CATALONIA

1. WHO Public Health approach in the planning and implementation of Palliative care: Experience and evidence from CataloniaXavier Gomez-BatistePal Care , Institut Catala d’OncologiaSocio-Health, Catalan Department of HealthSpanish Society for Pall care (SECPAL)

2. 6.7 milion habitants > 16% > 65 1 million > 65 ys 100.000 elderly with pluripathology and dependency Dementia: 90.000 Cancer mortality: 13.000 Aids: 300 CATALONIA

3. Catalonia: Public Health Care system (universal coverage, free access) Hospitals: 14.000 beds Regional Cancer Institute Sociohealth Centers: 5.000 Residential: 45.000 Primary care network

4. Background • British experience on Hospices: model of care and internal organisation, but outside the NHS • The Public Health approach: E. Wilkes (1985) + Jan Stjernsward (WHO) + V Ventafridda

5. PCPC: global results 2004 • Nº total resources: 162 • Interventions/year: > 20.000 • Coverage cancer: 75% • Cancer vs noncancer: 60/40% • Coverage, geographical: 100% • Total beds: 550 • Beds /milion hab: 85 • Full time doctors: 140

6. Units 2001: placement Hosp Univ: 6 Hosp Gen: 4 ICO: 1 CSS: 38 MEP: 11 • Nº total: 60 • Beds: 550 (9.5/UCP) • Length stay: 22.8 days • Mortality: 69.7% • Discharges home: 23.0%

7. Home Care Support Teams • Nº total: 62 • Nº new patients/year: 250 • Cancer (46%), geriatrics (46%), chronic • Prevalents: 30-40 • Time intervention: 6 weeks • Place of death: 61% home, 19% CSS, 12% HA • Nº total professionals (2003): 318 • Cost: savings of 1.000 euros/patient

8. CP: levels of complexity Complete teams Units Reference: complexity+ training+ research Basic Support Teams General Measures in Conventional Services

9. Complex metropolitan systems (300-500.000 hab): levels, coordination

10. ICO: Palliative Care Service • Unit 16 beds • Outpat’s/DC • Support team CSUB ICO PADES + UCPSS

11. PCS at ICO: basic outputs • New patients/year: 1.000 (Cancer 100%) • Median survival 1st visit: 3.5 months • Mean age: 60 years • Length of stay (Unit) : 9 days • Mortality (Unit): 50% • Cost: 30% of Medical Oncology

12. PCS at ICO: other aspects • Reference for training (Master, Intermediate, Basic): more than 5.000 profesionals trained • Research: CATPAL cooperative group (more than 17 studies) • Quality improvement: EFQM model

13. ICO 1998: the “ping-pong” model CIR HMT ONC ORL PAIN PAL CARE RDT URG Cuidados Paliativos

14. ICO 2005: interphase Oncology-Pal care UFP PACMAC UFM Palliative Care Service: clinic, unit, support team Case management Continuing care Emergencies Coordination UFORL UFGINE USAC “From competition to cooperation”

15. Death Diagnosys Bereavement Specific Treatment Suportive care Palliative care Terminal care Complexity vs prognosis Definitions and trams

16. PVAA 166,8 million € 3% of total CHS budget PCPC: 23,7 million € 0,43 % total CHS budget

17. Legislation and standards • Decret Catalunya 1990 • Recomendaciones de la SECPAL, Ministerio de Sanidad (1993) • Estàndards de cures pal.liatives, SCS, SCBCP (1993) • Decreto/orden 1993 (Opioides) Ministerio • Plan Nacional de Cuidados Paliativos (2001) • Guía de criterios de calidad en cuidados paliativos: SECPAL, Ministerio Sanidad (2002) • Indicadores de calidad en cuidados paliativos: SECPAL, Ministerio de Sanidad

18. Spain 2002 by Regions Fuente: Directorio SECPAL

19. Spain 1984-2002 Fuente: Directorio SECPAL

20. Results on the use and cost of reources

21. COMPARISON 1992-2002: USE/COST OF RESOURCES INGR: % malalts / ESTMITJ: dies / URGENC: %malalts COST: euros x 100 (XGB et al, 2002)

22. TESISTAULESTEXTCAPVI1 Hospital Costs: 1992 vs 2001(Cost / process-patient / 6 weeks at 2001 prices) • 1992: 4.987 euros • 2001: 1.701 euros • Difference: 3.286 euros / patient

23. National Policy: Elements • Evaluation of needs • Defined targets, aims and principles • Leadership • Implementation of specific services • General measures in conventional services • Opioid availability • Education and training • Standards, legislation, definition of services • Financing model • Evaluation • Implementation plan with specific budget

24. Principles • Measures in all places • Sectorized • Insertion in preexisting services, including sociohealth • Gradual implementation • Public Planning • Public Financement

25. Aims • Coverage: for all in everywhere • Equity and accesibility • Quality: effectiveness, efficiency, satisfaction • Reference WHO

26. Initial key procesess • Clear ideas • Clear definition of clients and services • Leadership • Training • References/experiences • Institutional support pva20

27. Leadership Joint venture between • Ministry of health and financing agency • Professionals: well trained and highly committed • Organisations (Providers): public, profit, nonprofit • Academic (Universities)

28. General measures • Targets: Hospitals (oncology, internal medicine, geriatrics, emergencies), mid-term and long-term resources (nursing homes), primary care teams • Training: policies, sessions, formal training, local references • Change of organisation: teamwork, presence and support of the family • Liaison of resources

29. Specific Resources • Specific nurses • Support teams: in hospitals, community, both, systems • Units: type, dimension, placement • Nº beds: 80-100/milion • Placement: 10-20% acute, 40-60% sociohealth (mid-term), 10-20% residential, 10-20% hospices

30. Types of processes (always combined) • Implementation of new specific resources • Adaptation of conventional resources (general measures) • Reallocation of resources (reconversion) • “Catalythic”implementation or investment

31. Palliative care and geriatrics and cancer • Links with geriatrics in Sociohealth centers, nursing homes, and community • Links with cancer in hospitals, cancer centers, and the community • Both necessary

32. Common Resistances • “We are already doing so...” • “There is no need of specific services, we will do a lot of training....” • “Palliative care services will be seen as places to die....” • “This is good for England, USA, or Catalonia, but it will not work in our country....”

33. Expected results • Enormous improvement of the quality of care • Effectiveness • Efficiency: saving more than the structrural cost • Satisfaction: patients, families, professionals, and politicians

34. Palliative Care: added values • Care and organisation models useful in all the system • Model of care appliable to other conditions earlier • Emphasis in quality of life • Impact on the global efficiency • High patient’s and familie’s satisfaction • Ethical approach