PAIN makes a difference 1
yester day. large problem small solutions 2
not just compassion. 3
opioid consumption 2006!0.35 National healthcare service per capita disbursement 4
opioid consumption 2007!0.67 National healthcare service per capita disbursement 5
painless hospital committees 6
the patient Pain patients had few warranties and little information. They can choose where to have what kind of surgery, but choice is limited when it comes to treating pain. No guarantees of quality care professionals No minimum requirements of care for pain pts. Few, if any recognition for excellent care. Pain was not a condition as any. the healthcare system Little coordination/ information on own services Costs are paid without adequate information. Paid costs for care without having adequate information on results society Pays for chronic pain Pays to treat chronic pain Could not insure access to adequate therapy for chronic pain 7
Problems in palliative care 8
Inappropriate care 69.600 death due to cancer in acute 1.015.424 care hospitals inpatient days 346 million euros spent Data from 2006. Source: Min. for Labor, Healthcare and Social Policy 9
Law 39/1999 200 million euros for 188 centers 2025 beds 10
Bed availability in hospices <0.2 beds <0.3 beds <0.4 beds <0.5 beds!0.5 beds >0.6 beds Benchmark value (per 10 000 residents) 11
5 92 100 56 96 46 77 100 <0.2 beds <0.3 beds <0.4 beds <0.5 beds!0.5 beds >0.6 beds 48 94 76 87 79 17 100 77 81 50 16 46 % of funds spent 79 Min. Labor, Healthcare and Social Policy
Total L. 39/99 Funds Fondi erogati 21% 79% Claimed Available 13
In-hospice care expense Region Fondi erogati Amount Piemonte!258 PA Bolzano!410 PA Trento!109/120 Veneto!230/250 (!500/d pediatric pts) Liguria!191/215.50 Emilia-Romagna!237 Toscana!200 Lazio!170 + drugs/devices Campania!238/!350 (hospice) Basilicata!180 + drugs Puglia!196,22 Calabria!260 ( Via delle Stelle hospice only) Sicilia!201,40 Sardegna!138 + staff supplement 14
Home care expense Region Fondi erogati Piemonte Lombardia Amount!70/d Initial fee!150!60/d Marche!550-900 according to contract Lazio Campania Puglia Calabria Sicilia Sardegna!170/die + drugs/devices!90/die + drugs/devices!1200 (flat fee)!65/d!72.30/d!23 + staff supplement 15
Minimum requirements for palliative care in 2008 Cancer-related deaths in palliative care / all cancer-related deaths "65% Hospice beds 11 DPCM 20/1/00 + regional requirements 100% Days of home palliative care "17 710 Waiting times "72 h for home care access (% of total home care pts) Waiting times "72 h for hospice access (% of total hospice pts) Admissions "7 d / total hospice admissions Admissions #30 d / total hospice admissions "80% "40% #20% #25% DM 43/2007 in compliance with art. 1, comma 169, L. 311/2004 16
Where to? Taking advantage of available resources Bed occupation evaluation: too few places? Too many? Implementation of minimum requirements 17
moving over 18
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Selecting a winning team. 20
Primary Care Oncologists Government Commission Hospitals (anesth & other hospitalists) Hospices (palliative care specialists) NGOs Who are the players in chronic pain? 21
Primary Care Oncologists Hospitals (anesth & other hospitalists) Hospices (palliative care specialists) NGOs Real people behind organizations 22
Not just the frontmen 23
Specialist in the topic 24
Connected 25
Thinking big 26
Privileged spokespersons to lead the way 27
Privileged spokespersons to lead the way 28
Listening. 29
Moving out from walled gardens 30
to an outreaching program 31
Primary care From separate services Clinics To integrated systems Pain med centers 32
1. Textbook with procedural algorithm PAIN 1. Pathophysiology 2. Algorithms 3. Education 33
2. TtT Train the Trainer Education 34
3. Online Education Education 35
Primary care trusts Primary care 36
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GP Specialist From home 38
Inappropriate Admissions Cost Increase No treatment planning to acute care hospitals 39
The concept Primary Care Trusts Pain Medicine Clinics Pain Medicine Centers 40
The concept Local presence Widespread treatment Specialty centers Presidi Ambulatoriali Territoriali Pain Medicine Clinics Pain Medicine Centers 41
