Application ID: 0329 – PBH – LUN – SI

Urska Lunder

Research proposal

A model for classifying and paying for palliative care in Slovene health care system

SUMMARY

The objective of this project is to create a pilot study to test a classifying system and common protocol (clinical pathway) in order to identify optimal strategy of implementation process for palliative care services into Slovene national health care system. Through a pilot study three palliative care teams in different settings will be explored to test the modified clinical pathway for palliative care. The main intention is of delivering proposals for change across the entire range of settings where palliative care is given, from hospitals, primary care, hospice and nursing homes in Slovenia. An efficient classifying and payment system together with permanent education will be a tool to encourage sensible changes in the way palliative care is provided and standards developed. It is a period of health care reform in Slovenia and a very convenient moment for such a project with a recommendation to Ministry of health as a result of a one year research.

OBJECTIVES OF THE PROJECT

The main aim of the project is to establish and propose a successful model of palliative care services implementation into Slovene health care system, through research and a one-year pilot study with the following goals:

• to prepare a short analyze of present status of palliative care in Slovenia,

• to compare successful models of palliative care in other countries (United Kingdom, Canada, Sweden, Australia, Spain-Catalonia),

• to create and organize a pilot study to test a classifying model and modified clinical pathway in order to identify optimal strategy of implementation of palliative care services into Slovene national health care system,

• to propose a financing model for palliative care services,

• to establish ways of empowering individual initiatives for palliative care teamwork,

• to write a research and produce a policy paper for Slovene Ministry of Health;

METHODS

In the exploratory stage first step should involve a review of current practice in Slovenia to identify opportunities for improvement of palliative care. Next step would be to compare Slovenia and selected other countries in terms of data systems, clinical practice and payment models. The aim is to develop an understanding of the strengths and weaknesses of current arrangements, build agreement on what might be done in short and long terms, and establish a better basis for describing palliative care in the payment system.

It seems likely that main issues relate to identifying patients who need palliative care (how patients are selected and where they are provided with care: hospitals, primary care, nursing homes, their own homes – to achieve that the place of dying is closer to the patients desires). There may also be concerns about care practices, for which the development and use of protocols (such as clinical pathways) will be needed. Finally, there could be concerns about how staff is educated and community involved.

Through a pilot project three palliative care teams in different settings will be explored to test the modified clinical pathway for palliative care. With the intention of finding an appropriate classifying system of patients and services of multidisciplinary palliative care team, adaptable to all levels of health care system, a proposal will be developed for change across the entire range of national palliative care services. A separate budget pool for palliative care will be proposed, where each institution has a share from the inpatient or outpatient palliative care pool in proportion to the work it is contracted to undertake.

There are many tasks that need to be undertaken, and they could not be done all at once but step by step:

• clarification of what constitutes good clinical practice (define basis for national clinical standards in palliative care)

• the scope of the budget pool (the services to be financed from the pool)

• the unit of service

• data needed to be collected

• the audit method (how actual practice will be determined, and quality assessed)

The model should support direct incentives to maximize quality of care.

Introduction of clinical pathway has many advantages. If there is a commitment to improved clinical practice through better teamwork, better outcomes, and improved communications between clinicians and patients/their relatives, clinical pathway should be easy to implement. In order to successfully introduce clinical pathway, workshops on information about a new tool will be organized, together with training of skills and exploration of attitudes of multidisciplinary teams towards palliative care issues.

Clinical pathways in palliative care should be more flexible (incorporating choices), less time dependent (in terms of intervals between care steps), and more holistic (in terms of addressing all aspects of quality of life). Regardless of the structure, the objectives will be the same as in other medical disciplines: avoiding omissions and duplications, encouraging multidisciplinary teamwork, keeping patients and their relatives informed, offering the same level of standard for the same type of service in all settings, better education opportunity and better outcome measure. Proposed model will serve to all settings where palliative care is given, from hospitals, primary care, nursing homes and hospice, with a possibility for modification to the level of professional care (general palliative care, specialist palliative care). An important focus will be given to the community involvement.

EXPECTED RESULTS

1. From the results of present status analyses of end of life care in Slovenia the basis for evaluation of changes through our intervention of pilot study could be measured.

2. Analyses of comparison of successful models of palliative care from other countries will help to create an appropriate classifying and financing model.

3. Pilot study of testing palliative care clinical pathway together with classifying and financing proposal will bring a model for the organization of palliative care in the national health care system.

4. The main aspects of clinical skills and attitudes, together with communication skills will be introduced to the participants of the study through the workshops for implementation of clinical pathway and classifying regimen in the pilot study.

5. Research analyses and classifying/payment proposal will serve as a proposal to Ministry of Health and National Insurance Institute for organized implementation of palliative care services to national health care system.

6. Slovene model could be useful to other countries, especially to those countries emerged from former Yugoslavia, with modifications to their system and culture.

CONCLUSION

Improvement of end of life care is necessary in Slovene national health care system. It is a very appropriate moment to investigate and propose a good model of implementation for organized palliative care services at the present time of health care reform in Slovenia. It will be more difficult to make changes later. Through the pilot study ways of effective team approach and use of integrated clinical pathway could be explored together with classifying and payment model.

Changes in attitudes and encouragement of motivation for improvement in medical culture are possible to be achieved and some solutions are proposed through the pilot study, which incorporates also workshops on these issues.

This project has a potential to move end of life care on a higher quality level in Slovenia through the proposal for the organizational change across the entire range of palliative care services: hospitals and non-hospital settings.

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