PalliSupport – The development, feasibility and implementation of a transitional integrated care pathway for older patients with palliative care needs

摘要

Introduction - Marjon van Rijn (5 minutes) : For the development, implementation and evaluation of a transitional integrated care pathway for older patient with palliative care needs we used the Medical Research (MRC) Framework. The overall aim of this transitional integrated care pathway is to test the effectiveness of a transitional integrated care pathway for older patients with palliative care needs. This pathway includes a better recognition of palliative care needs, end-of-life preference discussion, improved handover and involvement of informal caregivers. A transitional palliative care team will facilitate these interventions and consist of a general practitioner, community care nurse, professionals from the hospital, as well as professional specialized in the social and spiritual domain. In this workshop all steps of the MRC framework will be presented using the PalliSupport project as a best practice. The main aim of this workshop is to exchange experiences on the development, implementation and evaluation of complex integrated care interventions. Development, feasibility and pilot of a transitional integrated care pathway for older patient with palliative care needs, a process evaluation – Marjon van Rijn (20 minutes) Base on previous experiences and research findings we developed a transitional care pathway with a project group, including older persons. A first step is to investigate the feasibility and to conduct a pilot study. The process evaluation of this pilot study aims to gain insight into factors that influences the implementation of the care pathway. Semi-structured interviews were held with care professionals in both primary and hospital care and informal care givers. These results were then used to optimize the care path for the step wedge cluster randomized study. This presentation discusses experiences of those involved with training, conversations about the end of life, multidisciplinary consultation, the palliative care team and roles. PalliSupport – Implementation and evaluation of a transitional integrated care pathway for older patient with palliative care needs – Bianca Buurman (20 minutes) The transitional integrated care pathway will be implemented and evaluated using a stepped wedge cluster randomized study design. This study will be conducted in five regions, consisting of a hospital and the surrounding primary care organizations. 600 patients ≥65 years of age with acute hospitalization and a positive score on frailty scales participate in this study. The PalliSupport project consists of interventions at hospital level, palliative team and primary care level. The control group receives care as usual. The primary outcome is the number of patients with an unplanned readmission within six months after discharge. Secondary outcomes are death at place of preference, quality of life, symptom burden, informal caregiver burden and health care utilization. In addition, a process evaluation and cost-effectiveness analysis will be performed. Furthermore a business case is written to facilitate implementation after the study period. During this presentation the design, components of the intervention, implementation strategies and preliminary results of the research will be presented. Interactive discussion (15 minutes) : The interactive discussion will facilitate exchange of experiences, ideas and advice for future practice and research on complex integrated care interventions.