Pain Medicine Clinics Existing centers meeting requirements in terms of procedure range, minimum volume and device availability Specialist, ambulatory procedures Interactions with palliative care specialists/centers 42
Pain Medicine Centers In-hospital care, with potential 1-day admission, multiple specialties, advanced diagnostics & procedures Invasive procedures for which admission is indicated Patient recruitment, treatment start and hand-off to local care 43
Palliative care/rehab constantly present PCT PMCl PMCe 44
education45
2009 Educational project in pilot regions Education 46
2009 Emilia-Romagna coordinating region Experimental project 47
Education based on territorial distribution of (human) resources 48
Education project Budget Goals Delivery! 300.000 Improve general practitioners approach to pain Distance learning, live events, reference texts 49
Training the trainers 50
TtT Train the Trainer Education 51
Local GP trusts 52
Trainer & trainees 1:50 relationship between trainer GP and trainees GPs 53
in every region 3 60 3000 courses trainers operators Cost effectiveness 54
Simplification of enteral opioid prescriptions 55
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In Senate: 334 Promoters 630 Total members unanimous approval 57
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! A new law Policies to guarantee access to palliative care and pain medicine impact & perspectives? Guido Fanelli gfanelli@parmanesthesia.com
60! Art. 1 This law grants citizens the legal right to have access to palliative care and pain medicine.
Palliative care Interventions for patients and families in the presence of progressive disease with negative prognosis, not amenable to specific treatment. " Art. 2 Definitions Pain medicine Diagnostics and therapeutics aimed at suppressing or controlling pain of any etiology Patient Person who suffers from chronic, evolving illness and/or chronic pain.
Art. 3: responsibilities National health service Palliative care and pain medicine are priority objectives; implementation is required for access to complementary funding by the government. " Ministry of health Defines guidelines for publicity, development and coordination of regional policies State-Regions Committee Verifies:! Status of implementation of the law! Appropriateness of interventions! Adequacy of available resources with respect to performance Photo by hidden side - http://flic.kr/p/3ddzwd Colby Cosh - http://flic.kr/p/4shqky
Information & Education " Art. 4 "350.000 for information campaigns Art. 6 Pain-free Territory "2.450.000 for practical education of personnel Photo c 2009 Marco Baciarello. Some rights reserved. ib yn ld
! Art. 5 State-Regions Committee! Institutions Accreditation Criteria! Staff Accreditation Criteria! System coordination! Reimbursement control! Care homogeneity
65 Art. 7! Pain as vital sign: Regular assessment in patients medical records
Pain management is the patient s right, and the caring physician s duty Art. 7 66! Law requirements Written records of treatments and outcomes
Art. 8 Educational Activities! Medical school masters and postgraduate masters (by the Ministry of Education and Research)! CME for physicians and other staff! Compulsory internships/ rotations (where applicable)! Special education for volunteers and charities/ NGOs " Photo 2008 Marilyn Nieves. Used with permission.
Art. 9 & 11 Photo c 2007 Flickr user hidden sites. bna Process Control National commission monitors and reports to Parliament about:! Network development! Performance & Efficiency! Education! Public information! Research! Budget! Technical reports by experts "
69 Art. 10! Simplification of prescription rules No more special logs for oral or transdermal opioid formulations Easier access to analgesics for acute and chronic outpatients. Egging on Europe s most reluctant opioid prescribers
Art. 12 " Budget for services: Ministry and State- Regions Permanent Conference: "!100 million/year taken from National Health Fund
! Pain Medicine & Assistance We can make a difference
! Pain Medicine & Assistance Guido Fanelli gfanelli@parmanesthesia.com