure Lynn et al Bregje Thoonsen room 3a Lack of systematic proactive approach Reactive management Communicative en moral problems Strain of informal carers Worse symptom control Lack of clarity of problems and needs of patient and carer Location of death at other place than preference 3

4 Impeccable assessment Proactive palliative care Anticipation Structured Dying scenario Inventory of problems and needs of patient /carer Multi-disciplinary Aim Overall aim of project To investigate if early identification of palliative care patients by the GP and proactive palliative care improves different aspects of palliative care Method RCT Intervention Training indicators for early identification proactive palliative care planning Coaching/feedback van palliative care consultant Meetings 120 GP s 60 GP s intervention 60 GP s usual care 4

5 Training: Early identification and proactive care planning in palliative care patients in primary care Two four hours sessions and two booster session: Day 1: Proactive care approach; multidimensional and scenarios care planning Cancer, COPD and Heart failure Day 2: Early identification, using consultation pall care expert, information for OoH care Booster session: role play talking with patients about start palliative care trajectory Training: Identificatie en proactieve zorgplanning bij palliatieve patiënten in de eerste lijn Uitgereikte instrumenten: Opsporingsindicatoren Probleemkwadranten Proactief palliatief zorgplan Overdrachtsformulier 5

6 Research question To which extend trained GPs use early identification and proactive care planning two years after start of training? How do they evaluate training? Which suggestions do they have for future training? Methode (1) Semi structured interviews by telephone Fully transcribed Coded by two researchers Content analysis Methode (2) Participants of study (N=58) Target GP (N=52) Loss of follow up during intervention(n=6) Random selection (N=13) refusal (N=4) interview (N=9),17% deelnemers 6

7 Results overall Certain need for this training inclusion of over 120 GPs in 2 weeks! Topics: - early identification - multidimensional assessment - pro active care plan - information for OoH care - talking with patient palliative care trajectory Results Indicators Feasible in clinical practice and used during intervention period Less formal use in clinical practice Triggers use of clinical assessment it helps me to start thinking on the needs of this patient, I do not take the card to assess all items (HA4) It is more a matter of intuition (HA7) Results: Inventarisation of problems (multidimensional) Highly valued; helps to get an overview Less formally used after training, incorperated in clinical work In a certain way you alway try to assess all dimensions, but in an unstructured manner. Now you check all domains and see what you miss or how problems are interrelated (HA2) 7

8 Results: Proactive care plan Positively evaluated: helps to anticipate and think about possible scenarios in all dimensions. Feasibility resonable: on paper vs electronic medical record, time consuming Still use it in clinical practice It helps you to assess and to think how the process in this patient can develop and to think about future problems. I still use it for myself not to discuss with patients (HA4) Results: Information form out of hours care Too long, to extensive form Not used after intervention period; use of local information forms, regional electronic patient record no need to use it any more, we can have a look in the patients record, the form was too long anyway. (HA4) Results communication Communication with patiënts about pall care trajectory: Need to mark and discuss it with patients Still difficult to have these conversations important but most of the time also emotional and hard to have these conversations (HA4) You can prepare patients and carers better and you are better prepared yourself as well (HA3) 8

9 Resultats(3) Assess, think about future problems, discuss them and anticipate on it. It is not just providing more care, medical or nursing and see what happens. I can plan and evaluate better. It can be more nursing care but also anticipate with prescibing drugs, studying in guidelines or consult a collegue. (HA8) Strength and weaknesses method + insight in use clinical practice + use of approach and tools after long period of time + suggestions for future interventions and training - Risk of socially correct answers - Limited results Conclusions 1 Training in general positively evaluated Multidimensionality and proactive care approach valuable for GPs In general use of tools integrated in clinical practice Feasibility tools limited 9

10 Conclusions 2 Recomendations of GPs Early identification of COPD and HF patients Extended training in communication Predicting future problems in complex patients Make tools electronically available What do patients think about this approach Use of comprehensive care plan in patients with chronic disease and multimorbidity (supportive care) More about early identification high function palliative care intensity interference follow up care informal carer GP low death time stable fase terminal fase? Fig 1. Modification figure Lynn et al Bregje Thoonsen room 3A 10